Multiple knee ligament tear: Magnetic Resonance imaging diagnosis

The rupture of the anterior cruciate ligament is common during physical activities; however, when associated with a multiple ligament injury, it represents an uncommon condition. The diagnosis of this injury is commonly delayed or missed. Consequently, the incidence of this injury may in fact be higher than reported. We present a case of a 27-year-old man with complete tear of the anterior cruciate ligament and of the medial collateral ligament and partial tear of the posterior cruciate, lateral collateral and patellar ligaments treated surgically.

A ruptura do ligamento cruzado anterior é comum durante atividades físicas; entretanto, quando associada a lesão ligamentar múltipla, representa uma condição incomum. O diagnóstico desta lesão é comumente tardio ou esquecido. Consequentemente, a incidência desta lesão pode de facto ser superior à relatada. Apresentamos o caso de um homem de 27 anos com ruptura completa do ligamento cruzado anterior e do ligamento colateral medial e ruptura parcial dos ligamentos cruzado posterior, colateral lateral e patelar tratados cirurgicamente.

La rotura del ligamento cruzado anterior es común durante las actividades físicas; sin embargo, cuando se asocia con una lesión de múltiples ligamentos, representa una condición poco común. El diagnóstico de esta lesión comúnmente se retrasa o se pasa por alto. En consecuencia, la incidencia de esta lesión puede ser mayor de lo informado. Presentamos el caso de un varón de 27 años con rotura completa del ligamento cruzado anterior y del ligamento colateral medial y rotura parcial de los ligamentos cruzado posterior, colateral lateral y rotuliano tratados quirúrgicamente.

Stress changes of knee joint with different degrees of medial collateral ligament injury / 中国组织工程研究

BACKGROUND:The incidence of medial collateral ligament injuries in the knee joint is easy to lead to secondary meniscus and cartilage damage,and long-term chronic damage can lead to the occurrence of osteoarthritis.At present,there are few studies on the mechanics of meniscus and articular cartilage injury caused by medial collateral ligament rupture. OBJECTIVE:To investigate the effect of different degrees of medial collateral ligament injury on the biomechanics of meniscus and cartilage of knee joint. METHODS:The CT and MRI examinations of the knee joint of a healthy volunteer were performed to obtain the image data.The scanning data were imported into Mimics,Geomagic,and Solidworks software in turn.After registration and fusion,a 3D model of normal knee joint was established.On this basis,models of medial collateral ligament injury in different degrees of knee joint were simulated,which were divided into four groups,including:(1)medial collateral ligament was intact;(2)deep medial collateral ligament fracture;(3)superficial medial collateral ligament fracture;(4)complete rupture of medial collateral ligament.Finally,Ansys software was introduced to apply three modes of loads to the knee joint:(1)10 N·m valvaration torque was applied to the top of the femur.(2)A 4 N·m internal torque was applied to the top of the femur.(3)A 4 N·m external torque was applied to the top of the femur.The effects of four groups of models on knee biomechanics under different loads were analyzed. RESULTS AND CONCLUSION:(1)In the extension position of the knee joint,when a 10 N·m valgus torque was applied to the knee joint,the overall stress of the posterolateral meniscus increased with different degrees of medial collateral ligament injuries,while the stress of the articular cartilage did not change significantly.The peak stress of the posterolateral meniscus increased significantly with superficial medial collateral ligament rupture.(2)In the knee extension position,when a 4 N·m internal rotation torque was applied to the knee joint,the overall stress of the medial and lateral meniscus increased after different degrees of medial collateral ligament injury.When superficial medial collateral ligament rupture occurred,the peak stress of the meniscus shifted from the anterior horn of the medial meniscus to the anterior horn of the lateral meniscus.(3)In the knee extension position,applying a 4 N·m external rotation torque to the knee joint,the peak stress of the posterolateral meniscus increased more significantly than that of the medial meniscus,and the stress of the articular cartilage changed less.(4)These results show that the risk of meniscus injury secondary to superficial medial collateral ligament rupture is much higher than that of deep medial collateral ligament rupture when the knee is in extension,and the lateral meniscus is more vulnerable to injury than the medial meniscus.Both superficial medial collateral ligament and deep medial collateral ligament play an important role in the rotational stability of the knee joint.

Modified versus traditional open wedge high tibial osteotomy for varus knee osteoarthritis / 中华创伤骨科杂志

Objective:To compare the clinical efficacy between modified open wedge high tibial osteotomy (MOWHTO) versus traditional open wedge high tibial osteotomy (TOWHTO) for varus knee osteoarthritis (KOA).Methods:A retrospective study was conducted to analyze the 50 patients (60 knees) with varus KOA who had received high tibial osteotomy at Department of Sports Medicine, The Affiliated Hospital of Qingdao University between September 2019 and December 2020. The patients were divided into 2 groups according to different ways of osteotomy: a traditional group and a modified group. In the traditional group subjected to TOWHTO, there were 25 cases (30 knees); in the modified group subjected to MOWHTO, there were 25 cases (30 knees). In MOWHTO, the bone block attached to the medial collateral ligament (MCL) of the knee was first chiseled at the MCL insertion before osteotomy to reduce excessive stripping of the MCL in the osteotomy area, and then the bone fragment attached to the MCL was filled into the osteotomy area to increase bone filling and bone coverage after the alignment of the lower limb was corrected. The hip-knee-ankle angle (HKAA), medioproximal tibial angle (MPTA), and joint line convergence angle (JLCA) were measured preoperatively and at 18 months postoperatively in both groups to evaluate correction of the alignment of the lower limb. Fracture healing time, bone loss in the osteotomy area, Hospital for Special Surgery (HSS) knee score and visual analogue scale (VAS) were recorded to evaluate the postoperative efficacy.Results:There was no statistically significant difference between the TOWHTO and MOWHTO groups in the general clinical data before operation, showing comparability ( P>0.05). At 18 months after operation, HKAA was (179.1° ± 1.1°) in the TOWHTO group and (179.3° ± 0.7°) in the MOWHTO group while MPTA was (91.9° ± 0.4°) in the TOWHTO group and (91.9° ± 0.4°) in the MOWHTO group, showing no statistically significant difference between the 2 groups ( P>0.05) but a significant difference between preoperation and postoperation in each group ( P<0.05). At 18 months after operation, JLCA was (1.8° ± 0.4°) in the TOWHTO group, significantly larger than that in the MOWHTO group (1.5° ± 0.4°), HSS score was 81.5 (79.5, 83.0) points in the TOWHTO group, significantly lower than that in the MOWHTO group [85.0 (82.5, 87.5) points], and VAS was 1.8 (1.6, 2.0) points in the TOWHTO group, significantly higher than that in the MOWHTO group [1.5 (1.5, 2.0) points] (all P<0.05). At 18 months after operation, the preoperative JLCA was significantly improved in both groups ( P<0.05). The time required for a fracture healing score higher than 4 points was (3.3 ± 0.6) months in the TOWHTO group and (4.5 ± 0.9) months in the MOWHTO group, and the rate of bone loss in the osteotomy area was 20% in the TOWHTO group (6/30) and 0 (0/30) in the MOWHTO group, both showing a significant difference between the 2 groups ( P<0.05). Conclusions:Both TOWHTO and MOWHTO can effectively treat varus KOA. MOWHTO is more effective in promoting bone healing in the osteotomy area, reducing bone defects in the osteotomy area and improving knee function.

