Diagnosis and treatment progress in the femoral insertion injury of medial collateral ligament of knee_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WANG Yong , YU Zeping ,  LI Jian , LI Qi

Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

LI Jian, Email: hxlijian@163.com

Keywords：

Knee joint; medial collateral ligament; insertion injury; anatomy

DOI：

10.7507/1002-1892.202211057

Video：

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Objective To summarize the diagnosis and treatment progress in the femoral insertion injury of the medial collateral ligament (MCL) of knee, and to provide a clinical reference for diagnosis and treatment. Methods The literature on the femoral insertion injury of the MCL of knee was widely reviewed. The incidence, mechanisms of injury and anatomy, the diagnosis and classification, and status of treatment were summarized. Results The mechanism of the femoral insertion injury of the MCL of knee is related to its anatomical and histological characteristics, as well as the abnormal valgus of the knee joint, excessive external rotation of the tibial platform and it is classified according to the injury characteristics to guide the refined and individualized clinical treatment. Conclusion Due to different understanding of femoral insertion injury of MCL of knee, the treatment methods are different, and thus is the healing effect. Additional studies are still needed to promote the healing of insertion injuries.

Citation： WANG Yong, YU Zeping, LI Jian, LI Qi. Diagnosis and treatment progress in the femoral insertion injury of medial collateral ligament of knee. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(2): 215-220. doi: 10.7507/1002-1892.202211057 Copy

