Management of Knee Injuries: An Evidence
Based Update
Management and
Myths of Ligamentous
Injury
Kenneth G. Swan, Jr., M.D.
Clinical Assistant Professor
Rutgers Robert Wood Johnson Medical School
June 1, 2019
Levels of Evidence
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Knee Ligaments
• MCL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
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Knee Ligaments
• MCL – Posteromedial Corner (PMC)
• LCL
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Knee Ligaments
• MCL – Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, Anterolateral (AL) and Posteromedial (PM)
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, AL and PM
• ACL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, AL and PM
• ACL
– Anterolateral Ligament (ALL)?
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Medial Collateral Ligament (MCL)
• Superficial MCL
• Posterior oblique ligament
• Deep MCL
• Oblique popliteal ligament
• “PMC”
• [Semimembranosis]
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MCL
• Injury: valgus force, typically contact injury (~75%)
• Medial based pain
• Difficulty with WB
• If isolated injury, no effusion
• Pain/laxity to valgus stress testing (30*)
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MCL
• Injury Severity Grading
– Grade I
• MCL focal tenderness, minimal to no laxity; structures strained but intact
– Grade II
• Diffuse MCL tenderness, + laxity in 30* flexion, with endpoint; tearing of sMCL
– Grade III
• Significant tenderness and swelling, gross laxity, no endpoint at 30*, laxity in full extension, + anteromedial rotatory instability in 90* flexion; tearing of sMCL and PMC
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MCL Injury: Management
• R-I-C-E
• Protected WB prn
• Immobilization? – Animal studies show Increased
collagen mass and Improved biomechanical properties if early ROM utilized over immobilization***
MRI if severe/add’l injuries suspected
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MCL Injury: RTP
• Grade I – <1-2 weeks
• Grade II – 2-4 weeks
• Grade III – ~6 weeks
– Pending additional injuries
– ~75% have add’l injury, most commonly ACL • Kovachevich, KSSTA, 2009
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MCL Reconstruction
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MCL repair vs reconstruction
• Dong, Arthroscopy, 2015 – Level 2 study – Better objective results with reconstruction, similar subjective
scores
• Wijdicks, AJSM, 2013
– Anatomic, biomechanical study – Equivalent results between “anatomic” repair and reconstruction
• Bottom line: No high-level evidence to support
reconstruction over repair. However, many surgeons prefer repair for acute avulsions; reconstruction favored over repair in sub-acute and chronic situation
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Lateral collateral ligament (LCL)
• PLC (posterolateral corner)
– Lateral collateral ligament
– Popliteus tendon
– Popliteal fibular ligament (arcuate ligament)
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LCL/PLC
• Injury: Direct varus force and/or hyperextension injury
• Usually (~75%) in combination with cruciate injury*
• Biceps, fibular head, ITB, peroneal nerve often injured as well
• Popliteal artery
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LCL/PLC Injury
• Exam: lateral swelling and tenderness over LCL
• Laxity to varus stress in 30* flexion, and in extension (Grade III)
• + Dial test
– Prone, 30 degrees flexion, check ER
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Dial Test -- PLC
LCL/PLC Injuries: Management
• Grade I – LCL sprain; non-operative, RICE, early ROM
• Grade II – Similar to Grade I, longer recovery, Rare
• Grade III – High Energy injury
– Typically additional [major] injuries
– Needs surgery to LCL/PLC in addition to other injured structures
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LCL/PLC
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LCL/PLC Repair vs Reconstruction
• Late: >3-4 weeks; Reconstruction
• Early: <3-4 weeks – Avulsions can be repaired
– Several studies show better results with reconstruction vs repair, even in early stages, even with avulsions • 37% failure rate in repair vs 9% in reconstruction group
– Stannard, AJSM, 2005 [Level II study]
– Levy, AJSM, 2010 [Level III study]
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PLC repair?
