Grade I or II MCL injuries alone or in combination with ACL or PCL injuries can be treated successfully nonoperatively with edema control, bracing, early motion, and functional rehabilita-tion.30,31 Treatment of acute grade III MCL injuries in association with ACL/PCL injuries remains controversial. Treatment recommendations have included nonoperative treatment of the MCL and early reconstruction of the ACL/PCL, nonoperative treatment of the MCL, and delayed cruciate reconstruction, or
Table 56-3 Order of Bicruciate Ligament Reconstruction in the Multiligament Injured Knee
Rights were not granted to include this table in electronic media. Please refer to the printed publication.
ACL, Anterior cruciate ligament; PCL, posterior cruciate ligament. From Cole BJ, Harner CD: The multiligament injured knee. Clin Sports Med 1999;18:241-262.
treatment of all acute grade III injuries.10,31-33 Others have advocated treating grade III MCL tears based on the location of the tear, selecting nonoperative treatment for proximal or midsub-tance tears, and treating more distal tears with early repair because of a propensity for poor healing.34,35 It is important to check for involvement of the posteromedial capsule. If patients have laxity to valgus stress in full extension with associated rotatory instability, acute repair of the MCL and posteromedial capsule is warranted. Regardless of the protocol chosen, important principles to follow include accurate diagnosis of both the degree of medial instability and the location of the acute injury. All tools of diagnosis must be used including initial examination, examination under anesthesia, MRI (Fig. 56-7), and arthroscopic findings (Fig. 56-8).
Repair of acute medial instability is performed through a straight medial incision extending from the medial epicondyle to 4 cm distal to the joint line. Care must be taken to protect the saphenous nerve. This approach allows access to the superficial MCL, deep MCL, medial meniscus, and posteromedial
capsular structures. The superficial MCL should be isolated and the zone of injury identified. The injury will usually be located either proximally or distally, allowing the ligament to be tagged with a locking whipstitch and reflected to allow access to deep structures. Tears in the deep MCL and meniscal capsular attachments are repaired using a minimum of three suture anchors placed just below the articular margin. The posteromedial capsule should be evaluated and repaired mid-substance or reat-tached with suture anchors if avulsed. The superficial MCL can then be repaired to its anatomic position either proximally or distally and secured with a spiked washer or suture anchors. In cases in which the superficial MCL is injured mid-substance, the repair may be augmented with either a hamstring autograft or an allograft. The medial-side repair should be completed prior to final fixation of the cruciate ligaments.
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