1.	Andrews K, Lu A, Mckean L, et al. Review: Medial collateral ligament injuries. J Orthop, 2017, 14(4): 550-554.
2.	Vosoughi F, Rezaei Dogahe R, Nuri A, et al. Medial collateral ligament injury of the knee: A review on current concept and management. Arch Bone Jt Surg, 2021, 9(3): 255-262.
3.	Cinque ME, Chahla J, Kruckeberg BM, et al. Posteromedial corner knee injuries: Diagnosis, management, and outcomes: A critical analysis review. JBJS Rev, 2017, 5(11): e4. doi: 10.2106/JBJS.RVW.17.00004.
4.	Luyckx T, Verstraete M, De Roo K, et al. High strains near femoral insertion site of the superficial medial collateral ligament of the Knee can explain the clinical failure pattern. J Orthop Res, 2016, 34(11): 2016-2024.
5.	Patel S, Caldwell JM, Doty SB, et al. Integrating soft and hard tissues via interface tissue engineering. J Orthop Res, 2018, 36(4): 1069-1077.
6.	Memarzadeh A, Melton JTK. Medial collateral ligament of the knee: anatomy, management and surgical techniques for reconstruction. Orthopaedics and Trauma, 2019, 33(2): 91-99.
7.	余正红, 蔡胥, 李鉴轶, 等. 膝内侧稳定结构的解剖特征与软组织平衡的关系. 中国临床解剖学杂志, 2009, 27(4): 371-374.
8.	Encinas-Ullán CA, Rodríguez-Merchán EC. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev, 2018, 3(7): 398-407.
9.	周殿阁, 吕厚山, 方竞, 等. 膝关节侧副韧带解剖特点与膝关节置换股骨假体旋转定位轴线的关系. 中国修复重建外科杂志, 2006, 20(6): 594-597.
10.	Forkel P, Seppel G, Imhoff A, et al. Suturing and refixation of the medial collateral ligament in severe acute medial instability of the knee. Oper Orthop Traumatol, 2015, 27(2): 155-171.
11.	Tadros AS, Huang BK, Pathria MN. Muscle-tendon-enthesis unit. Semin Musculoskelet Radiol, 2018, 22(3): 263-274.
12.	Athwal KK, Willinger L, Shinohara S, et al. The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically. Knee Surg Sports Traumatol Arthrosc, 2020, 28(12): 3709-3719.
13.	Wijdicks CA, Michalski MP, Rasmussen MT, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med, 2013, 41(12): 2858-2866.
14.	Woo SL, Gomez MA, Seguchi Y, et al. Measurement of mechanical properties of ligament substance from a bone-ligament-bone preparation. J Orthop Res, 1983, 1(1): 22-29.
15.	Cooper RR, Misol S. Tendon and ligament insertion. A light and electron microscopic study. J Bone Joint Surg (Am), 1970, 52(1): 1-20.
16.	Doschak MR, Zernicke RF. Structure, function and adaptation of bone-tendon and bone-ligament complexes. J Musculoskelet Neuronal Interact, 2005, 5(1): 35-40.
17.	Georgiev GP, Telang M, Landzhov B, et al. The novel epiligament theory: differences in healing failure between the medial collateral and anterior cruciate ligaments. J Exp Orthop, 2022, 9(1): 10. doi: 10.1186/s40634-021-00440-0.
18.	Liu YX, Thomopoulos S, Birman V, et al. Bi-material attachment through a compliant interfacial system at the tendon-to-bone insertion site. Mech Mater, 2012. doi: 10.1016/j.mechmat.2011.08.005.
19.	Willinger L, Shinohara S, Athwal KK, et al. Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc, 2020, 28(12): 3720-3732.
20.	Lundblad M, Hägglund M, Thomeé C, et al. Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study. Knee Surg Sports Traumatol Arthrosc, 2019, 27(11): 3692-3698.
21.	Marchant MH, Tibor LM, Sekiya JK, et al. Management of medial-sided knee injuries, part 1: medial collateral ligament. Am J Sports Med, 2011, 39(5): 1102-1113.
22.	Elkin JL, Zamora E, Gallo RA. Combined anterior cruciate ligament and medial collateral ligament knee injuries: anatomy, diagnosis, management recommendations, and return to sport. Curr Rev Musculoskelet Med, 2019, 12(2): 239-244.
23.	Jarrett DY, Kramer DE, Laor T. Magnetic resonance imaging of medial collateral ligament avulsion fractures of the knee in children: a potentially underestimated injury. Pediatr Radiol, 2021, 51(9): 1705-1713.
24.	Mendes LF, Pretterklieber ML, Cho JH, et al. Pellegrini-Stieda disease: a heterogeneous disorder not synonymous with ossification/calcification of the tibial collateral ligament-anatomic and imaging investigation. Skeletal Radiol, 2006, 35(12): 916-922.
25.	Hassebrock JD, Gulbrandsen MT, Asprey WL, et al. Knee ligament anatomy and biomechanics. Sports Med Arthrosc Rev, 2020, 28(3): 80-86.
26.	Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med, 2004, 32(2): 337-345.
27.	Narvani A, Mahmud T, Lavelle J, et al. Injury to the proximal deep medial collateral ligament: a problematical subgroup of injuries. J Bone Joint Surg (Br), 2010, 92(7): 949-953.
28.	Phisitkul P, James SL, Wolf BR, et al. MCL injuries of the knee: current concepts review. Iowa Orthop J, 2006, 26: 77-90.
29.	Nakamura N, Horibe S, Toritsuka Y, et al. Acute grade Ⅲ medial collateral ligament injury of the knee associated with anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a treatment regimen. Am J Sports Med, 2003, 31(2): 261-267.
30.	Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 84-90.
31.	Owens BT, Neault M, Benson E, et al. Primary repair of knee dislocations: Results in 25 patients (28 knees) at a mean follow-up of four years. J Orthop Trauma, 2007, 21(2): 92-96.
32.	Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament. Sports Med Arthrosc Rev, 2006, 14(2): 105-110.
33.	Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med, 2006, 34(7): 1134-1140.
34.	Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19, 457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 2450-2459.
35.	孙正宇, 张承昊, 唐新, 等. 一期修复重建膝关节脱位多发韧带损伤的疗效观察. 中国修复重建外科杂志, 2016, 30(6): 690-694.
36.	Dold AP, Swensen S, Strauss E, et al. The posteromedial corner of the knee: anatomy, pathology, and management strategies. J Am Acad Orthop Surg, 2017, 25(11): 752-761.
37.	Tandogan NR, Kayaalp A. Surgical treatment of medial knee ligament injuries: current indications and techniques. EFORT Open Rev, 2017, 1(2): 27-33.
38.	LeVasseur MR, Uyeki CL, Garvin P, et al. Knee medial collateral ligament augmentation with bioinductive scaffold: Surgical technique and indications. Arthrosc Tech, 2022, 11(4): e583-e589.
39.	DeLong JM, Waterman BR. Surgical repair of medial collateral ligament and posteromedial corner injuries of the knee: A systematic review. Arthroscopy, 2015, 31(11): 2249-2255.
40.	Stannard JP, Black BS, Azbell C, et al. Posteromedial corner injury in knee dislocations. J Knee Surg, 2012, 25(5): 429-434.
41.	Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med, 2005, 33(9): 1380-1385.
42.	Kim SJ, Lee DH, Kim TE, et al. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg (Br), 2008, 90(10): 1323-1327.
43.	Abermann E, Wierer G, Herbort M, et al. MCL reconstruction using a flat tendon graft for anteromedial and posteromedial instability. Arthrosc Tech, 2022, 11(3): e291-e300.
44.	Lee DW, Kim JG. Anatomic medial complex reconstruction in serious medial knee instability results in excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc, 2020, 28(3): 725-732.
45.	Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res, 2012, 470(3): 806-814.
46.	Lamplot JD, Rodeo SA, Brophy RH. A practical guide for the current use of biologic therapies in sports medicine. Am J Sports Med, 2020, 48(2): 488-503.