Correlation analysis for the lateral condylar tibial plateau fracture and complete medial collateral ligament rupture / 中华骨科杂志

Objective:To investigate the relationship between the CT images of a lateral condylar tibial plateau fractures and complete medial collateral ligament (MCL) injury.Methods:Data of 59 patients with lateral condylar fracture of tibial plateau complicated with MCL injury admitted to Tianjin Hospital from January 2020 to November 2021 were collected, including 32 males and 27 females, aged 42.4±12.3 years (range, 19-65 years), there were 26 cases of extension injury and 33 cases of flexion injury. The patients were separated into two groups: those with partial MCL injury and those with total rupture based on preoperative MR examination and intraoperative valgus stress test following fracture fixation. According to the ABC fracture classification of lateral condyle tibial plateau proposed by Sun et al., the fracture locations were determined on CT images, and the lateral plateau collapse depth (LPD) was measured. The relationship between LPD and MCL complete rupture was analyzed by receiver operating characteristic (ROC) curve.Results:Among 59 patients with lateral condylar tibial plateau fracture and MCL injury, 42 had partial injuries and 17 had complete ruptures. According to the ABC fracture classification, there were 26 cases of extension injury (involving area A), 21 cases of AB type, and 5 cases of ABC type; and 33 cases of flexion type injury, 19 cases of B type, 12 cases of BC type, and 2 cases of C type. All the 17 cases of MCL complete fracture occurred in extension injury, including type AB (14 cases) and type ABC (3 cases). The difference between the mean LPDs of the MCL full rupture group and the partial injury group was not statistically significant ( t=0.11, P=0.567), and the mean LPDs of both groups were 11.7±5.3 mm (range, 4.3-28.1 mm) and 11.5±4.8 mm (range, 3.8-23.6 mm), respectively. The area under the curve (AUC) of the ROC curve analysis was 0.504, and there was no statistical correlation between lateral platform collapse depth and MCL injury. Among the 26 patients with extensional injury area, MCL was completely ruptures in 17 cases and partially injury in 9 cases, LPD was 11.7±5.3 mm (range, 4.3-28.1 mm) and 6.6±1.8 mm (range, 3.8-9.4 mm), respectively, and the difference was statistically significant ( t=3.57, P=0.009). The best predictive cut-off value of LPD was 7.25 mm, the sensitivity was 88.2%, the specificity was 77.8%, and the AUC was 0.868. Conclusion:When the lateral condyle fracture of the tibial plateau is located in the extensional injury area (involving the A area in the ABC fracture classification) and the LPD measured on the CT image is greater than 7.25 mm, the complete rupture of the MCL should be considered. Clinical MCL repair is required after the fracture fixation surgery for improved surgical outcomes.

Anatomical Study of the Medial Region of the Knee: Qualitative, Quantitative Analysis and Description of the Anterior Oblique Ligament / Estudo anatômico da região medial do joelho: Análise qualitativa, quantitativa e descrição do ligamento oblíquo anterior

Abstract Objective To describe all ligamentous, capsular, tendinous and bone landmarks structures of the medial region of the knee, as well as a new ligamentous structure identified in a series of anatomical dissections of cadaveric specimens. Methods Twenty cadaver knees were dissected to study the medial compartment. The main structures of this region were identified during dissection. The morphology of the structures and their relationship with known anatomical parameters were determined both qualitatively and quantitatively. The collected data were analyzed and interpreted using descriptive statistics. Results In the dissection of all specimens, all ligamentous structures previously described in the anatomical study of the medial part of the knee were identified, and objective measures that can help as parameters for surgical ligament reconstruction were identified. When dissecting the medial collateral ligament, a bony prominence immediately distal to its proximal tibial insertion was observed and described, as well as a bursa below the ligament, in which it was not inserted. We also described a ligamentous structure with extracapsular location, originated anteriorly to the medial epicondyle and following obliquely towards the tibia. These structures were named, respectively, interinsertional tubercle, interinsertional bursa and anterior oblique ligament. Conclusion In addition to the description and measurement of the structures and parameters already existing in the anatomical study of the medial part of the knee, it was possible to describe three new structures not yet described in the literature: the interinsertional tubercle, the interinsertional bursa, and the anterior oblique ligament. These structures were found in all dissections performed.

