Torn MCL ligament : Medial collateral ligament: a very common injury

Torn MCL from femoral insertion.


Repair of torn MCL from Tibial insertion.

PCL reconstruction : We do PCL with an All arthroscopic technique using 2 posteromedial portals.

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Knee Ligament   ACL/PCLmultipleligaments                               
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Arthroscopy has set up major advancement in the treatment of knee ligament injuries.

ACL is the most common of the knee ligament torn. It can be reconstructed arthroscopically. Following this surgery the results are good and most patients can even participate in sport activity.

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The anterior cruciate ligament, or ACL, is one of four major knee ligaments. The ACL is critical to knee stability, and people who injure their ACL often complain of symptoms of their knee giving-out from under them. Therefore, many patients who sustain an ACL tear opt to have surgical treatment of this injury.An ACL tear is most often a sports-related injury. ACL tears can also occur during rough play, mover vehicle collisions, falls, and work-related injuries. About 80% of sports-related ACL tears are "non-contact" injuries. This means that the injury occurs without the contact of another athlete, such as a tackle in football. Most often ACL tears occur when pivoting or landing from a jump. The knee gives-out from under the athlete when the ACL is torn. 

Female athletes are known to have a higher risk of injuring their anterior cruciate ligament, or ACL, while participating in competitive sports.The diagnosis of an ACL tear is made by several methods. Patients who have an ACL tear often have sustained an injury to the knee. The injury is often sports-related. They may have felt a "pop" in their knee, and the knee is giving out from under them. 
ACL tears cause knee swelling and pain.
An MRI may also be used to determine if the ligament is torn, and also to look for signs of any associated injuries in the knee.

If surgery is required, it is a relatively simple operation and has a short post-surgery heal time. The surgeon will go in and either sew up the meniscus tear or shave off portions of the injured cartilage, depending on the ACL injury. After surgery the patient will have to wear a knee brace to limit movement, but should be back to regular activities in a few weeks. Sports and other physical activity should be avoided until cleared by a doctor, usually 6-8 weeks after surgery.

When performed by an experienced surgeon, approximately 98% of patients that receive meniscus tear, or ACL injury repair surgery, report positive results. It should be noted that patients that suffer from a knee injury, will develop an increased risk of developing arthritis later in life.

MRI of a patient showing torn ACL.

Most ACL injuries may be diagnosed through a careful history emphasizing mechanism of injury coupled with a good physical examination.

 Remember that a previous ligamentous injury may be the cause of instability. When discussing the history, be sure to document mechanism of injury for this episode and any previous episodes.

  • Noncontact injury
    • An audible pop often accompanies this injury, which often occurs while changing direction, cutting, or landing from a jump (usually a hyperextension/pivot combination).
    • Within a few hours, a large hemarthrosis develops.
    • Patients usually are unable to return to play, secondary to pain, swelling, and instability or giving way of the knee.
  • Contact and high-energy traumatic injuries
    • These injuries often are associated with other ligamentous and meniscal injuries.

    Associated risk factors include the following:

  • High-risk sports
    • Based on a study performed by Kaiser Permanente, football, baseball, soccer, skiing, and basketball account for up to 78% of sports-related injuries.
    • Hewson and associates found a 100-fold increase in the incidence of ACL injury in college football players when compared to the general population.
  • Sex
    • Female athletes are more susceptible to ACL injuries. Studies have shown a 2-fold increase in collegiate soccer players and a 4-fold increase in basketball compared with their male counterparts.
    • Differences may be due to experience, differences in training, different strength-to-weight ratios, limb alignment, joint laxity, muscle recruitment patterns, and notch index, but further studies to document a definitive cause are ongoing. One study has determined that ACL laxity does not vary with the menstrual cycle, thus dismissing this possible etiology.
  • Femoral notch stenosis (the ratio of the femoral notch width to the width of the femoral condyles)
    • A notch width index of less than 0.2 is defined as notch stenosis.
    • Individuals with notch stenosis have a higher risk of noncontact ACL injuries.
  • Footwear: Cleats, which have a predominant grip on the periphery, have a higher coefficient of friction on artificial turf and may result in a higher incidence of ACL injuries.
Physical Therapy

Before any treatment, encourage strengthening of the quadriceps and hamstrings, as well as ROM exercises. Performance of ROM helps reduce the amount of effusion and helps the patient regain motion and strength.

Surgical Intervention

When deciding whether to perform reconstructive surgery, the physician should consider the following factors:

  • Preinjury activity level
  • Desire to return to high-demand sports (eg, basketball, football, soccer)
  • Associated injuries
  • Abnormal laxity
  • Patient's expectations

Generally, the older recommendation is that surgical intervention be delayed at least 3 weeks following injury to prevent the complication of arthrofibrosis. But with modern techniques surgical reconstruction can be carried out immediately after the injury without any significant complications.The methods of surgical repair may be categorized into 3 groups, primary repair, extra-articular repair, and intra-articular repair.

  • Intra-articular reconstruction of the ACL has become the criterion standard for treating ACL tears.
  • Bone-patella-bone autografts are currently popular because they yield a significantly higher percentage of stable knees with a higher rate of return to preinjury sports. The major pitfall of these grafts is their association with postoperative anterior knee pain (10-40%).
  • Hamstring tendon grafts are associated with a faster recovery and less anterior knee pain.Advance hospital uses Hamstring autograft in most of its cases. Critics believe that these are more susceptible to graft elongation. But in our own follow ups we have not seen any problems in long term outcomes of hamstring graft