J Knee Surg 2020; 33(08): 785-791
DOI: 10.1055/s-0039-1688689
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Midterm Outcomes following Acute Repair of Grade III Distal MCL Avulsions in Multiligamentous Knee Injuries

Vishal S. Desai
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
,
Isabella T. Wu
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
,
Christopher L. Camp
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
,
Bruce A. Levy
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
,
Michael J. Stuart
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
,
Aaron J. Krych
1   Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
2   Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
› Author Affiliations
Funding None.
Further Information

Publication History

22 August 2018

18 March 2019

Publication Date:
08 May 2019 (online)

Abstract

There is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4–9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

 
  • References

  • 1 Roach CJ, Haley CA, Cameron KL, Pallis M, Svoboda SJ, Owens BD. The epidemiology of medial collateral ligament sprains in young athletes. Am J Sports Med 2014; 42 (05) 1103-1109
  • 2 Chen L, Kim PD, Ahmad CS, Levine WN. Medial collateral ligament injuries of the knee: current treatment concepts. Curr Rev Musculoskelet Med 2008; 1 (02) 108-113
  • 3 Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 1979; 61 (01) 56-62
  • 4 Hughston JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Joint Surg Am 1994; 76 (09) 1328-1344
  • 5 Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J 2006; 26: 77-90
  • 6 Naik AM, Rao SK, Rao PS. Medial collateral ligament avulsion from both tibial and femoral attachments: a case report. J Orthop Surg (Hong Kong) 2007; 15 (01) 78-80
  • 7 Varelas AN, Erickson BJ, Cvetanovich GL, Bach Jr BR. Medial collateral ligament reconstruction in patients with medial knee instability: a systematic review. Orthop J Sports Med 2017; 5 (05) 2325967117703920
  • 8 American Medical Association. Committee on the Medical Aspects of Sports, Subcommittee on Classification of Sports Injuries. Standard Nomenclature of Athletic Injuries. MI: American medical Association; 1966
  • 9 Noyes FR, Grood ES, Torzilli PA. Current concepts review. The definitions of terms for motion and position of the knee and injuries of the ligaments. J Bone Joint Surg Am 1989; 71 (03) 465-472
  • 10 Duffy PS, Miyamoto RG. Management of medial collateral ligament injuries in the knee: an update and review. Phys Sportsmed 2010; 38 (02) 48-54
  • 11 Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res 1988; (226) 103-112
  • 12 Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am 1983; 65 (03) 323-329
  • 13 Reider B, Sathy MR, Talkington J, Blyznak N, Kollias S. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med 1994; 22 (04) 470-477
  • 14 Noyes FR, Barber-Westin SD. The treatment of acute combined ruptures of the anterior cruciate and medial ligaments of the knee. Am J Sports Med 1995; 23 (04) 380-389
  • 15 Robins AJ, Newman AP, Burks RT. Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries. The effect of medial collateral ligament rupture location. Am J Sports Med 1993; 21 (01) 20-25
  • 16 Corten K, Hoser C, Fink C, Bellemans J. Case reports: a Stener-like lesion of the medial collateral ligament of the knee. Clin Orthop Relat Res 2010; 468 (01) 289-293
  • 17 Keyhani S, Mardani-Kivi M. Anatomical repair of Stener-like lesion of medial collateral ligament: a case series and technical note. Arch Bone Jt Surg 2017; 5 (04) 255-258
  • 18 Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: a clinical and anatomic study. Bone Joint J 1962; 44-B (04) 869-879
  • 19 Irrgang JJ, Anderson AF, Boland AL. , et al. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 2001; 29 (05) 600-613
  • 20 Johnson DS, Smith RB. Outcome measurement in the ACL deficient knee--what's the score?. Knee 2001; 8 (01) 51-57
  • 21 Wright RW. Knee injury outcomes measures. J Am Acad Orthop Surg 2009; 17 (01) 31-39
  • 22 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10 (03) 150-154
  • 23 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985; (198) 43-49
  • 24 Schenck Jr RC. The dislocated knee. Instr Course Lect 1994; 43: 127-136
  • 25 Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med 2005; 33 (09) 1380-1385
  • 26 Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med 2009; 37 (06) 1116-1122
  • 27 Marx RG, Hetsroni I. Surgical technique: medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res 2012; 470 (03) 798-805
  • 28 Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International Knee Documentation Committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS), knee outcome survey activities of daily living scale (KOS-ADL), Lysholm knee scoring scale, Oxford knee score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), activity rating scale (ARS), and Tegner activity score (TAS). Arthritis Care Res (Hoboken) 2011; 63 (Suppl. 11) S208-S228
  • 29 Hanley JM, Anthony CA, DeMik D. , et al. Patient-reported outcomes after multiligament knee injury: MCL repair versus reconstruction. Orthop J Sports Med 2017; 5 (03) 2325967117694818
  • 30 Kovachevich R, Shah JP, Arens AM, Stuart MJ, Dahm DL, Levy BA. Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc 2009; 17 (07) 823-829
  • 31 Mitsou A, Vallianatos P, Piskopakis N, Maheras S. Anterior cruciate ligament reconstruction by over-the-top repair combined with popliteus tendon plasty. J Bone Joint Surg Br 1990; 72 (03) 398-404
  • 32 Briggs KK, Steadman JR, Hay CJ, Hines SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med 2009; 37 (05) 898-901
  • 33 Kim SJ, Lee DH, Kim TE, Choi NH. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br 2008; 90 (10) 1323-1327
  • 34 Kitamura N, Ogawa M, Kondo E, Kitayama S, Tohyama H, Yasuda K. A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries: clinical outcomes. Am J Sports Med 2013; 41 (06) 1274-1281
  • 35 Liu X, Feng H, Zhang H. , et al. Surgical treatment of subacute and chronic valgus instability in multiligament-injured knees with superficial medial collateral ligament reconstruction using Achilles allografts: a quantitative analysis with a minimum 2-year follow-up. Am J Sports Med 2013; 41 (05) 1044-1050
  • 36 Bonadio MB, Helito CP, Foni NO. , et al. Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel. Knee Surg Sports Traumatol Arthrosc 2017; 25 (10) 3024-3030
  • 37 Bin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy 2007; 23 (10) 1066-1072
  • 38 Xu H, Kang K, Zhang J. , et al. An anatomical-like triangular-vector ligament reconstruction for the medial collateral ligament and the posterior oblique ligament injury with single femoral tunnel: a retrospective study. J Orthop Surg Res 2017; 12 (01) 96