Resumo Objetivo Descrever todas as estruturas ligamentares, capsulares, tendinosas e marcos ósseos da região medial do joelho, assim como uma nova estrutura ligamentar identificada em uma série de dissecções anatômicas de espécimes cadavéricos. Métodos Vinte joelhos de cadáveres foram dissecados para estudar o compartimento medial. As principais estruturas dessa região foram identificadas durante a dissecção. A morfologia das estruturas e sua relação com parâmetros anatômicos conhecidos foram determinados tanto de forma qualitativa quanto de forma quantitativa. Os dados coletados foram analisados e interpretados por meio de estatística descritiva. Resultados Na dissecção de todos os espécimes, foram identificadas todas as estruturas ligamentares já descritas anteriormente no estudo anatômico da porção medial do joelho, e foram realizadas medidas objetivas que podem auxiliar como parâmetros para a reconstrução ligamentar cirúrgica. Foram observados e descritos, ainda, ao se desprender o ligamento colateral medial superficial, uma proeminência óssea imediatamente distal à sua inserção tibial proximal, uma bursa abaixo do ligamento, na qual o mesmo não se mostrava inserido, assim como uma estrutura ligamentar localizada extracapsularmente e com origem na face anterior do epicôndilo medial, seguindo obliquamente em direção à tíbia, aos quais foram dados os nomes, respectivamente, de tubérculo interinsercional, bursa interinsercional e ligamento oblíquo anterior. Conclusão Além da descrição e medida das estruturas e parâmetros já existentes no estudo anatômico da porção medial do joelho, foi possível a descrição de três novas estruturas: o tubérculo interinsercional a bursa interinsercional e o ligamento oblíquo anterior, ainda não descritos na literatura. Essas estruturas foram encontradas em todas as dissecções realizadas.

Imaging Findings of Knee Trauma on Magnetic Resonance Imaging

Background: Knee is one of the major joints involved in kinesis. With increasing involvement in sports related activities especially in young people, Trauma related knee pathologies have increased. An accurate diagnosis regarding the type and extent of injuries is essential for early operative as well as non-operative treatment. Methods:This prospective study included total of 82 cases. The patients were referred to the department of Radiodiagnosis from indoor and outdoor departments of Guru Nanak Dev Hospital, Amritsar with suspicion of internal derangement of the knee and with history of knee trauma.Results:The most common age group involved was young males between 15-34 years. In all age groups most of the patients were males. Most common ligament to be injured was Anterior Cruciate Ligament (ACL). Partial tears were more common than complete tears. Posterior Cruciate Ligament (PCL) tears were less common. Medial Collateral Ligament (MCL) tears outnumbered Lateral Collateral Ligament (LCL) tears and grade 2 tears were more common in both. Among the meniscal injuries Medial Meniscus (MM) tears were more common than LM and grade 3 signal was more common in both. Most of the patellar retinaculum injuries were associated with Anterior Cruciate Ligament ACL tears.Conclusions:Post-traumatic pre-arthroscopic MR imaging evaluation has proved to be cost-effective. MRI is an accurate imaging modality complementing the clinical evaluation and providing a global intra-articular and extra-articular assessment of the knee.

Comparison of the effect of medial open wedge high tibial osteotomy for moderate and severe knee osteoarthritis / 中华骨科杂志

Objective:To investigate the effect of medial open wedge high tibial osteotomy (HTO) on moderate and severe medial compartmental knee osteoarthritis.Methods:This study retrospectively reviewed patients treated with medial open wedge HTO between January 2017 and January 2019. All cases were followed up for more than 2 years. There were 28 patients with severe osteoarthritis, including 11 males and 17 females, aged 56.36±5.06 years. There were 32 patients with moderate osteoarthritis, including 12 males and 20 females, aged 54.16±6.3 years. Kellgren-Lawrence (K-L) grading, hip-knee-ankle angle (HKA), weight bearing line (WBL) ratio, joint line convergence angle (JLCA), medial joint space (MJS), posterior tibial slope (PTS), medial meniscus extrusion (MME) and medial meniscus extrusion ratio (MMER) were evaluated on radiographs before and 2 years after surgery. The International Cartilage Repair Society (ICRS) of the cartilage of medial femoral condyle (MFC) and medial tibial condyle (MTC) were evaluated under arthroscopy. The clinical outcomes were assessed by the Western Ontario and McMaster University (WOMAC) score, visual analogue scale (VAS) and the degree of medial collateral ligament (MCL) pseudo-relaxation. Predictors of MCL pseudo-relaxation were screened by binary logistic regression analysis.Results:K-L grading, HKA, WBL ratio and MJS improved in both groups after surgery, with no statistical significance between groups ( P>0.05). The postoperative JLCA was improved, whereas MME and MMER were not. And the severe group was higher than the moderate group before and after surgery ( P<0.05). Cartilage of MFC: in the severe group, 2 cases of ICRS 3 grade, 26 of 4 grade improved to 11 of 2 grade, 12 of 3 grade, 5 of 4 grade; in the moderate group, 12 cases of ICRS 2 grade, 18 of 3 grade, 2 of 4 grade improved to 30 of 2 grade, 2 of 3 grade. Cartilage of MTC: in the severe group, 2 cases of ICRS 3 grade, 26 of 4 grade improved to 17 of 2 grade, 8 of 3 grade, 3 of 4 grade; in the moderate group, 11 of 2 grade, 8 of 3 grade, 3 of 4 grade improved to 27 of 2 grade, 5 of 3 grade. The postoperative WOMAC score of the severe group improved from 50.71±8.07 to 3.86±1.84, while in the moderate group it improved from 44.09±6.63 to 3.34±2.24. The postoperative VAS score of the severe group decreased from 7.14±1.21 to 3.34±2.24, whereas it decreased from 6.38±1.24 to 0.44±0.62 in the moderate group ( P<0.05). There was no significant difference between the postoperative groups ( P>0.05). In the severe group, the degree of pseudo-relaxation of the MCL improved from preoperative 25 of I degree, 3 of II degree to postoperative 28 of 0 degree at the 0° position, and from 25 of I degree, 3 of II degree to 24 of 0 degree, 4 of I degree at 30° position ( P<0.05). In the moderate group, the degree of pseudo-relaxation of the MCL improved from preoperative 31 of 0 degree, 1 of I degree to postoperative 32 of 0 degree at the 0° position, and from 28 of 0 degree, 4 of I degree to 32 of 0 degree at the 30° position ( P<0.05). JLCA ( OR=0.08, 95% CI: 0.007, 0.948, P=0.045), MME ( OR=0.11, 95% CI: 0.100, 1.32, P=0.082) and MMER ( OR=0.66, 95% CI: 0.422, 1.030, P=0.067) were independent predictors of MCL pseudo-relaxation (the difference was statistically significant at P<0.10). Conclusion:Medial open wedge HTO has significant short-term clinical effect on the treatment of moderate and severe medial compartmental knee osteoarthritis, which can effectively relieve pain symptoms, improve joint function, and restore medial knee stability. Preoperative large JLCA, MME and MMER indicate pseudo-relaxation of the MCL.

