Transplantation of ligament-tissue-derived stem cells has become a promising approach in the repair of injured ligament. Neovascularization plays an important role in ligament healing and remodeling. ...Recently, human umbilical-cord-blood-derived CD34+ cells have been reported to contribute to neoangiogenesis. Therefore, we performed a series of experiments to test our hypothesis that the combination of medial collateral ligament stem cells (MCL-SCs) and umbilical-cord-blood-derived CD34+ cells has synergistic effects on tendon healing. MCL-SCs and umbilical-cord-blood-derived CD34+ cells were isolated and cultured. Rat MCL injury was treated by MCL-SCs and/or CD34+ cells. Response to the cell therapy was assessed by gross observation, histological evaluation and biomechanical testing at 2 and 4 weeks after each treatment. Although each cell therapy group induced macroscopic and morphological recovery in healing MCLs, the combined use of MCL-SCs/CD34+ cells led to further improvement in healing quality. Capillary density was significantly higher in the CD34+ cell transplantation groups than in the other groups at week 2. Biomechanical testing demonstrated that the failure load of the healing ligament was greatest in the combination therapy group. The combination of MCL-SCs and CD34+ cells as a cell therapeutic thus enhances healing and restores biomechanical function toward normal after MCL injury. The findings obtained in our study suggest that the combination of MCL-SCs and CD34+ cells transplantation represents a promising strategy for ligament injury.
Purpose
To describe a novel repair for tibial-sided superficial medial collateral ligament (sMCL) lesions and determine whether it restores medial joint opening to uninjured state. Agreement among ...experienced knee surgeons when evaluating medial joint laxity was also explored.
Methods
On a series of eight human cadaveric knees, surgical elevation of the distal insertion of the sMCL was performed to replicate injury. The cut ligament was repaired using a novel double-row ‘suture-bridge’ technique. Valgus stress fluoroscopic images were taken with the ligament in three states: (I)ntact, (C)ut and (R)epaired, in two positions: 0 and 20° flexion. Joint opening was measured on calibrated fluoroscopic images (in mm) based on methods described by LaPrade. Joint space opening was also estimated by three experienced knee surgeons without fluoroscopy.
Results
On fluoroscopy, no significant differences in mean joint opening were observed between an intact versus repaired ligament in 0 and 20° flexion 0.5 mm (95 % CI −1.6, 0.73; n.s.) and 0.3 mm (95 % CI −1.17, 1.71; n.s.), respectively. Agreement among surgeons was substantial (ICC = 0.622, 95 % CI 0.52, 0.73).
Conclusion
The surgical technique adequately restored joint opening to an intact state with response to valgus stress. Agreement among surgeons when quantifying joint opening in mm was substantial. This paper addresses a technically difficult problem and provides pragmatic and practical information for surgeons who manage complicated multi-ligament knee injuries.
Background: Proximal or distal realignment procedures have long been selected as treatment for recurrent patellar dislocation, but associated
knee osteoarthritis has been a substantial problem that ...leads to poor results. A new approach, medial patellofemoral ligament
reconstruction, has recently started, but there have been no reports on the long-term follow-up.
Hypothesis: Anatomical medial patellofemoral ligament reconstruction can lead to satisfactory long-term outcome and a low association
rate of knee osteoarthritis.
Study Design: Case series; Level of evidence, 4.
Methods: Twenty-four knees from 22 patients who underwent medial patellofemoral ligament reconstruction for recurrent patellar dislocation
were reviewed at a mean follow-up of 11.9 years (range, 8.5â17.2 years). A lateral release was done on 14 of 24 knees. The
clinical/physical outcome and the association of knee osteoarthritis were investigated. Patellofemoral and femorotibial osteoarthritis
on the radiographs was evaluated using the Crosby/Insall and the Kellgren/Lawrence grading systems.
Results: According to the Crosby/Insall criteria, 11 knees (46%) were classified as excellent, 10 (42%) as good, 3 (12%) as fair/poor,
and none as worse at follow-up. Further lateral subluxation or dislocation occurred in only 2 knees. The mean Kujala score
improved significantly from 63.2 points preoperatively to 94.2 points at follow-up ( P < .0001). According to the Crosby/Insall grading system, patellofemoral osteoarthritis was none to mild in 23 of the 24 knees
and moderate in 1 knee, pre-operatively. At the final follow-up, 21 knees were none to mild, and 3 knees were moderate. There
were only 2 knees that had definite progression from none to mild to a moderate grade.
Conclusion: The association of definite knee osteoarthritis in medial patellofemoral ligament reconstruction with or without lateral
release was small in the long-term follow-up. The conclusion is that medial patellofemoral ligament reconstruction not only
prevents further patellar dislocation but also shows no or only slight progression of knee osteoarthritis.
