Combined ACL Medial Side Injuries MCL Requires Operative Repair - - PowerPoint PPT Presentation

GC Fanelli

Combined ACL Medial Side Injuries MCL Requires Operative Repair

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 570-271-6700 gregorycfanelli@gmail.com

GC Fanelli

Disclosure

• Royalties:

– Springer

• PCL Textbooks
• Multiple Ligament Injured Knee Textbooks
• Stock options: None
• Consultant:

– Biomet Sports Medicine

• PCL ACL Instrumentation System
• Speaker

– Conmed

• Speaker
• Research support: None
• Educational support: None
• Other support: None

2013

2nd Edition

2015

2nd Edition

GC Fanelli

Hughston Sports Medicine Foundation, 2000

Anatomy

Robinson, J Biomechanics, 2005

• Superficial MCL
• Deep MCL
• Posteromedial capsule

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Medial Side Biomechanics

Robinson, AJSM, 2006 Wijdicks, JBJS Am, 2009

• Posteromedial capsule

– Controls valgus, internal rotation, and posterior drawer in extension

• Superficial MCL

– Resists valgus loads all angles

• Dominant 30` to 90`

– Controls internal rotation in flexion

• Deep MCL

– Controls anterior tibial drawer of the flexed externally rotated knee – Secondary restraint to valgus stress

• Controls valgus and axial rotation

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ACL Medial Side Instability Classification

• Type A

– Increased external tibial rotation – Positive anteromedial drawer

• Type B

– Increased external tibial rotation – Positive anteromedial drawer – Valgus laxity, soft end point

• Type C

– Increased external tibial rotation – Positive anteromedial drawer – Valgus laxity, no end point

Fanelli GC, Harris JD. Techniques In Knee Surgery, 2007; 6 (2):99-105

GC Fanelli

• Lachman test
• Greater excursion
• Pivot shifting phenomenon

– More pronounced

• Anteromedial drawer test
• Valgus laxity

– 30° knee flexion – 0° knee flexion – Hyperextension

• Gait analysis

– Valgus thrust

• Drive thru sign

ACL Medial Side Injuries Physical Examination

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• Predictive value of MRI
• Nakamura, et al, AJSM,

2003

• Acute combined MCL (III) +

ACL injuries

• Correlated MCL ability to

restore valgus stability with fiber injury location

• Injuries entire length of

superficial MCL

– Residual valgus laxity despite bracing

Imaging Studies Medial Knee Ligament Injuries

GC Fanelli

• Ma, et al, Acta Orthop Scand, 2000
• Kanamori, J Orthop Sci, 2000
• Matsumoto, J Orthop Sci, 2001
• Zaffagnini, CORR, 2007
• Halinen, AJSM, 2006
• Increased forces in an ACL graft in an MCL deficient knee
• ACL reconstruction alone

– Diminishes valgus laxity

• Better intraoperative physical examination

– Medial side will not heal

• Axial rotation and valgus laxity

– Increased ACL graft forces with subsequent failure

• Results in residual laxity

– Type C to Type B to Type A – Make medial side decision before ACL reconstruction

• Surgically address

– Pathologic axial rotation, valgus laxities – Superficial MCL, capsular structures Effect of Unhealed Medial Side Laxity

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• Acute ACL MCL injury

– Grade 3 MCL

• Clearly defined MRI
• Brace medial side six weeks
• ACL + - medial side reconstruction six weeks

– Intraoperative physical examination

• Make medial side decision before ACL reconstruction

– Grade 3 MCL

• Diffuse MRI pattern

– Nakamura, AJSM, 2003

• Complex injury pattern

– Entrapped capsule

• Acute medial side repair-reconstruction within first week
• ACL reconstruction (usually 4-6 weeks after medial side surgery)

– Quiet knee, good ROM

• Surgically address

– Pathologic axial rotation, valgus laxities – Superficial MCL, capsular structures

What do I do in my practice?

GC Fanelli

High Grade Acute Medial Side Tear

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Chronic Medial Reconstruction

GC Fanelli

Chronic Medial Reconstruction

GC Fanelli

My practice trends: ACL medial side % of RACLR

• 2005

70%

• 2006

75%

• 2007

45.5%

• 2008

66.7%

• 2009

22%

• 2010

16%

• 2011

14%

• 2012

0%

• 2013

40%

• 2014

25%

• Mean 37.4% (Range 0 to 75%)

GC Fanelli 2013

2nd Edition

2015

2nd Edition

Thank you to my patients

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com