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Repair and Reconstruction of Medial- and Lateral-Sided Knee Injuries

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Repair and Reconstruction of Medial- and Lateral-Sided Knee Injuries 47 SYMPOSIUM Repair and Reconstruction of Medial- and Lateral-sided Knee Injuries Robert F. LaPrade, MD, PhD Lars Engebretsen, MD, PhD Robert G. Marx, MD, MSc, FRCSC Abstract Surgical treatment of medial and lateral knee injuries using repair and/or reconstruction techniques is often necessary to restore knee ligament stability and optimize function. Successful execution of these repairs and reconstructions requires a sound understanding of basic anatomy and biomechanics. Against this backdrop, numerous repair and reconstruction techniques have been developed. Although me- dial knee injuries are often amenable to healing, posterolateral knee injuries often do not heal after a complete tear. Posterolateral corner repair should be attempted only in acute lateral knee injuries and never for midsubstance tears. Postoperative rehabilitation follows a period approach, with an emphasis on early range-of-motion exercises and protection of the surgical repair or reconstruction. By following these approaches to medial and lateral knee repairs and reconstructions, it is possible to restore stability to an injured knee and expedite return to desired levels of activity. Instr Course Lect 2015;64:531–542. Treating medial- or lateral-sided knee treatment, depending on which struc- attempted in patients with multiliga- injuries requires a thorough under- tures are damaged and the severity of mentous injuries or knee dislocations. standing of knee anatomy and biome- injury. Medial-sided injuries often can Chronic, medial-sided knee injuries chanics to successfully restore native be managed nonsurgically. However, with valgus misalignment should be knee kinematics. Injuries to either primary repair or reconstruction of treated with a two-stage approach. A side of the knee may warrant surgical the medial knee structures should be distal femoral osteotomy should be per- formed rst, followed by reconstruction Dr. LaPrade or an immediate family member serves as a paid consultant to or is an employee of Arthrex and Smith & of the medial knee structures. Nephew; has received research or institutional support from Arthrex, Smith & Nephew, Ossur, and Linvatec; and serves Lateral-sided knee injuries usually do as a board member, owner, of cer, or committee member of the American Orthopaedic Society for Sports Medicine; the not heal and require surgical treatment. International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; the Arthroscopy Association of North America; and the European Society for Sports Traumatolog y, Knee Surgery and Arthroscopy. Dr. Engebretsen Primary repair should be attempted or an immediate family member has received royalties from Arthrex; is a member of a speakers bureau or has made paid for acute repairs except for midsub- presentations on behalf of DePuy and Arthrex; serves as a paid consultant to or is an employee of Nycomed, Arthrex, stance tears. A variety of reconstruc- and Smith & Nephew; has stock or stock options held in iBalance; has received research or institutional support from Smith & Nephew; and serves as a board member, owner, of cer, or committee member of the European Society for Sports tion techniques have been developed Traumatolog y, Knee Surgery and Arthroscopy. Dr. Marx or an immediate family member serves as a board member, owner, for posterolateral corner knee injuries. of cer, or committee member of the International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. This chapters authors recommend © 2015 AAOS Instructional Course Lectures, Volume 64 531 Sports Medicine Although the proximal tibial attachment has a much lower load to failure (88 N) than the distal attachment (557 N), both attachments provide substantial func- tional contributions, including resisting valgus gapping, and therefore should be restored during sMCL repair or re- construction.3 The sMCL is the primary restraint against valgus stress, external rotation at 30° of exion, and inter- nal rotation (along with the posterior oblique ligament) at all exion angles.4,5 Posterior Oblique Ligament The posterior oblique ligament consists of fascial attachments extending from the distal aspect of the semimembrano- Figure 1 Photograph of the medial aspect of a right knee showing the sus tendon, which can be divided into gross anatomy. AMT = adductor magnus tendon, MGT = medial gastrocne- three arms: the super cial, central, and mius tendon, POL = posterior oblique ligament, SM = semimembranosus, 2,6,7 sMCL = superfi cial medial collateral ligament. capsular arms. Of the three attach- ments, the central arm is the largest, anatomic-based reconstructions, which surgical repairs or reconstructions. By