Knee Ligament Injuries

Overview

Ligament Anatomy Biomechanics Ligament Specific

Epidemiology Classification Clinical exam Imaging Tx

Ligament Anatomy

Type 1 collagen (70%) Elastin Extracellular matrix Hierarchical structure Fibrils > fibres >subfascicular unit >fasciculus Longitudinal fasciculi (MCL, LCL) Helical fasciculi (ACL, PCL)

Anatomic Features

Bonding Crimping Random collagen alignment Complex blood supply Diffusion from synovium Proprioception and nociception

Biomechanics

Laxity Stiffness Strength Viscoelastic behavior (creep, stress relaxation, hysteresis) Dynamic properties

Ligament healing

Immobilization
Loading dramatically affects recovery of normal mechanical properties Decrease strength Insertion site vs. midsubstance

Exercise

Favourable effect

Epidemiology

Increasing incidence Combined injuries common Females > males Conditioned vs. unconditioned

Conditioned

Unconditioned

ACL Anatomy

Intracapsular Extrasynovial Varied blood supply FAMPLE Origin / Insertion

ACL Function

Limit anterior displacement 20 restraint rotation 20 restraint varus / valgus in extension

Mechanism / Hx

Usually noncontact Change direction Stop / jump Audible pop Instability Swelling

General Ligament Exam

Difficult acutely Early exam beneficial Pt. relaxed Displacement Endpoint quality Compare

ACL Exam

Lachman best Pivot Shift diagnostic Anterior drawer chronic tear Associated injuries

ACL Imaging

XRAY
R/O # ACL avulsion Segond #

Arthrography - poor Arthroscopy - gold standard

ACL MRI

95% accurate Low signal intensity Saggital view Acute injury high signal intensity on T2 image Bone bruising

ACL Tx

Pt selection Operative vs. Non-operative

Demand level Modify lifestyle ACL dependent Other lesions

Non-operative

Acutely splint & crutches Early active ROM Closed chain WB to strengthen Avoid high risk Functional bracing controversial

Operative

Pt selection
High demand Young Good ROM

Open vs. endosopic Learning curve

Graft

Auto vs. allo Collagen lattice Resorption revascularization restructuring Bone-patellar tendon-bone Semitendinosus/gracilis tensioning

Rehab

Closed kinetic chain strengthening Acutely fixation weak Graft weakest 6-12 wks Outcome

>90% stable 3-5 yrs

MCL Anatomy

Origin femoral condyle Insertion 4cm below joint line + posterior obl. Lig. + middle capsular ligament Parallel collagen

MCL

Most common isolated ligament injury Valgus force Post. Obl. Lig. damage with rotn. injury Associated ACL common

MCL exam

Valgus force Flex. 300 isolated Extension

Assoc. POL,ACL,PCL

5-8 mm difference significant Swelling

Hemarthrosis vs. soft tissue

MCL Tx

Non-surgical RICE Bracing Strengthening Functional brace

MCL Classification / Tx

Grade 1 : 1-5 mm

Symptomatic Tx

Grade 2 : 610 mm

Hinge brace 2-3 wks

Hinge brace 3-4 wks

Grade 3 : 11-15 mm

Physio

PCL Injury

1.5 x ACL strength 5% all knee lig. inj. 10 restraint post. translation tibia Forced flexion Dashboard Associated injuries

PCL

Pain Usually stable Posterior subluxation Medial & patellofemoral OA

PCL exam

Posterior drawer test best

Grade I - III

Quadriceps active test Post sag sign

Non-operative

Aggressive rehab Focus quadriceps No support for bracing closed kinetic chain Open kinetic chain extension avoided 90% quads strength prior to normal athletics

PCL Tx

Repair :
Associated posterolateral corner Associated ACL / MCL Grade 3 Drawer test Bony avulsion 20% athletes with isolated injury require repair

Operative Repair

Require good ROM pre-op Graft > 40mm No good rehab protocol

Posterolateral Complex

Combination of Structures
ITB biceps femoris fibular collateral Popliteus complex Capsule etc

Posterolateral corner

Usually assoc with:

PCL Knee dislocation Rarely ACL

Instability esp descending inclines Peroneal N. inj. 10% pain

Biomechanical

Increased:
External tibial rotation Varus rotation Posterior tibial translation

Exam

Swelling / bruising Gait : Varus thrust AP translation > 300 than 900 Best tests:
Varus stress opening > 300 than 00 Prone external rotation test

Other tests

Operative

10 Repair
Acute injury Bony avulsion

Reconstruction
Biceps tenodesis / arcuate lig advancement : mixed results Graft - results pending

Varus malalignment - HTO

Conclusion

Common injuries Easily missed Large area Ongoing research