Prevalencia de lesión del ligamento colateral medial de la rodilla valorada por resonancia magnética / Prevalence of injury of the medial collateral ligament of the knee assessed by magnetic resonance

Resumen: Introducción: El ligamento colateral medial (LCM) es uno de los principales estabilizadores de la rodilla, pero su lesión se presenta en conjunto con otras lesiones ligamentarias. Objetivo: Determinar la prevalencia de lesiones del LCM por resonancia magnética, sus grados y lesiones asociadas en nuestra institución. Material y métodos: Estudio retrospectivo de Enero a Abril de 2018, se evaluaron resonancias magnéticas de rodilla donde se presentó lesión del LCM para evaluar grado y tipo de lesiones asociadas. Resultados: Se incluyeron 368 estudios, prevalencia de lesión aislada del LCM de 3.07%, una grado I y una grado II, la prevalencia de lesiones de LCM concomitantes fue de 17.66%, grado I (75%), grado II (15%) y grado III (3%). Las lesiones asociadas fueron lesión del menisco medial (46.15%), lesión del ligamento cruzado anterior (30.7%), contusión ósea aislada (18.46%), lesiones condrales (37.58%), lesión de vasto medial (14.51%), lesión del retináculo medial patelar (14.51%), lesión del vasto lateral (9.23%), lesión del ligamento cruzado posterior (6.15%), lesión del menisco lateral (4.61%), tenosinovitis banda iliotibial (4.61%), fractura de avulsión de la faceta medial (3.07%), tenosinovitis de la Pes Anserinus (3.07%). Conclusión: Prevalencia de 17.66% de lesiones del LCM en nuestro hospital por resonancia magnética, predominan los dos primeros grados con un espectro amplio de lesiones asociadas de la rodilla.

Abstract: Introduction: The medial collateral ligament (MCL) is one of the main stabilizers of the knee, but its injury occurs in conjunction with other ligaments. Objective: To determine the prevalence of MCL lesions by magnetic resonance imaging, their degrees and associated lesions in our institution. Material and Methods: Retrospective study from January to April 2018 where KNEE MRIs were evaluated where the MCL lesion was presented to evaluate the degree and type of associated injuries. Results: We included 368 studies, prevalence of isolated MCL lesion of 3.07%, grade I and grade II, prevalence of concomitant MCL lesions was 17.66% grade I (75%), grade II (15%) and grade III (3%). Associated injuries were medial meniscus injury (46.15%), anterior cruciate ligament injury (30.7%), isolated bone contusion (18.46%), chodral injuries (37.58%), medial vastus injury (14.51%), patellar medial retinacular injury (14.51%), vastus lateral injury (9.23%), posterior cruciate ligament injury (6.15%), lateral meniscus injury (4.61%), iliotibial band tenosynovitis (4.61%), medial facet avulsion fracture (3.07%), Pes Anserine tenosynovitis (3.07%). Conclusion: Prevalence of 17.66% of the MCL injuries in our hospital by magnetic resonance, the first 2 degrees predominate, with a wide spectrum of associated knee injuries.

A comparative immunohistochemical and quantitative study of the epiligament of the medial collateral and anterior cruciate ligament in rat knee / Estudio inmunohistoquímico y cuantitativo del epiligamento del ligamento colateral medial y cruzado anterior en rodilla de rata

SUMMARY: The aim of the present study was to evaluate the importance of the epiligament for the difference in the healing potential of the knee anterior cruciate and medial collateral ligament. To do so, we compared the structure of the anterior cruciate and the medial collateral ligament and evaluated the differences in the expression of collagen types I, III and V in a rat knee. We have also conducted a comparative quantitative analysis of the number of cells per mm2 in the two ligaments. Tissue samples were obtained from the anterior cruciate and medial collateral ligament of 10 knee joints taken from five 8-month-old Wistar rats. We used standard hematoxylin and eosin staining, in addition to immunohistochemical staining with monoclonal antibodies against collagen types I, III and V. A semi-quantitative analysis of the expression was made through ImageJ, while Student's T-test was used for the statistical analysis. Our results showed higher expression of all collagen types in the epiligament, compared to the ligament proper and difference in the expression between the medial collateral and the anterior cruciate ligament in favor of the first. We also reported a statistically significant difference in the number of cells per mm2 between the two ligaments and their epiligaments. Our findings show a higher number of cells and a stronger expression of certain collagen types in the epiligament of the medial collateral compared to the anterior cruciate ligament, which may be related to the difference in their healing potential.