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LCL/PLC Reconstruction
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Posterior Cruciate Ligament (PCL)
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PCL Injury
• Mechanism:
– direct blow to proximal tibia (helmet, dashboard)
– Hyperextension
– Hyperflexion
• Can go undiagnosed for years
• Often not as dramatic or symptomatic as an ACL tear
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PCL: exam
• ISOLATED PCL INJURY
– FROM; ABLE TO SLR – MAY HAVE PAIN WITH HYPEREXTENSION – LOOK FOR POSTERIOR SAG IN THE FLEXED
KNEE – + POSTERIOR DRAWER
– DON’T GET FOOLED BY “FALSE LACHMANS”
OR “FALSE ANTERIOR DRAWER”
– SHOULD NOT HAVE VARUS/VALGUS INSTABLITY
– CHECK ROTATION WITH DRAWER TESTING
(ALWAYS!) AND WITH SUPINE AND PRONE DIAL TEST
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PCL Grading
• PCL Instability Grade
– I: <5mm, still anterior to femoral condyles
– II: 5-10mm, even with femoral condyles
– III: >10 mm, posterior to femoral condyles
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PCL Injury
• Grade I – Minimal posterior translation on posterior drawer – PT
• Grade II
– Moderate posterior translation on posterior drawer – PT, expectant management, RTP in 3-4 weeks
• Grade III
– Significant posterior translation on posterior drawer – HIGH INCIDENCE OF ADDITIONAL INJURY; RARE TO HAVE
ISOLATED GRADE III PCL
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PCL Reconstruction
• Autograft vs Allograft
• Technically more demanding and dangerous than ACLR
• More often in combination with multi-ligamentous repair
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PCL Controversies
• Operative vs Non-Operative for isolated Grade III injuries
• Single bundle vs Double Bundle
• Transtibial (arthroscopic) vs Open Inlay technique
CONSISTENT LEVEL I/II DATA IS LACKING
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Anterior Cruciate Ligament (ACL)
• Relatively common injury
• 70% Non-Contact
• More common in females (~3-6x more common)
• Meniscal injuries common (~50%)
– Acute: lateral meniscus
– Chronic: medial meniscus
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ACL bundles (AM, PL)
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ACL Risk Factors
• Female Gender
• Family Hx
• Notch Width
• Posterior tibial slope
• ACL size
• Ligamentous laxity
• PRIOR ACL INJURY
• High BMI
• Jump landing mechanics
• Hormonal
• Playing Surface
Smith, SportsHealth, 2012
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ACL Risk Factors
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ACL Re-Injury
• Not uncommon to have repeat ipsilateral or contralateral ACL injury
• Rates vary from 5-30% • Allograft much higher (~4x) risk of re-injury • Highest risk is in Young, Active, Female, cutting/pivoting sport
athletes
• Shelbourne, AJSM 2009 (LEVEL II) • Paterno, AJSM 2014 (LEVEL II) • Wiggins, AJSM 2014 (LEVEL II) • Andernod, AJSM 2015 (LEVEL II)
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ACL Myths/Controversies
• “Double bundle ACLR is better than single bundle”
• “The Anterolateral Ligament is the reason why my ACL keeps failing”
• “ACL Suture Ligament Augmentation is the wave of the future”
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ACLR: Double Bundle vs Single Bundle
• Mayr, Arthroscopy, 2018 – Prospective, RCT – Level I – 53 patients; 5 year f/u – Findings:
• No difference in Subjective or Objective scores • No difference in Osteoarthritis at 5 years
• Most similar studies agree--- a few show more
objective stability with DB, but no difference in subjective scores
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Anterolateral Ligament
• ALL: Capsular expansion that runs from the lateral epicondyle to lateral tibial plateau
• Early descriptions including by Segond, 1879
• May play a role in rotatory instability, pivot shift
• ALL reconstruction in combination with ACLR now advocated by some
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• ALL Articles:
– 2000-2012: Zero
– 2012-2016: One
– 2016: 45 Articles
All Level IV or V
No RCT, No prospective
Moroz, Clin Sports Med 2018
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NY Times 2013
ALL “Expert Group” Consensus Paper, J Orthopaedic Traumatology, 2017
• Anatomic:
– The ALL is a distinct ligament – ALL in males 2x as thick as females!
• Biomechanical: – ALL is a Secondary stabilizer to internal tibial rotation and pivot shift
• Clinical: – ACL+ALL may have increased pivot shift, but confounding factors (meniscus,
increased tibial slope) not accounted for in studies
• Conclusions: ALL reconstruction or tenodesis during ACLR have NOT been shown to improve clinical outcomes or decrease ACL re-tear rates [but may be considered in some highly unstable, ligamentously lax re-tears]
• LEVEL V Opinion Paper
• “Expert Group”: 13 international surgeons, *8 paid consultants
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ACL repair with “Suture Augmentation”
• aka “Internal Bracing” or “Bridge Enhanced ACL” • Early results: 53% re-injury rate at 5yrs f/u
• Feagin, CORR, 1996
• More recently: – van Eck, AJSM, 2017; Systematic Review of poor quality studies – Suture or scaffold used to repair ACL; biologics added
– Data scant, but:
• Braided suture > Monofilament • Early > Late repair • Skeletally immature > Mature • Proximal avulsions > Mid-substance
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ACL REPAIR
• Perrone, J Orthop Res 2017 – “Bridge-enhanced” ACL repair (BEAR) with collagen scaffold
and whole blood
– Porcine model, shows equivalent biomechanical results vs autograft!