thickest, and most functionally impor- have been validated biomechanically to understanding the key relationships of tant.2,4 The proximal aspect of the restore knee function. Rehabilitation ligament and tendinous structures to central arm attaches 1.4 mm distal and should involve early range of motion these bony landmarks, it is possible to 2.9 mm anterior to the gastrocnemius (ROM), with the goal of full return perform anatomically accurate medial tubercle on the medial side of the fe- to activity after the patient has been knee surgical repair and reconstruction mur. This relationship is essential for cleared by the physician. techniques.1 anatomic medial knee reconstructions. Many previous studies have reported Medial-sided Knee Injuries Superfi cial Medial that the posterior oblique ligament at- Anatomy and Biomechanics Collateral Ligament tachment is closer to the adductor tu- Understanding the anatomy and bio- The sMCL is the largest medial knee bercle and other nearby structures.7-9 mechanics of the medial knee provides structure and consists of a femoral The distal posterior oblique ligament an essential foundation for effectively attachment and proximal and distal tib- attachment is adjacent to the semimem- diagnosing and treating medial knee ial attachments (Figure 1). At its prox- branosus tendon and has an additional injuries. The primary medial knee sta- imal attachment, the sMCL is located attachment to the medial meniscus. bilizers are the super cial medial col- 3.2 mm proximal and 4.8 mm poster- lateral ligament (sMCL), the posterior ior to the medial epicondyle.2 From its Deep Medial Collateral Ligament oblique ligament, and the deep medial proximal attachment, the sMCL courses The dMCL represents a thickening in collateral ligament (dMCL). On the distally, attaching rst to the proximal the middle-third medial capsular liga- medial aspect of the femur, three bony tibia 1.2 cm distal to the proximal joint ment.2 The structure is divided into a prominencesthe medial epicondyle, line over the anterior aspect of the proximal meniscofemoral division and a the adductor tubercle, and the gastroc- semimembranosus tendon. The sMCL distal meniscotibial division, with a rm nemius tuberclemay be referenced to continues distally, where it attaches meniscal attachment in the middle por- locate the sMCL, the posterior oblique once again to the tibia approximately tion (Figure 2). The meniscofemoral ligament, and dMCL footprints during 6.1 cm distal to the proximal joint line. portion attaches 12.6 mm distal to the 532 © 2015 AAOS Instructional Course Lectures, Volume 64 Repair and Reconstruction of Medial- and Lateral-sided Knee Injuries Chapter 47 proximal sMCL attachment, whereas the distal meniscotibial portion attaches adjacent to the tibial plateau articular cartilage approximately 3.2 mm distal to the joint line and 9.0 mm proximal to the proximal tibial sMCL attachment. The meniscofemoral portion is con- sistently longer and thinner than the shorter and thicker meniscotibial divi- sion. Wijdicks et al3 reported that the mean load to failure of the dMCL was 101 N. The dMCL functions to resist valgus gapping. Other Medial Knee Structures The adductor magnus tendon also at- taches along the medial aspect of the knee. The femoral attachment of the adductor magnus tendon is located an Figure 2 Photograph of the deep medial collateral ligament and the sur- average of 3.0 mm posterior and 2.7 rounding anatomy. The (dMCL) consists of a proximal meniscofemoral (MF) mm proximal to the adductor tuber- portion and a distal meniscotibial (MT) portion. AMT = adductor magnus tendon, MGT = medial gastrocnemius tendon, MM = medial meniscus, SM = cle.2 In addition, there is a thick fascial semimembranosus tendon. component that fans out posteromedi- ally toward the medial gastrocnemius tendinis prominence.2 Between these Repair tendon. The vastus medialis obliquus two layers, a semimembranosus bursa Primary Repair muscle attaches along both the lateral is formed. Indications for the primary repair of aspect of the adductor magnus tendon The saphenous nerve and its infra- medial knee structures include acute and the thick posteromedial aspect of patellar and sartorius branches course cases of multiligamentous injuries or the tendon insertion. through the medial aspect of the knee knee dislocations.15 Torn structures The medial gastrocnemius tendon and should be avoided during a me- can be repaired with sutures alone or attaches 2.6 mm proximal and 3.1 mm dial knee surgical approach.10-13 One sutures plus suture anchors. Early, ag- posterior to the gastrocnemius tuber- study reported that the mean distance gressive ROM in a safe zone, which cle.2 It originates from the medial aspect between the anterior border of the is predetermined by the surgeon and of the medial gastrocnemius tendon and sMCL and the
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