1. Andrews K, Lu A, Mckean L, et al. Review: Medial collateral ligament injuries. J Orthop, 2017, 14(4): 550-554.
2. Vosoughi F, Rezaei Dogahe R, Nuri A, et al. Medial collateral ligament injury of the knee: A review on current concept and management. Arch Bone Jt Surg, 2021, 9(3): 255-262.
3. Cinque ME, Chahla J, Kruckeberg BM, et al. Posteromedial corner knee injuries: Diagnosis, management, and outcomes: A critical analysis review. JBJS Rev, 2017, 5(11): e4. doi: 10.2106/JBJS.RVW.17.00004.
4. Luyckx T, Verstraete M, De Roo K, et al. High strains near femoral insertion site of the superficial medial collateral ligament of the Knee can explain the clinical failure pattern. J Orthop Res, 2016, 34(11): 2016-2024.
5. Patel S, Caldwell JM, Doty SB, et al. Integrating soft and hard tissues via interface tissue engineering. J Orthop Res, 2018, 36(4): 1069-1077.
6. Memarzadeh A, Melton JTK. Medial collateral ligament of the knee: anatomy, management and surgical techniques for reconstruction. Orthopaedics and Trauma, 2019, 33(2): 91-99.
7. 余正红, 蔡胥, 李鉴轶, 等. 膝内侧稳定结构的解剖特征与软组织平衡的关系. 中国临床解剖学杂志, 2009, 27(4): 371-374.
8. Encinas-Ullán CA, Rodríguez-Merchán EC. Isolated medial collateral ligament tears: An update on management. EFORT Open Rev, 2018, 3(7): 398-407.
9. 周殿阁, 吕厚山, 方竞, 等. 膝关节侧副韧带解剖特点与膝关节置换股骨假体旋转定位轴线的关系. 中国修复重建外科杂志, 2006, 20(6): 594-597.
10. Forkel P, Seppel G, Imhoff A, et al. Suturing and refixation of the medial collateral ligament in severe acute medial instability of the knee. Oper Orthop Traumatol, 2015, 27(2): 155-171.
11. Tadros AS, Huang BK, Pathria MN. Muscle-tendon-enthesis unit. Semin Musculoskelet Radiol, 2018, 22(3): 263-274.
12. Athwal KK, Willinger L, Shinohara S, et al. The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically. Knee Surg Sports Traumatol Arthrosc, 2020, 28(12): 3709-3719.
13. Wijdicks CA, Michalski MP, Rasmussen MT, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med, 2013, 41(12): 2858-2866.
14. Woo SL, Gomez MA, Seguchi Y, et al. Measurement of mechanical properties of ligament substance from a bone-ligament-bone preparation. J Orthop Res, 1983, 1(1): 22-29.
15. Cooper RR, Misol S. Tendon and ligament insertion. A light and electron microscopic study. J Bone Joint Surg (Am), 1970, 52(1): 1-20.
16. Doschak MR, Zernicke RF. Structure, function and adaptation of bone-tendon and bone-ligament complexes. J Musculoskelet Neuronal Interact, 2005, 5(1): 35-40.
17. Georgiev GP, Telang M, Landzhov B, et al. The novel epiligament theory: differences in healing failure between the medial collateral and anterior cruciate ligaments. J Exp Orthop, 2022, 9(1): 10. doi: 10.1186/s40634-021-00440-0.
18. Liu YX, Thomopoulos S, Birman V, et al. Bi-material attachment through a compliant interfacial system at the tendon-to-bone insertion site. Mech Mater, 2012. doi: 10.1016/j.mechmat.2011.08.005.
19. Willinger L, Shinohara S, Athwal KK, et al. Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc, 2020, 28(12): 3720-3732.
20. Lundblad M, Hägglund M, Thomeé C, et al. Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study. Knee Surg Sports Traumatol Arthrosc, 2019, 27(11): 3692-3698.
21. Marchant MH, Tibor LM, Sekiya JK, et al. Management of medial-sided knee injuries, part 1: medial collateral ligament. Am J Sports Med, 2011, 39(5): 1102-1113.
22. Elkin JL, Zamora E, Gallo RA. Combined anterior cruciate ligament and medial collateral ligament knee injuries: anatomy, diagnosis, management recommendations, and return to sport. Curr Rev Musculoskelet Med, 2019, 12(2): 239-244.
