mcllclall-191018124031.pptx. .

All knee ligament injuries

1. MCL,LCL & ALL injuries Dr. Akshay (PT)

2. MCL

3. Anatomical basis

4. Anatomical basis

5. Anatomy Location and Structure Location : The MCL is located on the inner side (medial side) of the knee. Structure : It is a broad, flat, and strong band of fibrous tissue. It extends from the medial femoral epicondyle (a bony prominence on the femur) down to the medial condyle of the tibia. Divisions The MCL is typically divided into two parts: 1. Superficial MCL : This part is more prominent and easily palpable. It runs from the femur to the tibia. 2. Deep MCL : This part is shorter and thicker, located beneath the superficial MCL, and it merges with the joint capsule.

6. Blood Supply and Innervation Blood Supply : The MCL receives blood supply from branches of the genicular arteries. Innervation : It is innervated by the tibial nerve, which provides sensory and motor functions to the knee area.

7. Function The sMCL is the main valgus stabilizer of the knee in all flexion angles The dMCL ia a secondary valgus stabilizer and has a minor role in the prevention of anterior tibial translation .

8. Mechanism of Injury Valgus Force T wisting or rotational movements Overextension of the knee Indirect trauma

9. Clinical Evaluation Valgus Stress Test Slocum’s Modified Drawer Test Anterior Drawer Test with External Rotation Palpation over the medial joint line from medial epicondyle of the femur to the medial tibial plateau

10. Valgus stress test

11. Resting ° 30 °

12. Radiological Evaluation The medial collateral ligament (MCL). is evaluated primarily on the coronal fat–saturated T2 or (STIR) sequences.

13. Radiological Evaluation Grade 1 intact ligament, normal in signal, with surrounding edema and/or hemorrhage . Grade 2 partial rupture, abnormal signal within t h e l i g ame n t it s elf a n d / o r fluid surrounding the ligament in the MCL bursa Grade 3 disruption ligament complete rupture, and dis c o n ti n u i t y of f r a n k the

14. Radiological Evaluation

15. Stener like lesion It is a lesion in the knee involves displacement and entrapment of the MCL, preventing it from healing properly. MOI: Trauma Displacement : the torn end of the MCL gets displaced and entrapped under or over adjacent structures. Radiological Evaluation

16. P el l egri n i St i eda l e s i on – it refers to the calcification or ossification of the MCL at its femoral attachment site. This condition is typically a result of previous trauma or chronic stress to the MCL, leading to the formation of calcified deposits over time.

17. Treatment Non operative treatment Isolated injury to the MCL results in a robust healing response Rich blood supply, Relatively wide surface area, Association with other secondary stabilizers, Extra-articular location. 80 % return to sports within 9 weeks , 20 % hidden meniscal or ACL injuries Holden DL, Eggert AW, Butler JE: The nonoperative treatment of grade 1 and 2 medial collateral ligament injuries to the knee. Am J Sports Med 1983. 91 % return to sports after grade 3 injury Jones RE, Henley MB, Francis P: Non-operative management of isolated grade III collateral ligament injury in high school football players. Clin Orthop 213:137, 1986.

18. Conservative Management The haematoma is aspirated and the knee is immobilized in a cylinder cast or commercially available knee immobilizer . Most cases of grade I and II injuries can be successfully treated by this method. After a few weeks, the swelling subsides, and adequate strength can be regained by physiotherapy.

19. Indications of operative treatment open injury MCL entrapment causing incongruent reduction of the tibiofemoral joint fracture avulsion of the MCL origin distal MCL avulsion and pes anserinus interposition (a ‘Stener’ lesion) multi-ligament knee injury (the timing of this is controversial) other injuries requiring surgery (e.g. meniscal tear ,ACL) chronic instability after non-operative management

20. Surgical Procedure The patient is typically placed under general anesthesia or regional anesthesia (spinal or epidural ). A medial parapatellar incision is made to expose the medial side of the knee. Careful dissection is performed to access the torn MCL while protecting surrounding structures. The surgeon assesses the MCL tear to determine its extent and location. The ligament may be torn at its femoral origin, tibial insertion, or mid-substance. Primary Repair : If the tear is at the bony attachment and the tissue quality is good, the ligament can be reattached using sutures or anchors. - Femoral Origin : Sutures or anchors are used to reattach the ligament to the femur. - Tibial Insertion : Sutures or anchors are used to reattach the ligament to the tibia. Reconstruction : If the MCL is extensively damaged or the tissue quality is poor, ligament reconstruction is performed using a graft. Autografts like the hamstring tendon or allografts can be used. The graft is prepared by harvesting the tendon and shaping it to match the required size and length. Tunnels are drilled into the femur and tibia at the anatomical attachment sites of the MCL. The graft is passed through the tunnels and fixed with screws, buttons, or anchors to secure it in place. The incision is closed in layers using sutures or staples . A sterile dressing is applied, and the knee is often placed in a brace or immobilizer.

