Chinese Journal of Traumatology 18 (2015) 367e369
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Case report
Posttraumatic incarceration of medial collateral ligament into knee joint with anterior cruciate ligament injury Sunil Gurpur Kini*, Karel du Pre, Warwick Bruce Department of Orthopaedics, Concord Repatriation General Hospital, Concord West, NSW 2128, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 December 2014 Received in revised form 10 May 2015 Accepted 21 May 2015 Available online 14 November 2015
Medial collateral ligament of the knee is an important coronal stabiliser and often injured in isolation or as combination of injuries. The article reports a case of incarcerated medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury in 20 year old male who presented to us 4 weeks after injury. Clinical examination and MRI was correlated to complete ACL tear with torn distal MCL and incarceration into the joint. Patient was taken up for ACL hamstring graft reconstruction with mini-arthrotomy and repair of the torn MCL. Patient was followed up with dedicated rehabilitation protocol with good functional results. At one year follow-up, patient exhibited full range of motion with negative Lachman, Pivot shift and valgus stress tests. This article highlights the rare pattern of MCL tear and also reviews the literature on this pattern of injury. © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Medial collateral ligament Knee Anterior cruciate ligament Reconstruction Knee joint
1. Introduction
2. Case report
Medial collateral ligament (MCL) is the most common ligament to be injured in the knee. The common mechanism is a valgus force to the flexed knee. Treatment depends on the extent of valgus laxity and associated injuries. MCL entrapment into the joint is a rare phenomenon usually associated with posterolateral corner injuries as described in the literature. We present a case of MCL injury resulting in distal rupture of the MCL with incarceration into the medial joint space associated with anterior cruciate ligament injury. Such a pattern of injury is extremely rare and the best treatment choice for the well motivated patient as in this case with a high activity level is MCL repair and ACL reconstruction simultaneously or as a staged procedure. Postoperative protocol in these cases must be closely monitored to ensure undue stress on the repaired MCL in the wake of ACL rehabilitation. We present a rare case of combined injuries of ACL and MCL rupture and discuss the literature review of MCL entrapment into the joint.
A 20 years old male presented to our clinic after being referred from a general practitioner. He had a history of valgus injury to flexed knee 3 weeks back while playing soccer. Although swelling reduced after a couple of days patient noticed slight unsteadiness in the gait and discomfort in the knee localized much to the medial aspect. Clinical examination revealed a positive anterior drawer and Lachman with soft end point. Pivot test was positive and stress test revealed grade 3 valgus laxity in 0 and 30 deg flexion. X-rays of the knee was normal. MRI revealed ACL tear with tear of superficial and deep fibres of the MCL at the joint line with incarceration of the MCL fibres into the knee joint with possible tiny bony fragment (Figs. 1 and 2). Meniscus and posterior cruciate ligament were found to be intact but subchondral bruising in the lateral femoral condyle and cartilage loss in the lateral tibial plateau was observed. Patient was taken up for arthroscopic ACL reconstruction with MCL exploration and repair. Hamstring tendons were harvested for ACL repair. Arthroscopic view revealed entrapped MCL in the joint (Fig. 3). Femoral and tibial tunnels were drilled and graft was secured using endobutton on the femoral side and interference screw technique on the tibial end. MCL showed grade 3 laxity and decision for operative intervention was taken. A medial based incision in the direction of the MCL fibres was undertaken.
* Corresponding author. Tel.: þ61 2 9735 3637. E-mail address:
[email protected] (S.G. Kini). Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.
http://dx.doi.org/10.1016/j.cjtee.2015.11.004 1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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S.G. Kini et al. / Chinese Journal of Traumatology 18 (2015) 367e369
Fig. 1. Coronal view of the knee showing medial collateral ligament tear with incarceration into the joint.
Fig. 2. Sagittal view of the knee showing anterior cruciate ligament tear.
