Collateral ligament injuries : Isolated/Combined

Transcription

1 Collateral ligament injuries : Isolated/Combined Russell C. Linton, M.D. Team Orthopaedic Surgeon Mississippi State University 6/21/2013 1

2 Teaser : Who s back first? 18 yo HS senior RB Grade II MCL Never been injured before Mild swelling Potential college scholarship 18 yo HS senior OG Grade II MCL Several previous minor injuries Mild swelling Potential college scholarship In residency I was taught that 2 x grade of injury = weeks out 6/21/2013 2

3 Factors Grade of laxity Position Cutting / twisting Easier to play in brace Previous injury Swelling Bone bruises Meniscal or chondral injury Player s intelligence (can he play on the weekend without having to practice all week?) Is there anything else we re still missing? 6/21/2013 3

4 Avoid tunnel vision Many knee injuries are just sprains not requiring surgery We all know grades I, II, III etc (will review later in talk) Other factors than only grade of laxity as to when athlete can return We deal with tons of these sprains in treating athletes and the question is not if it will heal but. When will he be able to play again doc? This discussion will center on these other variables in estimating return to activity 6/21/2013 4

5 Anatomy medial MCL relatively broad and flat with large surface area of attachment Superficial MCL 11 x 1.5cm Warren and Marshall s 3 layer concept Fascia Superficial MCL Deep capsular and posterior oblique ligament Creates sandwich Fibers usually stay in touch even if torn Anterior fibers lax in extension/ tight in flexion Posterior fibers and POL lax in flexion/ tight in extension, but POL can be dynamized by pull of semimembranosis MCL not truly isometric 6/21/2013 5

6 MCL anatomy / function Some stretching and relaxation of medial fibers with normal ROM Ligament can tolerate 5% or 2mm stretch without deformation Normal internal rotation of tibia on femur as knee flexes reduces stress on MCL Warren: anterior 5 mm of superficial MCL is primary restraint to abduction Grood: superficial MCL provides 57% 5 and 78% at 25 flexion Knee position at time of injury can influence degree of injury and structures torn 6/21/2013 6

7 Anatomy lateral Ligaments more cord-like with less surface area May tear and no longer be in continuity Much more prone to need surgery Structures IT band, biceps femoris, LCL, popliteus tendon, arcuate ligament, popliteofibular ligament 6/21/2013 7

8 Lateral functions In general work with PCL to resist posterior translation, varus stress, and external rotation LCL is 1 varus stabilizer Popliteus externally rotates femur as knee flexes Biceps (dynamic) ITB anterolateral stabilizer Arcuate in posterolateral corner analogous to POL medially Popliteofibular attaches popliteus tendon to fibular head posteriorly to lateral femoral condyle to restrain ER and posterior forces 6/21/2013 8

9 Mechanism of injury Medial Can get minor sprains without direct contact (foot planted and valgus force) Larger degrees of injury usually require lateral blow Lateral Almost always associated with blow to the knee in hyperextension or varus 6/21/2013 9

10 Physical exam Hughston : sideline exam > 90% at detecting site of ligament injury Important because femoral-sided MCL sprains usually heal quicker and more predictably than tibial-sided lesions Must rule out ACL/PCL injuries Grades of laxity I : 0-4mm with solid end point (pain with stress) II : 5-9mm with end point III : 10 or more mm laxity with mushy or no good end point 6/21/

11 Medial exam Valgus stress at 0 and 30 degrees Laxity at 30 tests superficial MCL Laxity in extension suggests posterior oblique injury Gross laxity in extension suggests cruciate ligament injury 6/21/

12 Valgus stress at 30 degrees 6/21/

13 Lateral and posterolateral corner Varus stress at 30 degrees tests LCL proper External rotation at 30 and 90 degrees ( compare to uninjured side ) 30 : posterolateral corner, > 10 degrees significant 90 : if rotates indicates PCL involvement 6/21/