RESUMEN: El objetivo del presente estudio fue evaluar la importancia del epiligamento para la diferencia en el potencial de curación del ligamento cruzado anterior y colateral medial de la rodilla. Comparamos la estructura del ligamento cruzado anterior y el ligamento colateral medial y evaluamos las diferencias en la expresión de los tipos de colágeno I, III y V en una rodilla de rata. También se realizó un análisis cuantitativo comparativo del número de células por mm2 en los dos ligamentos. Se obtuvieron muestras de tejido del ligamento cruzado anterior y colateral medial de 10 articulaciones de rodilla tomadas de cinco ratas Wistar de 8 meses de edad. Utilizamos tinción estándar con hematoxilina y eosina, además de tinción inmunohistoquímica con anticuerpos monoclonales contra colágeno tipo I, III y V. Se realizó un análisis semicuantitativo de la expresión mediante ImageJ, mientras que para el análisis estadístico se utilizó la prueba T de Student. Nuestros resultados mostraron una mayor expresión de todos los tipos de colágeno en el epiligamento, en comparación con el ligamento y una diferencia en la expresión entre el ligamento colateral medial y el ligamento cruzado anterior. También informamos una diferencia estadísticamente significativa en el número de células por mm2 entre los dos ligamentos y sus epiligamentos. Nuestros hallazgos muestran un mayor número de células y una expresión mayor de ciertos tipos de colágeno en el epiligamento colateral medial en comparación con el ligamento cruzado anterior, lo que puede estar relacionado con la diferencia en su potencial de curación.

Efficacy of arthroscopic anchor fixation of medial collateral ligament combined with anterior and posterior cruciate ligament reconstruction in the treatment of type KD-IIIM dislocation of knee joint / 中华创伤杂志

Objective:To compare the clinical effect of anchor fixation of medial collateral ligament（MCL）and non-repaired treatment combined with arthroscopic anterior and posterior cruciate ligament reconstruction in the treatment of type KD-IIIM（Schenck classification）dislocation of knee joint.Methods:A retrospective case-control study was conducted to analyze the clinical data of 41 patients with type KD-IIIM dislocation of the knee joint admitted to Xi'an Honghui Hospital of Xi'an Jiaotong University from September 2015 to September 2017. There were 26 males and 15 females，with the age range of 15-62 years［（37.7±13.9）years］. A total of 21 patients were treated by arthroscopic anterior and posterior cruciate ligament reconstruction and anchor fixation of MCL（repaired group）and 20 patients by arthroscopic anterior and posterior cruciate ligament reconstruction without MCL repair（non-repaired group）. The perioperative complications were observed. Comparisons between the two groups were made before operation，4 months after operation and at the last follow-up in terms of Lysholm score，International Knee Documentation Committee（IKDC）score，Visual Analogue Scale（VAS）and range of motion of joint flextion and extension. The medial opening distance of stress X-ray of lower limbs was also observed at the last follow-up.Results:All patients were followed up for 48-66 months［（54.4±5.1）months］. No perioperative complications were noted. The Lysholm score，IKDC score，VAS and range of motion of joint flextion and extension showed no statistical differences between the two groups before operation（ P>0.05），and all were improved from the preoperative level at 4 months after operation and at the last follow-up（ P<0.05）. The Lysholm score in repaired group were（69.7±5.1）points and（83.8±4.9）points at 4 months after operation and at the last follow-up，significantly higher than those in non-repaired group［（61.0±5.5）points and（74.6±6.0）points］（ P<0.05）. The IKDC score in repaired group was（71.8±4.0）points at 4 months after operation，significantly higher than that in non-repaired group［（71.1±3.9）points］（ P<0.05）. The IKDC score in repaired group was（82.3±5.1）points at the last follow-up，similar with that in non-repaired group［（83.2±4.0）points］（ P>0.05）. The VAS in repaired group was（2.5±0.6）points at 4 months after operation，significantly decreased in comparison with（3.2±1.2）points in non-repaired group（ P<0.05）. The VAS in repaired group was（2.0±1.4）points when compared to（2.2±1.3）points in non-repaired group at the last follow-up（ P>0.05）. The range of motion of joint flextion and extension in repaired group was（107.6±6.9）° and（125.9±7.8）° at 4 months after operation and at the last follow-up，significantly increased in comparison with（89.6±4.0）° and（120.9±5.2）° in non-repaired group（ P<0.05）. The medial opening distance in repaired group was（2.3±0.2）mm at the last follow-up，significantly decreased when compared to（3.1±0.2）mm in non-repaired group（ P<0.05）. Conclusion:For type KD-IIIM knee dislocation，arthroscopic anchor fixation of MCL or without MCL repair combined with anterior and posterior cruciate ligament reconstruction are both effective in satisfactory functional recovery，but MCL repair contributes to earlier function recovery，faster pain relief and more reliable joint stability.

Treatment of iatrogenic injury to medial collateral ligament in total knee arthroplasty / 中华创伤骨科杂志

Objective:To explore the treatment of iatrogenic injury to the medial collateral ligament (MCL) in total knee arthroplasty (TKA).Methods:From January 2009 to December 2016, 14 patients were treated at Department of Arthropathy, Zhengzhou Orthopedics Hospital for iatrogenic MCL injury in primary TKA (injury group). They were 3 males and 11 females with an age of (72.6±3.9) years. The MCL injury was body rapture in 9 cases and avulsion of femoral insertion in 5 ones. Interlacing suture was used for body rapture and reparative reconstruction with wire anchors or nails was performed for avulsion of femoral insertion. A restrictive condylar prosthesis was used instead in the 4 patients whose medial stability failed to be restored after repair of body rapture. A control group of 21 cases was enrolled who had suffered from no iatrogenic MCL injury in primary TKA at the corresponding period. There were 5 males and 16 females with an age of (73.2±3.9) years. The 2 groups were compared in terms of American Knee Society Score (KSS) and knee flexion.Results:There was no significant difference between the 2 groups in preoperative general data, showing comparability between groups ( P>0.05). The injury group was followed up for 18 to 36 months (mean, 33 months). Joint loosening was observed at 18 months after operation in 3 patients with nonrestrictive prosthesis who had to receive secondary revision. At the 36-month follow-up of the remaining 11 patients, normal knee extension and flexion was observed, the stress test of valgus showed no inner relaxation, their KSS increased significantly from preoperative 50.0±22.7 to 93.3±4.7, and their knee flexion was improved significantly from 90.4°±10.3° to 110.7°±8.8° ( P<0.05). There were no significant differences in KSS score or knee flexion between the 2 groups at 3, 6, 12 or 36 months after operation ( P>0.05). Conclusion:Iatrogenic MCL injury in primary TKA should be repaired and reconstructed by one-stage surgery because the patients can achieve curative results similar to those for the patients free from iatrogenic MCL injury in primary TKA.