– Human trial has now begun!!
• Gagliardi, AJSM 2019 – Level III retrospective study, comparing ACL suture ligament
augmentation (SLA) [of proximal avulsions] vs QTB autograft
– Adolescents
– 49% FAILURE RATE FOR SLA vs 4.7% for QTB
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Multiligamentous Knee Injury
• Can dislocate with only one cruciate torn, but typcially multiple ligaments torn
• Can be High-, Low- or Ultra Low-Velocity
• High incidence of Peroneal Nerve Injury (~25%)
• High incidence of Popliteal Artery injury (10-30%)
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Knee Dislocation: Controversies
• Operative vs Non-operative
• Early vs Late repair/reconstruction
• Staged vs All-at-Once
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Knee Dislocation: Controversies
• Operative vs Non-operative – Lysholm scores 85 vs 67
• Early vs Late repair/reconstruction
– <3 weeks – Staged with ACL later supported in some studies
• Repair vs Reconstruction
– Reconstruction fewer failures/re-operations
» Vicenti, Injury 2019 » Systematic Review , Majority Level IV studies
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THANK YOU!!!
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References
• Wijdicks CA, Griffith CJ, Steinar J, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 2010; 92:1266-1280
• Amiel D, Akeson WH, Harwood FL, et al. Stress deprivation effect on metabolic turnover of the medial collateral ligament collagen: A comparison between nine- and 12-week immobilization. Clin Orthop Relat Res 1983;172:265-270
• Padgett LR, Dahners LE. Rigid immobilization alters matrix organization in the injured rat medial collateral ligament. J Orthop Res 1992:10:895-900
• Dong J, Wang XF, Men X, et al. Surgical treatment of acute grade III medial collateral ligament injury combined with anterior cruciate ligament injury: Anatomic ligament repair versus triangular ligament reconstruction. Arthroscopy 2015; 31:1108-1116
• Wijdicks CA, Michalski MP, Rasmussen MT, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med 2013: 41:2858-2866
• Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am J Sports Med 2010; 38: 2502-2508
• Stannard JP, Brown SL, Farris RC, et al. The posterolateral corner of the knee: Repair vs Reconstruction. Am J Sports Med 2005; 33:881-888
• Levy BA, Dajani KA, Morgan JA: Repair vs Reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 2010; 38:804-809
• Reider B. Slippery Slope. Am J Sports Med 2019; 47:273-276
• Sonnery-Cottet B, Daggett M, Fayard J et al. Anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 2017; 18:91-106
• van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament? A systematic literature review. Am J Sports Med 2017; 46:2291-2298
• Perrone GS, Proffen BL, Klapour AM, et al. Bench-to-Bedside: Bridge-Enhanced Anterior Cruciate Ligament Repair. J Orthop Res 2017; 35:2606-2612
• Gagliardi AG, Carry PM, Parikh HB et al. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med 2019; 47:560-566
• Smith HC, Vacek P, Johnson RJ, et al. Risk factors for anterior cruciate ligament injury: A review of the literature—Part 1: Neuromuscular and anatomic risk. Sports Health 2012; 4:155-161
• Smith HC, Vacek P, Johnson RJ, et al. Risk factors for anterior cruciate ligament injury: A review of the literatrue—Part 2: Hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors. Sports Health 2012; 4:69-78
• Andernord D, Desai N, Bjornsson H, et al. Predictors of contralateral anterior cruciate ligament reconstruction: a cohort study of 9061 patients with 5-year follow-up. Am J Sports Med 2015; 43:295-302
• Paterno MV, Rauh MJ, Schmitt LC, et al. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med 2014; 42:1567-1573
• Vicenti G, Solarino G, Carrozzo M, et al. Major concern in the multiligament-injured knee treatment: A systematic review. Injury 2019
• Mayr HO, Bruder S, Hube R. Single-bundle versus double-bundle anterior cruciate ligament reconstruction-5-year results. Arthroscopy 2018; 34:2647-2653
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