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Arthroscopic localization of medial collateral ligament injury
Technical Note
Arthroscopic Localization of Medial Collateral Ligament Injury Heidi C. Ambrose, M.D., Peter T. Simonian, M.D., and William F. Sims, M.D.
Abstract: Injury to the medial collateral ligament has previously been assessed primarily using the clinical examination and magnetic resonance imaging. In this article, we describe an adjunct to these diagnostic tools: an arthroscopic observation to assess the specific location of the medial collateral ligament injury. Key Words: Arthroscopy—MCL diagnosis—Medial meniscus.
I
n the rare patient who requires surgical treatment of a medial collateral ligament (MCL) injury, identifying the specific location of the injury is a critical step in the surgical repair.1-3 Localization allows the surgeon to decrease the size of the incision and more rapidly access the site of injury. Common diagnostic methods of identifying the site of the damage within the MCL include the physical examination and magnetic resonance imaging. Additionally, because of the intimate relationship between the medial meniscus and the MCL, observable intra-articular changes occur in conjunction with grade III MCL injury. These changes involve disruption of the positioning of the medial meniscus relative to the medial femoral condyle and the medial tibial plateau. Often, patients with grade III MCL disruption require diagnostic arthroscopy regardless because of the high incidence of concomitant major ligamentous injuries.4 Therefore, we propose a technique here to obtain more information without increasing invasiveness or risk. TECHNIQUE In assessing the medial compartment arthroscopically, the standard arthroscopic technique for the knee
is used and standard portals are placed. After assessing all major compartments and gutters of the knee, attention is turned to the medial compartment. To optimize the view of this compartment, the knee is positioned in 10° to 30° of flexion, the tibia is externally rotated, and a valgus stress is applied. Further valgus stress will accentuate the findings we present in this article. In the presence of a grade III MCL tear, unique arthroscopic findings are often apparent. The relationship between the deep layer of the MCL and the medial meniscus mandates disruptions in one to cause disruptions in the other. This is indeed what we have seen. A tear of the MCL near the proximal femoral attachment is associated with an increased distance between the medial meniscus and the medial femoral condyle above (Fig 1). Conversely, a distal MCL tear is often associated with an increased distance between the tibial plateau and the medial meniscus (Fig 2). This increased bone-tomeniscus distance may not only suggest the location of the MCL tear, but also may indicate the severity of the tear. However, further research is needed to elucidate this.
DISCUSSION From the Department of Orthopaedic Surgery, The University of Washington, Seattle, Washington, U.S.A. Address correspondence and reprint requests to Peter T. Simonian, M.D., Department of Orthopedic Surgery, The University of Washington, Box 356500, Seattle, WA 98195, U.S.A. © 2001 by the Arthroscopy Association of North America 1526-3231/01/1705-2847$35.00/0 doi:10.1053/jars.2001.21257
The ability to arthroscopically determine the location of an MCL tear may have multiple implications. First, accurate localization of the injury may decrease the size of the necessary incision, thereby improving cosmesis of the procedure and decreasing the risk of wound complications. Because arthroscopy is fre-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: E21
1
2
H. C. AMBROSE ET AL.
FIGURE 1. (A) A proximal MCL tear creating an increased space between the superior surface of the medial meniscus and the inferior surface of the medial femoral condyle. (B) A distal MCL tear creating an increased space between the inferior surface of the medial meniscus and the superior surface of the medial tibial plateau.
FIGURE 2.
(A) Arthroscopic photograph of what is shown in Fig 1A. (B) Arthroscopic photograph of what is depicted in Fig 1B.
quently performed in conjunction with MCL repairs, there is no additional invasiveness in using this diagnostic technique. Lastly, further research is required to fully understand the correlation between the meniscal distances and the size and location of the MCL injury. This information could provide an exact localization and description of a tear before the actual MCL repair. In summary, we recommend arthroscopic evaluation of MCL injury before surgical repair as an adjunct to the clinical and imaging diagnostic tools currently in use.
REFERENCES 1. Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop 1988; 226:103-112. 2. Lundberg M, Messner K. Ten-year prognosis of isolated and combined medial collateral ligament ruptures. A matched comparison in 40 patients using clinical and radiographic evaluations. Am J Sports Med 1997;25:2-6. 3. Hillard-Sembell D, Daniel DM, Stone ML, Dobson BE, Fithian DC. Combined injuries of the anterior cruciate and medial collateral ligaments of the knee. Effect of treatment on stability and function of the joint. J Bone Joint Surg Am 1996;78:169-176. 4. Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee. Clin Orthop 1978;132:206-218.