21. Anatomic double bundle MCL reconstruction Anatomic single bundle MCL reconstruction Non Anatomic double bundle MCL reconstruction

22. Non Anatomic double bundle transfer (modified Bosworth)

23. Internal bracing

24. Internal bracing It is an advanced technique designed to provide additional support to the reconstructed MCL during healing phase. By using internal sutures or tension bands, this approach enhances stability and helps ensure that the graft heals in the correct anatomical position.

25. R ehabili t a tion Protected WB in hinged knee brace to 90 ° for 2 weeks Gradual flexion 6 weeks Discontinue brace after 6 to 8 weeks Avoid pivoting for 16 weeks Jogging 16 to 20 weeks Return to play 9 months

26. Risks and Complications - Infection : Risk of infection at the surgical site. - Stiffness : Postoperative knee stiffness may occur. - Graft Failure : The graft may fail to incorporate or re-tear . - Nerve Injury : Rarely, nearby nerves may be injured during surgery. - Residual Instability : Persistent instability if the repair is not successful or if other structures are damaged.

27. L CL

28. LCL & PLC

29. The LCL is the primary stabilizer to varus stress of the knee. The PFL provides an important restraint to external rotation. Popliteus is dynamic stabilizer +/- static LCL & PLC

30. Mechanism of injury Varus, Rotation, extension 75% combined injury (PCL, ACL or both ) CPN injury 15 %

31. Clinical Evaluation Varus stress test

32. Clinical Evaluation External Rotation–Recurvatum test

33. Clinical Evaluation The prone external rotation test (dial test ) Performed at both 30 and 90 degrees of knee flexion

34. X ray Stress views Arcuate sign Avulsion fractures

35. Radiological Evaluation Most commonly, LCL injury manifests as complete midsubstance disruption with surrounding soft tissue edema. Injury to the LCL complex can be graded on MRI, Grade 1 :- Edema surrounding an intact ligament . grade 2 :-Intrasubstance ligamentous signal, possibly with ligamentous thickening or thinning and surrounding edema. grade 3 :-Frank disruption and discontinuous fibers

36. Radiological Evaluation the popliteus muscle and tendon are best evaluated with both sagittal and coronal MRI sequences. They are most commonly injured at the musculotendinous junction in the setting of a traumatic knee injury and s ub s e que n t considered MRI, th e p o p l i t eus can be t h e “ windo w t o the posterolateral corner.”

37. Fanelli A Fanelli B Fanelli C Increase External rotation Increase external rotation and mild varus instability Significant rotational and varus instability Isolated injury to PFL Injury to PFL and partial FCL Complete injury to PFL, FCL, and cruciate ligaments PFL reconstruction Arciero Laprade Vs Arciero

38. T r e a t m e n t Repair Within 2-3 weeks Failure rate 38% Geeslin et al, AJSM 2016

39. Treatment Reconstruction La r ss e n Kim Arciero

40. T r e a t m e n t Reconstruction Laprade

41. Treatment R e c o n s t r u c ti o n

42. Treatment Chronic with malalignment

43. ALL

44. History As early as 1879, Paul Segond described a ‘‘pearly, resistant, fibrous band’’ at the anterolateral aspect of the knee. This eponymous Segond fracture was reported to occur in the tibial region above and behind the Gerdy’s tubercle

45. Anatomy

46. An a t o m y

47. Indications for combined reconstruction Patients with high-grade pivot shifts on preoperative examination Recurvatum > 10 ° Chronic ACL lesion Revision cases Participation in pivoting sports Associated Segond’s fracture Lateral femoral notch sign Feucht et al COP 2016

48. Combined ACL, ALL preconstruction

49. T e c h n i q u e