Exploration revealed that the superficial MCL was peeled off tibia with free distal based flap. This was addressed with primary repair and reinforcement using fibre wire and distal tibial fixation with suture anchors. At the end of procedure patient had a negative Lachmans test with no opening of the medial joint. The knee exhibited full range of movements at the end of the procedure. Patient was advised to continue knee brace for 6 weeks to protect the MCL repair. Initially the knee was advised to be kept in 30 deg flexion for a week followed by 20 deg in the second and full extension in a brace by the end of third week. Patient was followed up monthly from third to sixth week and then 6 weekly thereon. Patient was advised to return to sport gradually at about 6e9 months. At one year patient exhibited full range of motion with negative Lachman, pivot shift and valgus stress tests. 3. Discussion Few articles have described the intraarticular entrapment of the MCL into the knee joint in an adult. These have mostly been in association with posterolateral knee dislocations. Griswold1
reported 4 patients with irreducible posterolateral knee dislocation with button-holing of the medial femoral condyle through the medial joint capsule. Interposition of the MCL and joint capsule in the joint were noted and surgical intervention was required in all patients. Quinlan2 reported ‘button-holing’ of the medial femoral condyle in 6 patients with posterolateral knee dislocation which was confirmed on surgery. MCL tears, with no posterolateral knee dislocation, are usually transverse tears, as opposed to the ones in posterolateral knee dislocation that are usually vertical.3 MRI findings of MCL injury have been well described in the literature.4 The abnormalities evident on MRI range from soft tissue edema around the MCL and abnormal signal, to morphologic disruption and fibre discontinuity, as in this patient. Patel et al5 described a radiolucent “fat stripe” sign and adjacent skin dimpling on radiographs may be relatively specific indicators of this injury. The lateral compartment bone bruises identified are consistent with valgus stress and associated ACL injury. On sagittal imaging, the hypointense signal of the interposed MCL should not be confused with a medial meniscal tear. Tsiagadigui et al6 described the MRI findings in an adult with irreducible
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intraarticular entrapment of the end of the ligament, a large bony avulsion, a tibial plateau fracture, a complete tibial side avulsion in athletes, or when examination shows anteromedial rotatory instability. Intraarticular entrapment of the MCL with concomitant ACL injury in adults is extremely rare. MRI most often shows tear of the superficial MCL with incarceration into the joint which has to be differentiated from a meniscal tear. It is important to recognize this injury especially if the ligament is somewhat intact longitudinally (especially distal avulsion) since primary repair/refixation probably is much better and easier performed than secondary reconstructive MCL surgery that is more likely required after these injuries than after extracapsular more common MCL injuries. Closely monitored ACL rehabilitation programme is necessary so as to not strain the MCL repair. Conflicts of interest
Fig. 3. Arthroscopic view showing medial collateral ligament tissue in the joint.
Written and Informed consent has been obtained from the patient for inclusion in the journal. No conflicts of interest to declare. References
posterolateral knee dislocation and interposition of capsuloligamentous structures, although these were preoperatively mistaken for a medial meniscal tear. This combination of injury (intraarticular MCL entrapment with concomitant ACL injury) in an adult to the best of our knowledge is unreported in English literature. MCL injuries that may warrant operative intervention are grade III injuries, bony avulsion, tibial plateau fracture, intraarticular entrapment of the end of a ligament (as in our case), or anteromedial instability (positive anterior drawer test). If undertaken, surgical repair is usually carried out 7e10 days after injury.7,8 In combined MCL and ACL injuries, delayed ACL reconstruction is generally recommended to allow the MCL repair to heal.9 Surgery is performed after achieving full ROM, adequate strength, and resolution of knee effusion.10 Bollier11 recommended early ACL reconstruction and acute MCL repair when there is increased medial joint space opening with valgus stress in extension, a significant meniscotibial deep MCL injury (high-riding medial meniscus), or a displaced tibial-sided superficial MCL avulsion as in this case. Phisitkul et al8 recommended acute repair of medial structures in the presence of
1. Griswold AS. Irreducible dislocations of the knee joint. J Bone Jt Surg Am. 1951;33:787e791. 2. Quinlan AG. Irreducible posterolateral dislocation of the knee with buttonholing of the medial femoral condyle. J Bone Jt Surg Am. 1966;48:1619e1621. 3. Quinlan AG, Sharrard WJ. Postero-lateral dislocation of the knee with capsular interposition. J Bone Jt Surg Br. 1958;40:660e663. 4. Schweitzer ME, Tran D, Deely DM, et al. Medial collateral ligament injuries: evaluation of multiple signs, prevalence and location of associated bone bruises, and assessment with MR imaging. Radiology. 1995;194:825e829. 5. Patel JJ. Intra-articular entrapment of the medial collateral ligament: radiographic and MRI findings. Skelet Radiol. 1999;28:658e660. 6. Tsiagadigui JG, Sabri F, Sintzoff S, et al. Magnetic resonance imaging for irreducible posterolateral knee dislocation. J Orthop Trauma. 1997;11:457e460. 7. Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc. 2006;14:58e66. 8. Phisitkul P, James SL, Wolf BR, et al. MCL injuries of the knee: current concepts review. Iowa Orthop J. 2006;26:77e90. 9. Wijdicks CA, Griffith CJ, Johansen S, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Jt Surg Am. 2010;92: 1266e1280. 10. Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2006;34: 1134e1140. 11. Bollier M, Smith PA. Anterior cruciate ligament and medial collateral ligament injuries. J Knee Surg. 2014;27:359e368.
