mcl tears: they all - avera · 2016. 6. 26. · surgical management indications: chronic mcl...
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MCL Tears: They all
heal…..Or Do
They? ERIK D. PETERSON, MD
ORTHOPEDIC SPORTS MEDICINE SURGEON
CORE ORTHOPEDICS
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Incidence
Most Commonly Injured Ligament in the knee
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Mechanism
Valgus applied stress to fixed/planted foot
With increasing amounts of axial rotation, combined ligament
injuries occur, i.e. ACL
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Function
Primary restraint to valgus stress at
knee joint
Primarily in 30+degrees flexion (80%)
Extension (50%); ACL, PMC additional
Controls External Rotation
AMRI
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Anatomy
Warren Layers Concept
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Biomechanics
Extrarticular
11 cm length
Equal Strength of ACL
Majority of Tears at Femoral Insertion: Stress Concentration w/ valgus
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Minimal Contribution to
Valgus Stability.
Rotational control
mainly
Sectioning study = no
increased valgus
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Anatomy
Deep MCL
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Anatomy
5-7 cm distal insertion on tibia
Majority of tears at Proximal insertion
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Classification
AMA
Grade 1: 0-5mm
Grade 2: 6-9mm
Grade 3: 10+mm
Hughston
Grade 1: no tearing/sprain/no
instability
Grade 2: partial tearing/no
instability
Grade 3: high grade/complete
tear/varying degrees on
instability
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Incidence of MCL Tears Roach AJSM 2014
West Point Study
InterCollegiate and Intramural sports (all cadets participate)
Multi Sport participation not just incidence in a single sport gives
truest estimation of athletes risk. N=20
Incidence Rate (IR)
7.3 /1000 person-years (22-25/yr)
0.11 /1000 Athletic exposures
1 of 100 kids every 100 practices or games will tear MCL
Grade 1 (73%) Grade 2 (23%) Grade 3 (4%)
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Epidemiology Roach AJSM 2014
Men 2.6 times more likely to tear MCL
Hockey/Football highest prevalence = Male only at
West Point
Confounding
IR no different when comparing sex participating in same sport
i.e. Rugby
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Epidemiology
Roach AJSM 2014 Highest Risk IR/1000 AE = Wrestling>Judo>Hockey>Rugby
Wrestling IR = 0.57 / 1000 AE
1 of 100 kids will tear their MCL every 20 practice/match
Intercollegiate 57% higher IR compared w/ Intramural
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Demographics
Male > Female (Intercollegiate level) Roach AJSM 2014 & Stanley AJSM 2016
Female > Male (High School level) Stanley AJSM 2016
Contact > Non-Contact (opposite of ACL risk)
Football, Soccer, Hockey, Basketball
Higher Level of Participation increases risk of injury (opposite ACL)
Professional/Intercollegiate>High School>Adolescent
Roach AJSM 2014
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Demographics Playing Surface
Hershman AJSM 2012
NFL Injury database 2000-2009
FieldTurf vs. Grass
MCL injuries Not statistically increased on Turf vs Grass (p=.68)
ACL injuries 67% higher risk on Turf vs Grass (P<.001)
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Exam
*Valgus Laxity at 30 degrees and Zero degrees = 78%
prevalence of combined ACL/MCL injury
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Diagnostic Tests
Radiographs
Pelligrini Steida Lesion:
Chronic
Beware!!
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Diagnostic Tests
MRI I have a Low threshold
Higher Grade Lesions > MRI use
Grade 2/3 associated with increased concomitant knee injury
Medial Meniscus
ACL
78% of Grade 3 have additional injury (ACL/men)
Contra Coup edema
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MRI
Grade 1 sprain
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MRI
Grade 2 sprain
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MRI
Grade 3 sprain
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Treatment: Nonoperative
RICE
Controlled Motion > Immobilization
Hinged Brace
Weight bearing: initially w/ locked brace
NSAIDS: Avoid?? (Warden AJSM 06) Rat study w/ Celebrex
33% reduced load to failure at 2 week
Ultrasound: Improved strength, stiffness, energy absorption, cross sectional area at 6 wks (Sparrow AJSM 05)
High Success for Complete Healing
>98% when tear is femoral insertion of midsubstance
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Treatment: Nonoperative
ARP wave
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Recovery
Directly proportional to severity of Injury
Average Time Lost 23 days
Grade 1 : 13 days
Grade 2/3: 29 days
Grade 3: D1 college mean 9 wks (Indelicato AJSM 90)
Roach AJSM 2014
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Prevention
Systematic Review
JAT Pietrisimone 2008
We cannot advocate nor
discourage the use of
prophylactic bracing for
prevention of knee injuries
based on current levels of
evidence
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Prevention
Prophylactic Bracing
Albright AJSM 2004
Looking specifically at MCL injury risk
1000 Big Ten Football players followed prospectively for one season
50% braced
Stratified injury risk based on position
Conclusion
Consistent, but non statistically significant trend toward < MCL injuries
Linemen (offensive and defense)
Linebackers
Tightends
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Surgical Management
Indications:
Chronic MCL tear-unhealed, unstable
Acute Grade 3 MCL w/ concomitant ACL/PCL injury
Controversial
Early Surgery: repair/reconstruct
Delay Surgery, rehab, See if MCL heals
Early Surgery: Reconstruct ACL, rehab MCL
Millett JKS 04: No difference at Followup
Halinen AJSM 06: Prospective ACL +- MCL repair; early surgery: No difference
Grade 4 lesions
Tibia: Stener equivalent
Femur: Intraarticular entrapment
Avulsion Fracture of MCL origin
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Case Presentation
17 yo HS football player
Collision/Valgus stress
Immediate medial swelling
Excruciating Pain
Exam:
Superficial Ecchymosis
Negative Lachman
Stable Varus
Valgus 0 degrees: stable
Valgus 30 degrees: +3 opening 15mm
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MRI
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Stener-Like
MCL tear
Grade 4
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Stener Lesion: Skier’s thumb
UCL
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Case Presentation
60 yo woman
Painting on step stool
Fell to ground with leg twisting underneath her
Felt a pop
Excruciating Pain
Exam:
Positive Lachman
Stable Varus
Valgus 3+ in 0 & 30 degrees
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MRI
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Thank You