SLARD Symposium: MCL s Injuries

Transcription

1 SLARD Symposium: MCL s Injuries ISAKOS 11 th Biennial Congress Tue June 6 th :30 14:15 Shanghai, China Gustavo A. Rincón, MD Chairman Department Orthopedic Surgery Hospital de San José Bogotá - Colombia Assistant Professor, Knee Unit FUCS President Sports Medicine Chapter Colombian Orthopedic Society Practice profile: o Location: academic medical center (32 residents and 3 fellows) o Research: Clinical, Basic Science o Years in practice: 15 o Number of repair / augmentation MCL s /yr: 6-8 o Number of reconstruction MCL s /yr: 4-6 Anatomy o MCL has 3 components 1. Superficial Medial Collateral Ligament One femoral attachment and two tibial attachments 2. Posterior Oblique Ligament Fibrous extensión of the distal aspect of the semimembranosus Reinforces the posteromedial aspect of the joint capsule Three fascial attachments at the knee joint 3. Deep Medial Collateral Ligament Thickened of the medial aspect of Joint capsule. Two components: Meniscofemoral and Meniscotibial

2 Biomechanics o Superficial MCL is the primary restraint to valgus laxity of the Knee o Posterior Oblique Ligament functions as an internal rotator and valgus stabilizer at between 0 and 30 degrees of knee flexion o Complementary relationship between smcl and POL o Deep MCL is valgus stabilizer at 60 degrees and provide restraint against external rotation torque between degrees. o Classification o Accordance with the amount of laxity at 30 degrees of knee flexion with a valgus applied moment: (subjective gapping of the medial joint line) Grade 1+ 3 to 5 mm Grade 2+ 6 to 10 mm Grade 3+ > 10 mm Diagnosis o Mechanism of injury involving a contact or non contact valgus force o Pain and swelling along the medial aspect of the knee (femoral, midsubstance, tibial) o Chronic injuries: Instability with cutting and pivoting maneuvers Image evaluation o Valgus stress radiographs useful for quatitive grading o Magnetic Resonance Imaging is commonly used to identify place of injured MCL, other injuries to the knee, trabecular micro fractures and bone bruises Treatment o Non Operative Favorable outcome specially femoral and midsubstance injuries Early controlled motion, protected valgus stress and external rotation (4-6 weeks) Functional rehabilitation program o Operative Repair (Acute) - Primary repair - Recover tibial attach Repair with augmentation (Acute) Reconstruction Tecniques (Chronic) Don t use hamstrings Postoperative Rehabilitation o Motion of the knee as soon as posible (High risk of arthrofibrosis) o Weight bearing is encouraged when pain has subsided o Strengthening exercises o Hinged brace for 6-8 weeks o Return to sports 6-9 months

3 Conclusions: o Not all MCL injuries are the same o Most isolated MCL injuries are still treated non-operatively o Surgical decision regarding repair tibial attach is important in acute cases with medial instability. o Repair, or repair with augment is useful in the setting of multilig. injuries o Reconstruction just for chronic cases. Case Examples 1. MCL repair tibial attach o 26 years o ACL-MCL injury during soccer game o AL/AM instability o Pain at tibial insertion MCL o ACL reconstruction + MCL repair

4 2. MCL repair o 49 years o Motorcicle accident o Dislocated Knee o ACL/PCL/MCL. No vascular injury. (video) o (video) MCL repair Joint capsule Meniscotibial Lig smcl Protect infrapatellar branch of saphenous nerve

5 (Video) 3. MCL repair & augmentation (POL) o 53 years o Construction site accident o ACL/PCL/MCL No vascular injury o Dislocated Knee (Video)

6 o Dimple sign : Buttonholding of femoral condyle through capsule o MCL repair Joint capsule Meniscofemoral Lig MPFL smcl o POL (Augmentation with Allo Tib. Ant.)

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