Application of pie-crusting technique of deep medial collateral ligament under arthroscopy in repairing posterior horn of medial meniscus tears / 中国骨伤

OBJECTIVE@#To explore effectiveness and safety of an inside-out, arthroscopic deep medial collateral ligament pie-crusting release in treating posterior horn of medial meniscus (PHMM) tear in tight medial tibiofemoral compartment of knee joint.@*METHODS@#From January 2016 to December 2017, 61 patients (61 knees) were underwent arthroscopic partial meniscectomies for PHMM tear in tight medial tibiofemoral compartment of knee joint, who were divided into valgus group and pie-crusting group according to exposure of PHMM region . There were 28 patients in valgus group, including 12 males and 16 females aged from 27 to 60 years old with an average age of (35.75±7.57) years old;who were performed conventional valgused knee to exporsure PHMM region. There were 33 patients in pie-crusting group, including 15 males and 18 females aged from 26 to 58 years old with an average age of (36.06±7.93) years old;who were treated with inside-out, arthroscopic deep MCL pie crusting release technique with MM-Ⅱ meniscus suture package (Smith & Nephew). Operation time, preoperative and postopertaive Lysholm score of knee joint, injury of MCL between two groups were recorded and compared.@*RESULTS@#All patients were followed up from 12 to 18 months with an average of (15.19±2.22) months. The incisions were healed at stageⅠ. There were no statistical difference in anatomical classification of PHMM between two groups(@*CONCLUSION@#The inside-out, arthroscopic deep MCL pie-crusting release for the treatment of posterior horn of medial meniscus tear in tight medial tibiofemoral could expand working apace, shorten operation time, reduce injury to MCL and obtain good clinical efficacy.

Comparative study on posterior cruciate ligament reconstruction with autologous hamstring tendon and LARS artificial ligament in the treatment of KD-Ⅲ-M knee dislocation / 中国骨伤

OBJECTIVE@#To observe the curative effect of one-stage reconstruction of anterior cruciate ligament(ACL), posterior cruciate ligament (PCL) and medial collateral ligament (MCL) in patients with KD-Ⅲ-M knee injury, and to compare the operation time, hospitalization cost and curative effect after arthroscopic reconstruction of PCL with LARS artificial ligament and autogenous hamstring tendon, ACL reconstruction with autogenous hamstring tendon and MCL repair combined with limited incision.@*METHODS@#From March 2016 to January 2019, a total of 36 patients met the criteria of this study. Twenty patients in group A were treated with autogenous hamstring tendon reconstruction of ACL and PCL and repair of MCL, including 17 males and 3 females, with an average age of (34.7±9.2) years old. Sixteen patients in group B with LARS artificial ligament reconstruction of PCL, with an autogenous hamstring tendon reconstruction of PCL and MCL repair as before as group B, including 15 males and 1 female, with an average age of (36.8±8.6) years old. The operation time, hospitalization time and total hospitalization cost were compared between the two groups. The preoperative and postoperative functions of the two groups were evaluated by Hospital for Sepcial Surgery (HSS) score and Lysholm score respectively, and the curative effects were compared within and between groups.@*RESULTS@#All the patients in the two groups were followed up for at least 1 year. There were no complications such as infection and poor wound healing in both groups. There was significant difference in operation time between (120.25±9.55) min in group A and (106.63±8.85) min in group B (@*CONCLUSION@#There was no significant difference in the average hospitalization days between the two groups, but the operation time in group A was longerthan that in group B, and the hospitalization cost in group B was higher than that in group A. There was no difference in HSS score and Lysholm score before and follow-up for a certain period of time after operation.

The attachment sites and attachment areas of deltoid ligament related to clinical implications: a cadaveric study / Los sitios y las áreas de inserción del ligamento deltoideo relacionadas con las implicaciones clínicas: un estudio cadavérico

Currently, the treatment for patients with deltoid ligament injuries who require surgical treatment are anatomical repair and reconstruction. The clinicians should understand the exact knowledge of attachment areas of individual bands of deltoid ligament for a successful treatment. We studied 46 ankles of fresh frozen cadavers. The individual bands of deltoid ligament were divided to small fibers. Afterwards, each small fiber of each band was cut and marked with acrylic color on the origin and insertion followed by photo taking. Lastly, the photos of individual origin and insertion were used to calculate the attachment areas. We found six bands of deltoid ligament in all ankles except tibionavicular ligament. Moreover, we discovered deep to tibiocalcaneal and posterior to sustentaculum tali ligaments in 3 cases. Regarding the attachment area, the deep posterior tibiotalar ligament had the largest proximal and distal attachment areas which were 87.36±23.15 mm2 and 88.88±24.24 mm2, respectively. The anterior tibiotalar ligament had the least proximal and distal attachment areas which were 23.12±8.25 mm2 and 33.16±14.63 mm2, respectively. Hence, the accuracy and exact areas of attachment of deltoid ligament are important as it can help clinicians to select the suitable treatments including injury prevention.