14 Varus stress at 30 degrees 6/21/

15 Dial test at 30 degrees 6/21/

16 Dial test 6/21/

17 1+ PCL and 1+ PLC 6/21/

18 Dial test at 90 degrees. Patient in MVA with PCL and PL corner injuries both requiring reconstruction 6/21/

19 Other factors on exam Effusion MCL sprain can be totally extracapsular and never cause an effusion Grade III might disrupt capsule and hemarthrosis may escape Leg alignment Varus / valgus 6/21/

20 Weight bearing alignment Normal mechanical axis is center of femoral head thru center of knee then ankle. Normal anatomic axis is slight valgus of femoral to tibial shaft. The mechanical axis is what s important to our discussion. 6/21/

21 Genu varus Compression increased over medial side of joint Increased tension over lateral ligaments 6/21/

22 Genu valgus Increased compression on lateral side of joint Increased stress on medial collateral ligament Remember valgus stress can tear ACL, MCL, dislocate patella etc. 6/21/

23 Who s back first? RB had varus knee and played in 2 weeks OL had valgus knee and continued to swell and have pain over MCL and lateral joint (MRI showed contusion, but medial pain was the problem) he missed 8 weeks and still plays with brace and insert 6/21/

24 Varus or valgus? No I do not order full length standing x-rays If they are on exam bed in TR and ankles touch but knees don t = varus If knees touch and ankles don t = valgus Some knees are truly straight Others are really jacked up! 6/21/

25 Alignments 6/21/

26 When do I order an MRI? In general when I think they might need surgery or if unsure of diagnosis Only 5% meniscal injury with MCL Persistent effusion after 3 days Mechanical symptoms ACL / PCL? College / pro vs. HS / recreational Grade II or more lateral or posterolateral: up to 30% with meniscal damage and more prone to require OR, therefore quick trigger 6/21/

27 Can we predict who will return first based solely on MRI? 6/21/

28 Red shirt FR OL, grade II III MCL in November, valgus knee Exam now. Still swells 6/21/

29 Severe MCL injury with distal end of ligament flipped into joint and also displaced medial meniscus 6/21/

30 Clinical exam showed isolated grade III LCL 6/21/

31 Bone bruise / chondral contusion 6/21/

32 Bone bruises Chondral contusions MRI diagnosis Injury causes loss of water from cartilage leaving it less resistant to shear MRI can see the bone bruise but can t estimate cartilage injury unless there is a break in the surface Recovery time? Worse if in major weightbearing compartment or if meniscus removed 6/21/

33 Treatment MCL (isolated) Varus knee Minimal bracing Early weight bearing Ice, ROM, closed chain quads Bike, pool running, stair master Advance to dry land jogging No agilities until no pain with valgus stress 80% strength and no or minimal effusion to play Quicker return Valgus knee Longer NWB (must be pain free medial to advance) Longer immobilizer Bigger brace + locking hinge Inserts in shoes Unloader braces don t work as well for valgus OR on grade III? Usually tibial sided Late repair or reconstruction? 6/21/

34 Acute MCL surgery? Rare but not zero Usually tibial sided injury Repair capsular ligament, POL and superficial MCL (Hughston) 6/21/

35 Any other tricks? PRP or ACP Case reports Some science suggests it may help Yes we have tried it at Mississippi State 6/21/

36 Treatment LCL Valgus knee Grade I & II should do okay with bracing Grade III may still need surgical repair or reconstruction Varus knee Prolonged NWB Prone to stretch out Grade II & III may need OR (probably reconstruction) Have had to do osteotomy in past Varus + LCL can be tough problem but LCL injuries much less common than MCL 6/21/

37 Isolated grade III LCL avulsed off fibular head 6/21/

38 Previous patient currently practicing spring football 4 months post-op with stable knee and no pain.. Not everyone is so lucky. 6/21/

39 Posterolateral corner Need to repair early or jumbled mess Rarely pure avulsions which can be repaired directly with suture anchors Mid-substance repairs, chronic, or varus knees need augmentation or reconstruction Multiple options in literature My choice usually autograft semitendinosis if local tissue inadequate Watch for nerve and also check lateral hamstring tendon Post-op no or limited weight bearing for up to 8 weeks 6/21/

