Knee medial injury are those on the medial side - the inside of the knee - are the most common. The medial knee ligament complex consists of superficial medial collateral ligaments (sMCL), deep medial collateral ligaments (dMCL), and posterior oblique ligaments (POL). These ligaments have also been called medial collateral ligament (MCL), tibial collateral ligament, third capsule ligament, and sMCL tilting fiber, respectively. This complex is the main stabilizer of the medial knee. Injury to the medial side of the knee is most often isolated to this ligament. A thorough understanding of the anatomy and function of the medial knee structure, along with a detailed history and physical examination, is essential for diagnosing and treating this injury.
Video Medial knee injuries
Symptoms
Patients often complain of pain and swelling over the medial aspect of the knee joint. They can also report instability with side-to-side motion and during athletic performance involving cuts or pivots.
Complications
Jacobson previously described a common problem for medial knee surgery. It is emphasized that an adequate diagnosis is imperative and all injuries that may have to be evaluated and handled intraoperatively. Damage to the saphenous nerve and infrapatellar branches is possible during medial knee surgery, potentially causing numbness or pain over the medial knee and leg. Like all operations, there is a risk of bleeding, wound problems, blood vessel blockage, and infections that can complicate the rehabilitation outcome and process. Long-term complications of heterotopic arthrofibrosis and ossification (Pellegrini-Stieda syndrome) are the best-handled problems with the initial range of motion and following established rehabilitation protocols. Graft failure due to intrinsic mechanical strength must be prevented by proper preoperative alignment assessment (osteotomy treatment) and appropriate rehabilitation.
Maps Medial knee injuries
Cause
Knee medial injury is usually caused by a valgus knee force, a tibial external rotational force, or a combination of both. This mechanism is often seen in sports involving aggressive knee flexions such as ice hockey, skiing, and soccer.
Anatomy and Function
The structures on the medial side of the knee include the tibia, femur, meditic obliquus, semitendinosus tendons, gracilis tendons, sartorius tendons, adductor magnus tendons, gastrocnemius muscle medial head, semimembranosus tendon, medial meniscus, medial patellofemoral ligament (MPFL), sMCL, dMCL, and POL. It has been found that the most important structures for stabilization in these knee areas are ligaments: sMCL, dMCL, and POL.
Bone
The knee bone is the femur, the patella, the tibia, and the fibula. The fibula is on the lateral side of the knee and the patella has little effect on the medial side of the knee. The harmony of the medial knee bone consists of the opposite surface of the medial femoral condyle and the medial tibial plateau. In the medial femoral condyle there are three important bone landmarks: the medial epicondyle, adductor tubercle, and gastrocnemius tubercle. The medial epicondyle is the most distal and anterior advantage. The adductor tubercle is only proximal and posterior to the medial epicondyle. The gastrocnemius tubercle is only distal and posterior to the adductor tubercle.
Biomechanical Ligaments and Functions
SMCL connects the femur to the tibia. It originates only proximal and posterior to the medial epicondyle (not directly on the epicondyle) and is divided into two distinct parts. One part of the tibia attaches to the soft tissue, 1 cm distal to the joint line. The other tibia part attaches directly to the tibia, anterior to the posteromedial tibial peak, 6 cm distal to the joint line. This distal attachment is stronger than the two and forms the floor of anserine pessa. The proximal tibia sMCL is the main stabilizer for valgus strength in the knee, whereas distal tibialis is the main stabilizer of external rotation at 30 ° of knee flexion.
The dMCL is thickening of the medial aspect of the capsule around the knee. It comes from the distal 1 cm femur to the origin of sMCL and inserts 3-4 mm distal to the joint line. It runs parallel to and under sMCL. The dMCL connects directly to the medial meniscus and can therefore be divided into meniscofemoral and meniscotibial ligaments.
Meniscofemoral ligaments are longer than the meniscotibial ligaments, which are shorter and thicker in nature. The meniscofemoral ligament is the primary internal rotational stabilizer and secondary external rotation stabilizer, activated when sMCL fails. The meniscotibial ligament serves to stabilize internal rotation on a secondary basis.