Actualmente, el tratamiento para pacientes con lesiones del ligamento colateral medial de la articulación talocrural (ligamento deltoideo), que requieren tratamiento quirúrgico es la reparación y reconstrucción anatómica. Los médicos, para un tratamiento exitoso, deben conocer exactactamente las áreas de inserción de las partes de ligamento deltoideo. Estudiamos 46 tobillos de cadáveres congelados frescos. Las bandas individuales del ligamento deltoideo se dividieron en fibras pequeñas. Posteriormente, cada pequeña fibra de cada banda se cortó y marcó con color acrílico en el origen y la inserción, seguido de la toma de fotografías. Por último, las fotos de origen e inserción individuales se utilizaron para calcular las áreas. Encontramos seis bandas de ligamento deltoides en todos los tobillos, excepto el ligamento tibionavicular. Además, descubrimos en profundidad hasta los ligamentos tibiocalcaneaos y posteriores al sustentaculum tali en 3 casos. Con respecto al área de inserciónn, la parte tibiotalar posterior profundamente tenía las áreas de inserción proximal y distal más largas, que eran 87.36 ± 23.15 mm2 y 88.88 ± 24.24 mm2, respectivamente. La parte tibiotalar anterior del ligamento deltoideo tpresentaba áreas de unión menos proximales y distales 23.12 ± 8.25 mm2 y 33.16 ± 14.63 mm2, respectivamente. Por lo tanto, la precisión y las áreas exactas de inserción del ligamento deltoideo de la articulación talocrural son importantes, ya que pueden ayudar a los médicos a seleccionar los tratamientos adecuados, incluida la prevención de lesiones.

Reconstrucción de ligamento colateral medial: descripción de una nueva técnica de aumentación con aloinjerto y tornillos biocompuestos interferenciales / Reconstruction of medial collateral ligament: Description of a new augmentation technique with allograft and interference biocomposite screws

Resumen: Introducción: La inestabilidad del ligamento colateral medial (LCM) se asocia con lesiones multiligamentarias. Existen varios procedimientos para la reconstrucción del LCM, presentamos una técnica percutánea de aumentación. Nuestro objetivo es describir una nueva técnica de reconstrucción del LCM mediante injerto y fijación con tornillos biocompuestos. Material y métodos: Presentamos la técnica en un total de 21 pacientes consecutivos con lesión del LCM operados en el período de Diciembre de 2011 a Octubre de 2014. La reconstrucción del LCM se realizó con aloinjertos del tendón del peroneo largo, tibial posterior o flexor largo del Hallux en 18 pacientes y solamente en un paciente se utilizó autoinjerto. De los 20 pacientes, 18 presentaron lesiones asociadas: cinco con lesión de menisco medial, ocho con lesión del ligamento cruzado anterior, (LCA), ocho con lesión condral y uno con lesión del menisco lateral. Conclusión: La técnica quirúrgica presentada es sencilla de realizar, sin daño a otras estructuras y con una fijación resistente.

Abstract: Introduction: Medial Collateral Ligament (LCM) instability is associated with multi-ligamentary lesions. There are several procedures for the reconstruction of MCL, we present a percutaneous technique of augmentation. Our goal is to describe a new technique of reconstruction of the LCM by grafting and fixing with biocomposite screws. Material and methods: We present the technique in a total of 21 consecutive patients with MCL injury operated in the period of December 2011 to October 2014. Reconstruction of MCL was performed with long, tibial or long hallux tendon allografts in 18 patients and only one patient was used autograft. Eighteen of the 20 patients had associated lesions: 5 with medial meniscus injury, 8 with anterior cruciate ligament injury, (ACL), 8 with condral injury and 1 with lateral meniscus injury. Conclusion: The surgical technique presented is simple to perform, without damage to other structures and with a strong fixation.

Effects on Elbow Stability of the Terrible Triad Using Medial Collateral Ligament Repair and Ulnar Coronoid Process Fixation / 医用生物力学

Objective To investigate the effect of medial collateral ligament (MCL) repair and coronoid process fracture fixation on stability of the Terrible Triad of the elbow. Methods CT and MRI scan images of elbow joints from one healthy 28-year-old male volunteer were used to establish three elbow models. Model A: normal model. Model B: repair of coronoid process fractures, without MCL repair. Model C: repair of MCL, without repair of ulnar coronoid processes. Longitudinal loads were applied on the three models to analyze the displacement and stress distributions of the elbow joint under different working conditions and compare the stability of the elbow joint. Results The displacement and stress distributions of the three models were similar. The maximum displacement and maximum stress of the articular surface were located at the ulna pulley notch, while the minimum displacement was located at the coronoid process and its medial side. The minimum stress was located at the lower lateral side of the coronoid process. There were no statistical differences in the maximum displacement and stress among the three models (P>0.05). Conclusions When the lateral column is stable, the effect of repairing the MCL and fixing the fracture block of ulnar coronoid process is similar.

Application of percutaneous pie-crusting deep medial collateral ligament release for posterior horn surgery of medial meniscus / 中国骨伤

OBJECTIVE@#To explore clinical and radiographic effects of percutaneous pie-crusting deep medial collateral ligament release in patients with posterior horn tear of medial meniscus combined with tight medial compartment.@*METHODS@#From January 2012 to December 2016, 35 patients with medial meniscus posterior horn injury were treated with percutaneous pie crusting deep medial collateral ligament release technique, including 21 males and 14 females, aged from 21 to 55 years old with an average of (39.1±6.5) years old. Degree of meniscus extrusion were recorded before and 24 months after operation. The knee valgus stress test was performed to evaluate stability of medial collateral ligament, and compared difference between healthy and affected side. Lysholm and IKDC functional scores were compared before and 24 months after operation.@*RESULTS@#All patients were followed up from 27 to 60 months with an average of (36.7±6.8) months. All patients were underwent operation, the wound healed well without complications. Operative time ranged from 0.5 to 1.2 h with an average of (0.8±0.4) h. Nineteen patients were performed partial meniscectomy, 16 patients were performed repair suture. Convex of meniscus before operation was (1.5±0.7) mm, and (1.7±0.4) mm after operation;had no statistical difference(@*CONCLUSION@#For patients with medial meniscus tear of posterior horn combined with tight medial compartment, percutaneous pie-crusting deep medial collateralligament release could improve medial compartment space, and Knee valgus instability and meniscus extrusion are not affected.