Arthroscopic Localization of Medial Collateral Ligament Injury Heidi C. Ambrose, M.D., Peter T. Simonian, M.D., and William F. Sims, M.D.
Abstract: Injury to the medial collateral ligament has previously been assessed primarily using the clinical examination and magnetic resonance imaging. In this article, we describe an adjunct to these diagnostic tools: an arthroscopic observation to assess the specific location of the medial collateral ligament injury. Key Words: Arthroscopy—MCL diagnosis—Medial meniscus.
I
n the rare patient who requires surgical treatment of a medial collateral ligament (MCL) injury, identifying the specific location of the injury is a critical step in the surgical repair.1-3 Localization allows the surgeon to decrease the size of the incision and more rapidly access the site of injury. Common diagnostic methods of identifying the site of the damage within the MCL include the physical examination and magnetic resonance imaging. Additionally, because of the intimate relationship between the medial meniscus and the MCL, observable intra-articular changes occur in conjunction with grade III MCL injury. These changes involve disruption of the positioning of the medial meniscus relative to the medial femoral condyle and the medial tibial plateau. Often, patients with grade III MCL disruption require diagnostic arthroscopy regardless because of the high incidence of concomitant major ligamentous injuries.4 Therefore, we propose a technique here to obtain more information without increasing invasiveness or risk. TECHNIQUE In assessing the medial compartment arthroscopically, the standard arthroscopic technique for the knee
is used and standard portals are placed. After assessing all major compartments and gutters of the knee, attention is turned to the medial compartment. To optimize the view of this compartment, the knee is positioned in 10° to 30° of flexion, the tibia is externally rotated, and a valgus stress is applied. Further valgus stress will accentuate the findings we present in this article. In the presence of a grade III MCL tear, unique arthroscopic findings are often apparent. The relationship between the deep layer of the MCL and the medial meniscus mandates disruptions in one to cause disruptions in the other. This is indeed what we have seen. A tear of the MCL near the proximal femoral attachment is associated with an increased distance between the medial meniscus and the medial femoral condyle above (Fig 1). Conversely, a distal MCL tear is often associated with an increased distance between the tibial plateau and the medial meniscus (Fig 2). This increased bone-tomeniscus distance may not only suggest the location of the MCL tear, but also may indicate the severity of the tear. However, further research is needed to elucidate this.
DISCUSSION From the Department of Orthopaedic Surgery, The University of Washington, Seattle, Washington, U.S.A. Address correspondence and reprint requests to Peter T. Simonian, M.D., Department of Orthopedic Surgery, The University of Washington, Box 356500, Seattle, WA 98195, U.S.A. © 2001 by the Arthroscopy Association of North America 1526-3231/01/1705-2847$35.00/0 doi:10.1053/jars.2001.21257
The ability to arthroscopically determine the location of an MCL tear may have multiple implications. First, accurate localization of the injury may decrease the size of the necessary incision, thereby improving cosmesis of the procedure and decreasing the risk of wound complications. Because arthroscopy is fre-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: E21
1
2
H. C. AMBROSE ET AL.
FIGURE 1. (A) A proximal MCL tear creating an increased space between the superior surface of the medial meniscus and the inferior surface of the medial femoral condyle. (B) A distal MCL tear creating an increased space between the inferior surface of the medial meniscus and the superior surface of the medial tibial plateau.
FIGURE 2.
(A) Arthroscopic photograph of what is shown in Fig 1A. (B) Arthroscopic photograph of what is depicted in Fig 1B.
quently performed in conjunction with MCL repairs, there is no additional invasiveness in using this diagnostic technique. Lastly, further research is required to fully understand the correlation between the meniscal distances and the size and location of the MCL injury. This information could provide an exact localization and description of a tear before the actual MCL repair. In summary, we recommend arthroscopic evaluation of MCL injury before surgical repair as an adjunct to the clinical and imaging diagnostic tools currently in use.
REFERENCES 1. Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop 1988; 226:103-112. 2. Lundberg M, Messner K. Ten-year prognosis of isolated and combined medial collateral ligament ruptures. A matched comparison in 40 patients using clinical and radiographic evaluations. Am J Sports Med 1997;25:2-6. 3. Hillard-Sembell D, Daniel DM, Stone ML, Dobson BE, Fithian DC. Combined injuries of the anterior cruciate and medial collateral ligaments of the knee. Effect of treatment on stability and function of the joint. J Bone Joint Surg Am 1996;78:169-176. 4. Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee. Clin Orthop 1978;132:206-218.