40 PL surgical options IT band Biceps Free graft As a resident it was dealer s choice! 6/21/

41 LaPrade prospective study Acute repair if avulsed and can be reduced with knee in full extension Reconstruct midsubstance Main structures FCL, popliteus tendon, popliteofibular ligament Do acutely within 6 weeks Isolate and protect peroneal nerve Check biceps femoris for avulsion 6/21/

42 LaPrade More accurately identified exact anatomy of attachments of FCL and PFL to fibular head Order of inspection and repair or reconstruction important In combined lateral or posterolateral and cruciate injuries he opens laterally 1 st, identifies and tags structures prior to scope insertion and cruciate reconstruction 6/21/

43 LaPrade (surgical steps) Lateral incision First step is isolate peroneal nerve Next identify biceps femoris tendon 6/21/

44 Incision thru biceps bursa Next identify FCL attachment to fibular head and place traction suture 6/21/

45 Next identify popliteofibular ligament on posteromedial downslope of fibular styloid Can repair with suture anchor if torn off fibula May need to incorporate with reconstruction if mid substance or torn popliteus 6/21/

46 Split ITB and identify popliteus tendon and LCL attachments to femur LCL 1.4 mm proximal and 3.1mm posterior to lateral epicondyle Popliteus 18.5 mm away (many earlier procedures put both together) Recess procedure 6/21/

47 Finally identify lateral capsular ligament and possible injury there Order of repair laterally after scope and cruciate repair/ reconstruction: Femoral side Lateral meniscus Tibia side (capsule) Fibular head and styloid 6/21/

48 Lateral / PL reconstruction Autograft hamstring or allograft tissue of surgeon s choice Note fibular insertion of FCL (not straight anterior as per other authors) 6/21/

49 Fractured fibular head Pure bony avulsions can be repaired with sutures holding bone back in place 6/21/

50 Chronic MCL Five times in 23 years had to reconstruct MCL Once in young athlete ( played 4 months later ) Four used autograft semitendinosis and replicated superficial MCL and POL with good resulting stability One had MCL and MPFL laxity and used allograft ant tib to reconstruct both All 5 had valgus alignment 6/21/

51 Chronic MCL Sufficient tissue, but lax Insufficient tissue 6/21/

52 Combined instability Since perfect PCL reconstruction results are rare, I always repair the MCL and repair / augment / reconstruct the LCL or PL corner when in a combined injury My choice is the autograft quad tendon with a single tibial tunnel and 2 femoral tunnels for the PCL Since late instability can result with ACL surgery if the lateral structures are left alone, I always repair everything with this combination The real controversy is the ACL / MCL combination.. 6/21/

53 ACL / MCL More prone to arthrofibrosis and loss of motion Grade I or II MCL get motion first then do ACL alone Make sure no bucket handle meniscus that could be damaged by ROM and surgical delay (Shelbourne advocates 2 stage) Grade III is OR decision after ACL tensioned and fixed if too much valgus laxity 6/21/

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56 Surgical pearls ACL/MCL Tighten ACL with knee at 30 degrees and foot in neutral rotation If MCL repair needed place sutures but don t tie until knee taken through ROM Do not constrain the knee! Tension relieving box sutures sometimes needed Post op hinged brace may be needed, but goal is still 100% full ROM by week 6 6/21/

57 Why I hate the valgus knee Routine MCL sprains become a pain Prone to dislocate patella which ends many careers Prone to get hard to treat problems such as posterior tibial tendonitis and I think more prone to high ankle sprain More prone to ACL (pre-loaded) Always troubling lateral meniscal problems are exacerbated It means we got out recruited again (the slightly varus internally rotated knee has a mechanical advantage to run faster) 6/21/

58 Conclusions Obviously this is just the tip of the iceberg Look at the whole patient, the entire leg (varus, valgus, alta, rotation, foot, ankle, hip, etc.) This information can help predict how quick an athlete may return and who may need surgery 6/21/

59 T H A N K Y O U and. 6/21/

60 GO BULLDOGS! Good Luck at College World Series! 6/21/