ACL With Concomitant MCL Injuries It will heal fine! Darren L. - - PowerPoint PPT Presentation

ACL With Concomitant MCL Injuries It will heal fine!

Darren L. Johnson, MD Professor and Chairman Medical Director of Sports Medicine University of Kentucky

Evaluation

Ligament Exam ACL Lachman Pivot Shift MCL Palpation: Tenderness proximal vs distal Valgus 30º: Isolates MCL Valgus 0º: Cruciate or posteromedial capsular injury Anterior Drawer at 90º of flexion in External Rotation: Translation with injury to posteromedial capsule (POL, dMCL, and semimembranous attachment)

Combined ACL/MCL Injury

• Reconstruct ACL
• MCL:Does it involve POL!!!

– ± Repair – Location

• Proximal—Good Healing
• Mid Substance—Good healing
• Distal—Stener-like lesion????

– Severity

• Grade I
• Grade II
• Grade III

MRI

Anatomy

• Posterior Oblique

Ligament

– Insertions:

• Adductor tubercle
• Tibial joint line
• Posteromedial capsule
• Semimembranosus

– Loose in flexion – IR/ER restraint

8

• Sectioned sMCL and POL showed:
• increased knee internal rotation
• increased knee external rotation
• Increased knee anterior translation
• increased knee posterior translation

• ACL reconstruction and Non Op MCL

– Six studies with 185 patients – Flexion maximized by 9 months but deficits still in 12-28% of patients – Extension deficits in 8-14% of patients – Regain both sagittal and valgus stability – Strength continues to improve up to 2 years – High Lysholm scores

• ACL reconstruction and MCL Repair

– Four studies with 109 patients – Distal MCL regain ROM sooner than proximal injuries – 38% of cases needed additional intervention to regain ROM – Valgus stability usually achieved – Strength deficit of 10% at long term follow up – Lysholm scores mean=92 – IKDC rating 70%

• 6 weeks rehab with brace to stabilize MCL
• Most Grade III MCL tears do not need

repair/reconstruction

• ACL reconstruction

– + Valgus instability – MCL Repair or MCLR

• Level I
• 47 Patients with Acute ACL/MCL tear

– 23 ACL reconstruction with MCL repair – 24 ACL reconstruction with conservative MCL treatment

• Excluded Grade I-II MCL Injuries
• 2 year follow up

Results—No Difference!!

• Lysholm
• Anterior drawer
• Valgus stress radiography
• Quadriceps function
• Single leg hop
• IKDC
• Patient reported stability

Results/Conclusion

• End range of motion is equal

– Quicker return of motion in conservatively treated MCL group

• Strength

– Quicker return of quadriceps muscle power in conservatively treatment MCL group

• Non-operative treatment of the torn MCL

ACL/MCL: Non op MCL

• Over 90% of ones I see!!!
• Post op brace
• Locked at 30 while upright
• TTWB first two weeks
• No limits on motion
• Re examine at 2 weeks
• Lock brace at 0
• Re check at 4 weeks
• Schedule ACL recon
• Confirm at EUA/Drive through

ACL/MCL Case

• 39yo female(low demand) with L knee injury after

slipping on an icy patch and tumbling down slope while skiing. She had pain and effusion in her knee, and was unable to bear weight. Seen in clinic 10 days after injury.

• 0-80deg ROM, +Lachman with no endpoint, +valgus

laxity at 30 degrees with no endpoint: Stable at 0 degrees

• MRI: Complete tear of ACL and MCL
• PLAN: L ACL reconstruction with BPTB allograft and

possible MCL repair/recon with HS autograft

Medial drive-through sign during arthroscopy

WHEN DO I REPAIR A MCL WHEN COMBINED WITH ACL ?

When the MCL tear is distal avulsion injury and opens at zero with grossly positive drive through sign at surgery (less than 5%)

My Operative Indications

• Chronic MCL/POL deficiency

– Stress X-ray in surgery to confirm – Anatomical Surgery – Reconstruction; Free Graft – Eval for mal-alignment – Laprade Technique: MCL and POL

• Combined injury & Grade III MCL/POL

– Opens at 0 and 30 degrees – May have Increased ER/IR: Stress film – Positive scope drive through sign

• Isolated Grade III MCL/POL w/ avulsion off

tibia: Stener Lesion

– Opens at 0 and 30 degrees – Increased ER – Positive scope drive through sign MM MCL

Daniel stone; PCL/MCL/POL

Thank You