23. Jarrett DY, Kramer DE, Laor T. Magnetic resonance imaging of medial collateral ligament avulsion fractures of the knee in children: a potentially underestimated injury. Pediatr Radiol, 2021, 51(9): 1705-1713.
24. Mendes LF, Pretterklieber ML, Cho JH, et al. Pellegrini-Stieda disease: a heterogeneous disorder not synonymous with ossification/calcification of the tibial collateral ligament-anatomic and imaging investigation. Skeletal Radiol, 2006, 35(12): 916-922.
25. Hassebrock JD, Gulbrandsen MT, Asprey WL, et al. Knee ligament anatomy and biomechanics. Sports Med Arthrosc Rev, 2020, 28(3): 80-86.
26. Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med, 2004, 32(2): 337-345.
27. Narvani A, Mahmud T, Lavelle J, et al. Injury to the proximal deep medial collateral ligament: a problematical subgroup of injuries. J Bone Joint Surg (Br), 2010, 92(7): 949-953.
28. Phisitkul P, James SL, Wolf BR, et al. MCL injuries of the knee: current concepts review. Iowa Orthop J, 2006, 26: 77-90.
29. Nakamura N, Horibe S, Toritsuka Y, et al. Acute grade Ⅲ medial collateral ligament injury of the knee associated with anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a treatment regimen. Am J Sports Med, 2003, 31(2): 261-267.
30. Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 84-90.
31. Owens BT, Neault M, Benson E, et al. Primary repair of knee dislocations: Results in 25 patients (28 knees) at a mean follow-up of four years. J Orthop Trauma, 2007, 21(2): 92-96.
32. Edson CJ. Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament. Sports Med Arthrosc Rev, 2006, 14(2): 105-110.
33. Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med, 2006, 34(7): 1134-1140.
34. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19, 457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 2450-2459.
35. 孙正宇, 张承昊, 唐新, 等. 一期修复重建膝关节脱位多发韧带损伤的疗效观察. 中国修复重建外科杂志, 2016, 30(6): 690-694.
36. Dold AP, Swensen S, Strauss E, et al. The posteromedial corner of the knee: anatomy, pathology, and management strategies. J Am Acad Orthop Surg, 2017, 25(11): 752-761.
37. Tandogan NR, Kayaalp A. Surgical treatment of medial knee ligament injuries: current indications and techniques. EFORT Open Rev, 2017, 1(2): 27-33.
38. LeVasseur MR, Uyeki CL, Garvin P, et al. Knee medial collateral ligament augmentation with bioinductive scaffold: Surgical technique and indications. Arthrosc Tech, 2022, 11(4): e583-e589.
39. DeLong JM, Waterman BR. Surgical repair of medial collateral ligament and posteromedial corner injuries of the knee: A systematic review. Arthroscopy, 2015, 31(11): 2249-2255.
40. Stannard JP, Black BS, Azbell C, et al. Posteromedial corner injury in knee dislocations. J Knee Surg, 2012, 25(5): 429-434.
41. Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med, 2005, 33(9): 1380-1385.
42. Kim SJ, Lee DH, Kim TE, et al. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg (Br), 2008, 90(10): 1323-1327.
43. Abermann E, Wierer G, Herbort M, et al. MCL reconstruction using a flat tendon graft for anteromedial and posteromedial instability. Arthrosc Tech, 2022, 11(3): e291-e300.
44. Lee DW, Kim JG. Anatomic medial complex reconstruction in serious medial knee instability results in excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc, 2020, 28(3): 725-732.
45. Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res, 2012, 470(3): 806-814.
46. Lamplot JD, Rodeo SA, Brophy RH. A practical guide for the current use of biologic therapies in sports medicine. Am J Sports Med, 2020, 48(2): 488-503.

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Diagnosis and treatment progress in the femoral insertion injury of medial collateral ligament of knee

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