Evaluation and treatment of acute and chronic injuries to the capsular ligaments of the knee.

Injury to the capsular ligaments of the knee commonly occurs in conjunction with cruciate ligament injury. An untreated grade III sprain can lead to recurrent meniscal injury, failure of cruciate ligament reconstruction, and arthrosis. Careful clinical examination is necessary to identify injuries to discrete ligaments and estimate the severity of injuries not discernable on imaging studies. A classification system of capsular injury is useful to link the diagnosis to a treatment algorithm. Anatomically based surgical procedures for acute and chronic sprains of the posteromedial, anterolateral, and posterolateral capsular structures have been proven in long-term outcome studies. The goal is to restore the anatomy by repair (for an acute sprain) or capsular shift (for a chronic sprain), rather than to substitute extra-articular tendon routing.

Posterolateral reconstruction of the knee using capsular procedures for evaluation and treatment of posterolateral instability of the knee.

Posterolateral rotatory instability of the knee causes significant morbidity if unrecognized and left untreated. With both acute and chronic injuries, restoration of the normal anatomy is crucial for a good outcome. During capsular repairs, detailed knowledge of the anatomy will help the surgeon repair the pathoanatomy. To complement the direct approach, an osteotomy of the lateral femoral condyle that includes the attachments of the fibular collateral ligament and popliteal tendon allows superior visualization of the lateral meniscus and its attachments, as well as the associated deep structures. The osteotomy also permits placement of posterior capsular sutures that allow the capsular shift to tighten the injured structures. Fine-tuning the tension of these structures may be accomplished by slightly adjusting the position of the bone block as it is reattached without significantly affecting isometry. The osteotomy is not required for all reconstructions; however, it provides excellent access to the deep structures of the posterolateral corner. The capsular shift can complement the direct repair of structures and may be done as an isolated or staged procedure or in combination with other reconstructive treatment options.

The posteromedial corner of the knee: medial-sided injury patterns revisited.

BACKGROUND: Medial-sided knee injury patterns have been poorly defined in the available literature. The lack of definition can be attributed to the differing anatomic perspectives of physician authors and the functional significance they assigned to the posteromedial structures of the knee. HYPOTHESIS: Many so-called medial collateral ligament injuries can involve significant damage to the posteromedial corner structures that may not be appreciated. STUDY DESIGN: Retrospective cohort study. METHOD: The authors reviewed the charts of 93 patients (93 knees) with operatively treated isolated and combined medial-sided knee injuries and described the associated medial injury patterns. RESULTS: Ninety-nine percent of the knees were found to have an injury of the posterior oblique ligament. In the series, 70% of the knees also had an injury of the semimembranosus capsular attachment, and 30% were found to have complete peripheral detachment of the meniscus. Injury to the posterior oblique ligament was the common injury, but other sites of disruption capable of disabling this dynamic meniscocapsular complex were present. CONCLUSIONS: Before assigning function to the various posteromedial structures of the knee, we must better define medial-sided injury patterns, the purpose of the current work. From this review of medial-sided injuries in this series of patients, the authors have come to realize that a subgroup of these knee injuries involves injuries to the posteromedial structures that are under-appreciated.

Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee.

Injuries to the medial side of the knee are not always isolated injuries of the superficial medial collateral ligament. Medial-sided injuries can also involve the deep medial collateral ligament, the posteromedial corner, or the medial meniscus. Magnetic resonance imaging is a useful adjunct to the physical examination; however, the extent of medial-sided injuries is frequently underappreciated on these images. An understanding of the anatomy and biomechanics of the medial side of the knee and a thorough physical examination aids the physician in determining the full extent of injury and helping the physician to treat each unique injury pattern.