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 2013 2 nd Edition • Multiple Ligament Injured Knee Textbooks • Stock options: None • Consultant: – Biomet Sports Medicine • PCL ACL Instrumentation System 2015 • Speaker 2 nd Edition – Conmed • Speaker • Research support: None • Educational support: None • Other support: None GC Fanelli
Hughston Sports Medicine Foundation, 2000 Anatomy Robinson, J Biomechanics, 2005 •Superficial MCL •Deep MCL •Posteromedial capsule GC Fanelli
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 GC Fanelli
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
ACL Medial Side Injuries Physical Examination • 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 GC Fanelli
Imaging Studies Medial Knee Ligament Injuries • 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 GC Fanelli
Effect of Unhealed Medial Side Laxity • 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 GC Fanelli
What do I do in my practice? • 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 GC Fanelli
High Grade Acute Medial Side Tear GC Fanelli
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 2015 2 nd Edition 2 nd Edition Thank you to my patients Gregory C. Fanelli, M.D. 115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 GC Fanelli gregorycfanelli@gmail.com
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