Keywords:
osteoarthritis
medial patellofemoral ligament (MPFL)
patella
dislocation
Purpose
The aim of this study was to compare outcome data after isolated and combined (MCL) plus anterior cruciate ligament (ACL) reconstruction based on objective and subjective measures using data ...from the (DKRR). There are only a few small-sized case studies on outcomes after MCL reconstruction. MCL reconstruction was hypothesised to improve both objective and subjective outcomes.
Methods
All patients who were registered in the DKRR between 2005 and 2016 (
N
= 25,281) and who underwent isolated ACL (
n
= 24,683), isolated MCL (
n
= 103) or combined MCL plus ACL (
n
= 495) reconstructions were retrospectively identified. Objective (valgus knee stability and sagittal knee laxity) and subjective (Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scale score) outcomes in these three cohorts were evaluated at the 1-year follow-up by comparing pre- and post-operative values.
Results
Medial stability improved significantly pre- to post-operatively after both isolated MCL and combined MCL plus ACL reconstruction, with 26 (53%) and 195 (69%) of the patients, respectively, having normal valgus stability (0–2 mm laxity). Sagittal stability was similar after MCL plus ACL reconstruction and isolated ACL reconstruction (1.7 and 1.5 mm, respectively). At the 1-year follow-up, although the KOOS of the patients in the isolated MCL and combined MCL plus ACL reconstruction cohorts improved significantly, they were lower than those of the patients in the isolated ACL reconstruction cohort.
Conclusion
Both isolated MCL reconstruction and combined MCL plus ACL reconstruction resulted in significant and clinically relevant improvements in the subjective outcomes from pre-operative conditions to the 1-year follow-up. Valgus stability also improved significantly, with two-thirds of patients obtaining normal valgus stability after MCL reconstruction. Subjective outcomes were similar between isolated MCL reconstruction and combined MCL plus ACL reconstructions, but were poorer than isolated ACL reconstructions.
Level of evidence
Level III.
The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. The anterior cruciate ligament (ACL) is the most commonly injured ligament in conjunction with the MCL. Most ...MCL injuries can be treated nonoperatively, whereas the ACL often requires reconstruction. A good physical examination is essential for diagnosis, whereas radiographs and MRI of the knee confirm diagnosis and help guide treatment planning. Preoperative physical therapy should be completed before surgical management to allow for return of knee range of motion and an attempt at MCL healing.
Purpose
Medial collateral ligament (MCL) injury is the single most common traumatic knee injury in football. The purpose of this study was to study the epidemiology and mechanisms of MCL injury in ...men’s professional football and to evaluate the diagnostic and treatment methods used.
Methods
Fifty-one teams were followed prospectively between one and three full seasons (2013/2014–2015/2016). Individual player exposure and time-loss injuries were recorded by the teams’ medical staffs. Moreover, details on clinical grading, imaging findings and specific treatments were recorded for all injuries with MCL injury of the knee as the main diagnosis. Agreement between magnetic resonance imaging (MRI) and clinical grading (grades I–III) was described by weighted kappa.
Results
One hundred and thirty of 4364 registered injuries (3%) were MCL injuries. Most MCL injuries (98 injuries, 75%) occurred with a contact mechanism, where the two most common playing situations were being tackled (38 injuries, 29%) and tackling (15 injuries, 12%). MRI was used in 88 (68%) of the injuries, while 33 (25%) were diagnosed by clinical examination alone. In the 88 cases in which both MRI and clinical examination were used to evaluate the grading of MCL injury, 80 (92% agreement) were equally evaluated with a weighted kappa of 0.87 (95% CI 0.77–0.96). Using a stabilising knee brace in players who sustained a grade II MCL injury was associated with a longer lay-off period compared with players who did not use a brace (41.5 (SD 13.2) vs. 31.5 (SD 20.3) days,
p
= 0.010).
Conclusion
Three-quarter of the MCL injuries occurred with a contact mechanism. The clinical grading of MCL injuries showed almost perfect agreement with MRI grading, in cases where the MCL injury is the primary diagnosis. Not all grade II MCL injuries were treated with a brace and may thus indicate that routine bracing should not be necessary in milder cases.
Level of evidence
Prospective cohort study, II.
Medial varus proximal tibial (MPT) resection or soft tissue releases (STRs) of the medial collateral ligament (MCL) in the form of pie-crusting can be performed to achieve a balanced knee in a varus ...deformity. Studies comparing the 2 modalities have not been addressed within the literature. Therefore, the aims of this study were to assess the following: (1) compartmental changes between the 2 methods and (2) changes in patient-reported outcome measurements.
Using our institution’s total joint arthroplasty registry, patients who underwent primary total knee arthroplasty from January 1, 2017, to December 31, 2019, were identified. The MPT resection and STR patients were 1:1 matched with baseline parameters yielding 196 patients. Outcomes of interest included: changes in compartmental pressures at 10, 45, and 90° degrees and change to the Short-Form 12, Western Ontario and McMaster Universities Osteoarthritis Index, and Forgotten Joint Scores (FJSs) at the 2-year follow-up period. A P value less than .05 was used as our threshold for statistical difference.