POL (referred to by the old texts: oblique part of sMCL) is the expansion of the fascia with three main components: superficial, central (tibial), and capsular. The center arm is the strongest and thickest. It arises from the semimembranosus tendon and connects anteriorly and distally to the gastrocnemius tubercle via the posterior joint capsule. POL, therefore, is not a stand-alone structure, but a thickening of the posteromedial joint capsule. It stabilizes the internal rotation of the knee through all degrees of flexion but bears the most load when internally rotated in full extension. It also acts as a secondary external rotational stabilizer.
MPFL arises from the muscle fibers of the vastus medialis obliquus and is attached distally to the superior medial aspect of the patella. This ligament serves to keep the patella inside the trochlear groove during flexion and extension. Rarely injured due to medial knee injury unless there is subluxation or lateral patellar lateral dislocation.
Tendons & amp; Muscle
The adductor magnus tendon attaches to the distal medial femoral condyle only posteriorly and proximal to the adductor tubercle. It has a fascial expansion in the distal-medial aspect attached to the medial gastrocnemius tendon, the capsular arm of the POL, and the posteromedial joint capsule. The distal laterally distal aspect attaches to the medial supracondylar ridge. The adductor magnus tendon is an excellent and consistent landmark because it is rarely injured. The vastus medialis obliquus course muscles above the anteromedial thighs, attaching along the anterior magnetic adductor border and into the quadratus femoral tendon. The medial gastrocnemius tendon appears proximal and posterior to the gastrocnemius tubercle of the medial femoral condyle. This is another important landmark because it is rarely injured and attached closely to the capsular arm of POL, thus helping the surgeon discover the femoral attachment of POL.
Diagnosis
The majority of medial knee injuries are isolated ligament injuries. Most patients will tell a history of a traumatic blow to the lateral aspect of the knee (causing valgus strength) or non-contact valgus strength. Acute injuries are more easily diagnosed clinically, while chronic injuries may be less obvious because of difficulties in differentiating from lateral knee injuries, possibly requiring valgus stress radiographs.
Physical Exam
Physical examination should always begin with a visual examination of the joints for each trauma out sign. Palpation should follow attention to subjective effusions and tenderness during the exam. Practitioners should also evaluate contralateral knee (not injured) to note differences in appearance and landmarks. Palpation should focus specifically on the meniscofemoral and meniscotibial aspects of sMCL. It has been reported that injury to one other opponent has implications for healing, so localization of the location of the injury is favorable. Knee joint testing should be performed using the following techniques and findings compared with the contralateral, normal knee:
- Valgus pressure at 0Ã, Â ° and 20Ã, Â ° - This test places direct pressure on the medial structure of the knee, reproducing the injury mechanism. Valgus stress testing is performed with the patient supine at the exam table. Lower limb, supported by examiner, kidnapped. The radius of the examiner monitors the medial joint space to close while placing the opposite hand at the ankle. The knee is placed at 20 ° of flexion. Examiners then use their own thighs as a fulcrum in the knee and apply valgus strength (pulling the legs and ankles away from the patient's body). This style is then used to determine the amount of gapping present in the joint. It has been reported that 20 Â ° of flexion is best to isolate sMCL, allowing practitioners to establish the extent of injury (see Classification). Additional testing is performed at 0 ° to determine if there is a Grade III injury.
- Anteromedial drawer test - This test is performed with the patient supine with knees bent up to 80-90 Â °. The legs are rotated externally 10-15 Â ° and the examiner supplies the anterior and external rotational forces. The joint can then be evaluated for tibial anteromedial rotation, taking into account possible posterolateral angular instability that provides similar rotation test results. As always, compare tests on opposite knees.