Arthroscopic GraftLink technique reconstruction combined with suture anchor fixation for anterior cruciate ligament and medial collateral ligament injuries / 中国修复重建外科杂志

Objective: To investigate the effectiveness of arthroscopic GraftLink technique reconstruction combined with suture anchor fixation in treatment of anterior cruciate ligament (ACL) rupture and medial collateral ligament (MCL) grade Ⅲ injury. Methods: Between June 2015 and February 2018, 28 patients with ACL rupture and MCL grade Ⅲ injury were treated. Arthroscopic GraftLink technique was used to reconstruct ACL with autologous peroneus longus tendon (PLT), and suture anchor fixation was used to repair MCL. There were 22 males and 6 females, aged 21-47 years, with an average age of 30.4 years. The cause of injury included traffic accident in 18 cases, falling from height in 7 cases, and sports injury in 3 cases. The time from injury to admission was 1-2 weeks, with an average of 1.3 weeks. The preoperative Lysholm score of knee joint was 46.8±3.0 and the International Knee Documentation Commission (IKDC) score was 49.2±2.7. The American Orthopaedic Foot and Ankle Society (AOFAS) score of ankle joint was 98.29±0.72. Both Lachman test and valgus stress test were positive. There were 8 cases of meniscus injury and 2 cases of cartilage injury. Results: The operation time ranged from 55 to 90 minutes, with an average of 72.5 minutes. All incisions healed by first intention after operation, and no complications related to operation occurred. All patients were followed up 6-38 months, with an average of 20.7 months. At 3 months after operation, the range of motion of the knee joint was 116- 132°, with an average of 122°. Lachman test showed that the anterior translation more than 5 mm in 2 cases, and the others were negative; while the valgus stress test showed that all patients were positive. At 6 months after operation, the Lysholm score and IKDC score of knee joint were 90.2±1.8 and 93.5±2.3, respectively, which were significantly higher than preoperative scores ( t=31.60, P=0.00; t=29.91, P=0.01); AOFAS score of ankle joint was 97.86±0.68, with no significant difference compared with preoperative score ( t=2.89, P=0.08). KT-1000 test showed that the difference of anterior relaxation between bilateral knee joints was less than 2 mm in 25 cases and 3 to 5 mm in 3 cases. Conclusion: The method of ACL reconstruction via arthroscopic GraftLink technique with PLT and MCL repair via suture anchor fixation has the advantages of less knee injury and faster recovery, and there is no significant impact on ankle function after tendon removal.

Effect of posterior oblique ligament repair on rotational stability of knee joint / 中国修复重建外科杂志

Objective: To investigate effect of posterior oblique ligament (POL) repair on the rotational stability of the knee joint for the medial collateral ligament (MCL) combined with anterior cruciate ligament (ACL) ruptures. Methods: The clinical data of 50 patients (50 knees) with grade-3 MCL-ACL combined injuries who met the selection criteria between January 2013 and December 2015 were retrospectively analyzed. All ACLs were reconstructed with autogenous tendon and the superficial and deep layers of MCLs were sutured; then, POLs were also sutured in 25 patients of repair group and only received conservation treatment postoperatively in 25 patients of conservation group. There was no significant difference in gender, age, disease duration, and preoperative KT-1000 measuring, medial joint space opening, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, and knee range of motion between the two groups ( P>0.05). Results: All incisions of the two groups healed by first intention, no surgical related complications occurred. All patients were followed up, with follow-up time of 28-56 months (mean, 38.1 months) in repair group and 26-55 months (mean, 29.1 months) in conservation group. At last follow-up, the IKDC score, VAS score, KT-1000 measuring, medial joint space opening, and knee range of motion significantly improved in the two groups when compared with preoperative ones ( P0.05). The Slocum test showed that there was no instability of the anterior medial rotation in the two groups. Conclusion: The POL repair can't obtain more medial stability after ACL reconstruction and MCL repair (superficial and deep layers) for patients who have MCL-ACL combined injuries.

Different clinical therapeutic choices for injuries of the medial collateral ligament Ⅲ grade and anterior cruciate ligament / 中国医师进修杂志

Objective To compare the clinical efficacy of different treatments for injuries of medial collateral ligament (MCL) Ⅲgrade and anterior cruciate ligament (ACL). Methods Forty-six patients with MCLⅢgrade and ACL injuries admitted to Dalian Central Hospital from June 2013 to April 2017 were retrospectively analyzed, including 28 males and 18 females. Sixteen patients underwent arthroscopic reconstruction of the ACL, and medial collateral ligament was repaired with two anchors simultaneously in 2 weeks (group A); 15 patients were treated with reconstruction of the ACL in 2 weeks, and 4 times extracorporeal shock wave therapies were performed 2 weeks after surgery (group B); 15 patients were treated with reconstruction of the ACL in 2 weeks, and fixed with external fixation (group C). Patients were assessed in 3 months, 6 months and 12 months after surgery, and the Lysholm knee function score, the international knee documentation committee knee evaluation form (IKDC) score and the knee joint range of motion (ROM) were recorded. Results Three months after operation, the levels of Lysholm scores, IKDC scores and ROM in three groups were significantly improved compared with those before operation (P < 0.05). The IKDC scores and Lysholm scores in both group A and group B [IKDC score: (51.8 ± 3.1), (49.7 ± 3.9) scores; Lysholm score: (70.3 ± 3.7), (69.5 ± 3.4) scores] were better than those in group C [(44.5 ± 3.4), (59.3 ± 4.7) scores], and there were significant differences (P<0.05). Six months and 12 months after operation, the IKDC score, Lysholm score and the knee joint ROM in group A were better than those in group B and group C (P<0.05). Conclusions For knee joint MCLⅢgrade combined with ACL injuries, surgical treatment will obtain better functional scores and activity, and the effect of conservative treatment of MCL injury with extracorporeal shock wave therapy is not good.