The MPT resection led to significant reductions in compartmental pressures at 10° 43 versus 19 pounds (lbs.), P < .0001, 45° (43 versus 27 lbs., P < .0001), and 90° degrees (27 versus 16 lbs., P < .0001) compared to STR. MPT resection also had significantly improved Short-Form 12 (47 versus 38, P < .0001), Western Ontario and McMaster Universities Osteoarthritis Index (9 versus 21, P < .0001), and Forgotten Joint Score (79 versus 68, P = .005).
Bone modification was superior to pie-crusting of the MCL in achieving consistent pressure balancing and improved outcomes. The investigation can guide surgeons on the preferred method to achieve a well-balanced knee.
Recent biomechanical studies have clarified the role of the medial soft tissue stabilizers in restraining anteromedial rotatory instability (AMRI) of the knee: the superficial medial collateral ...ligament has been shown to be an important passive restraint to AMRI, with a relevant contribution of the deep medial collateral ligament (dMCL) near full extension. Clinically, concomitant injury of the anterior cruciate ligament (ACL) and dMCL or both dMCL and superficial medial collateral ligament, may lead to AMRI. Anterior drawer in external rotation, external rotation and valgus stress test are used to assess AMRI, although a feasible classification system has not yet been established. In cases of an acute ACL and high-grade MCL injury, it is still a matter of the debate whether both ligaments need to be addressed immediately or if a primary conservative treatment of the MCL should be followed by an ACL reconstruction. If not addressed adequately, chronic AMRI may arise and an increased rate of recurrent ACL insufficiency has to be assumed. In the setting of chronic AMRI, a combined ACL and MCL reconstruction with autologous tendon grafts should be considered. Nevertheless, indication for primary repair or reconstruction of the medial soft tissue stabilizers with autologous tendon grafts remains controversial and a lack of data exists regarding the potential of current treatment options for restoring AMRI.
Superficial medial collateral ligament (MCL) injury is an occasional intraoperative complication during total knee arthroplasty (TKA) that can lead to failure. Although previous studies have ...recommended complex repair or conversion to a constrained implant, the authors evaluated results of superficial distal MCL reapproximation using bone staples. Records of 31 patients who underwent staple reapproximation for superficial MCL avulsion from the tibial attachment during primary TKA from 2005 to 2015 were reviewed. They were compared with 685 patients who underwent uncomplicated TKA (primary control) and 18 who underwent revision TKA for instability (secondary control). Subjective knee instability was assessed with a patient questionnaire, and other end points included revision for instability or stiffness and manipulations under anesthesia. The authors prospectively collected Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analog scale satisfaction scores. The mean follow-up was 2.6 years. No patients treated with staple repair required revision for instability, whereas two patients were revised in the primary control. Subjective instability was reported in 19.2% of staple repair patients compared with 24.2 and 46.2% of patients in the primary and secondary controls. The mean KOOS for the staple group was 71.7 points, 77.3 for the primary control, and 49.3 for the secondary. KOOSs for the staple group were 5.6 points lower than the primary control, but 22.4 points higher than the secondary. Staple reapproximation is a simple and effective method for repairing the superficial distal MCL in primary TKA. The rate of instability and functional outcomes was comparable to uncomplicated primary TKA.
Abstract Background Precise biomechanical knowledge of individual components of the MCL is critical for proper MCL release during TKA. This study was to define the influences of the deep MCL and the ...POL on valgus and rotatory stability in TKA using cadaveric knees. Methods This study used six fresh-frozen cadaveric knees. All TKA procedures were performed using a cruciate-retaining TKA with a CT-free navigation system. We did a sequential sectioning on each knee, S1; femoral arthroplasty only, S2; medial half tibial resection with spacer, S3; anterior cruciate ligament cut, S4; tibial arthroplasty, S5; release of the dMCL, S6; release of the POL. The navigation system monitored motion after application of 10 N-m valgus loads and 5 N-m internal and external rotation torques to the tibia at 0°, 20°, 30°, 60°, and 90° of knee flexion for each sequence. Results There were no significant differences in medial gaps. Internal rotation angles significantly increased after S2 at 0°, 20°, and 30°, and after S6 at 90°compared with those after S1. External rotation angles significantly increased after S3 at 0°, S4 at 60°, S5 at 0°, 30°and 90°, and after S6 at 30°, 60° compared with those after S1. Conclusion Significant increases of rotatory instability were seen on release of the dMCL, and then further increased after release of the POL. Surgical approach of retaining the dMCL and POL has a possibility to improve the outcome after primary TKA.
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