• The management of MCL injuries has evolved over the past 30 years.
• Whereas most isolated anterior cruciate ligament (ACL) injuries are treated surgically, there remains a place for nonoperative management of isolated MCL injuries.
• In combined lesions with other ligaments, surgical repair/reconstruction of the MCL may be indicated.
• Whereas the knee has little tolerance for ACL laxity, as an isolated entity, it copes much better with residual MCL laxity even in athletes who perform high-level sports.
via its two divisions: the meniscotibial and meniscofemoral attachments.
Biomechanical studies have shown that the MCL is the prime medial stabilizer of the knee, which resists valgus loading.1,2 Due to the parallel arrangement of the collagen that composes the MCL, only a relatively small increase of laxity (approximately 5 to 8 mm) is indicative of a complete failure of the ligament. Another point to remember is that the deep capsular ligament (layer 3) is an important anchoring location for the medial meniscus. Therefore, although damage to this layer can extend into the substance of the meniscus, true substance tears of the medial meniscus are seldom seen in conjunction with complete disruption of the MCL.
The location of the proximal attachment site of the MCL places it near the knee's center of rotation. An intact MCL is fan shaped, and, as a result, some aspect of its structure is always under tension during knee flexion. As the knee goes into flexion, the anterior fibers of the MCL remain tight, whereas the posterior fibers slacken. The POL blends in with the posterior edge of the MCL and helps prevent medial opening with valgus loading with the knee in full extension. In a flexed position, the anterior aspect of the POL actually lies underneath the MCL. The bursa that separates the superficial from the deep MCL allows for the 1- to 2-cm anteroposterior excursion that must occur to the MCL during flexion/extension of the knee. While surgically repairing damage to the area, this relationship must be kept in mind. Suturing the anterior aspect of the POL to the posterior fibers of the MCL with the knee in more than 30 degrees of flexion could limit the necessary excursion of the MCL and lead to a significant flexion contracture postoperatively.
The complexity of the medial structures of the knee have led some authors to focus on the specific structures injured as opposed to grouping them as simply an injury to the MCL. Specifically in the work of Hughston and Eilers,5 Hughston,6 and Muller,7 the importance of the posteromedial corner of the knee as a dynamic and static stabilizer has been emphasized. These anatomic structures include the posterior horn of the medial meniscus, the POL, semimembranosus, meniscotibial attachments, and oblique popliteal ligament and serve as a restraint to anteromedial rotatory instability.7,8 In a series of 93 knees treated operatively for medial-side knee injuries by Sims and Jacobson8 of the Hughston Clinic and Tulane, 99% of the knees were found to have injury of the POL ligament and 70% had semimembranosus capsular attachment injuries.
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