- Dial test (anteromedial rotation test) - This test should be performed with the patient lying on his back and stomach. When the patient is supine, the knee should bend 30 Â ° from the table. The thigh is then stabilized and the foot is rotated externally. The examiner watches the tibia tuberculum of the affected knee to rotate when the leg is spinning, comparing it with the contralateral knee. A positive test will show a larger rotation of 10-15 Â ° rotation compared to the opposite knee. This is most easily assessed by hand placed over the tibia during testing. When the patient is susceptible, the knee is flexed to 90 ° and both legs are externally and compared, noting the difference from the unharmed joint. Similar to anteromedial drawer tests, a false-positive test can result from a posterolateral angle injury. Tests at 30 ° and 90 ° help to differentiate between these injuries: one should monitor where the tibial rotation occurs (anteromedially or posterolaterally) in the supine position and also assess for medial or lateral line gaps to distinguish between these two injuries./li>
Classification
The grading of the medial knee injury depends on the amount of joint medial crevice space found on testing the valgus stress with the knee at 20 ° of flexion. Grade I injuries do not have clinical instability and are only associated with tenderness, representing a mild sprain. Grade II injury has a wide tenderness above the medial knee and has some gapping with a strong endpoint during valgus testing; this is a partial tear of the ligaments. The Grade III injury has a complete ligament rupture. There will be no end point to test valgus stress. Historical quantification definitions of classes I, II, and III represent 0-5 mm, 5-10 mm, and & gt; 10 mm medial gap compartment, respectively. LaPrade et al. reported, however, that the simulation of grade III injury sMCL showed only a 3.2 mm increase in medial compartment gap compared with intact circumstances. In addition, with the knee in full extension, if the valgus stress test revealed more than 1-2 mm from the present medial compartment lump, the anterior cruciate ligament (ACL) ligament or posterior ligament injury (PCL) is suspected.
Radiography
Anterior-posterior (AP) radiographs are useful for reliably assessing normal anatomical landmarks. A picture of bilateral valve pressure AP can show differences in the medial joint spacing. It has been reported that sMCL tear level III will show a medial improvement of the 1.7 mm gapping compartment at 0 Â ° of knee flexion and 3.2 mm at 20 ° of flexed knee, compared with the contralateral knee. In addition, complete medial ligament disorder (sMCL, dMCL, and POL) will show a gap increase of 6.5 mm at 0 Â ° and 9.8 mm at 20 Â ° during valgus stress testing. Pellegrini-Stieda syndrome can also be seen on AP radiography. This finding is due to calcification of sMCL (heterotopic ossification) caused by chronic ligament tear.
MRI
Magnetic resonance imaging (MRI) may be helpful in assessing ligament injury on the medial side of the knee. Milewski et al. have found that class I to III classifications can be seen in MRI. With high-quality images (1.5 tesla or 3 tesla magnet) and no prior knowledge of the patient's history, the musculoskeletal radiologist can accurately diagnose a medial knee injury of 87% of the time. MRI can also show bruises on the lateral side of the knee, as demonstrated by one study, occurring in nearly half of medial knee injuries.
MRI knee should be avoided for knee pain without mechanical symptoms or effusion, and on the unsuccessful results of a functional rehabilitation program.
Treatment
Medial knee injury treatment varies depending on the location and classification of injuries. The consensus of many studies is that isolated grade I, II, and III injuries are usually best suited for non-operative treatment protocols. Class III acute injury with concurrent multilateral injury or knee dislocation involving a medial side injury should undergo surgical treatment. Class III chronic injury should also undergo surgical treatment if the patient experiences rotational instability or side-to-side instability.
Nonoperative Treatment
Conservative treatment of an isolated medial knee injury (level I-III) begins by controlling the swelling and protecting the knee. Swelling is well managed with rest, ice, elevation, and compression wrapping. Protection can be performed using a hinged brace that stabilizes against varus and valgus stress but allows full flexion and extension. Brace should be used for the first four to six weeks of rehabilitation, especially during physical exercise to prevent trauma to the healing ligament. Stationary bike exercise is a recommended exercise for active range of motion and should be improved as tolerated by the patient. Movement from side to side of the knee should be avoided. Patients are allowed to bear the weight as tolerated and should perform strength exercises of the quads along with various motion exercises. The typical return-to-turn time frame for most athletes with grade III medial knee injuries undergoing rehabilitation programs is 5 to 7 weeks.
Operation Maintenance
It has been reported that acute and chronic medial grade III knee injuries often involve sMCL in combination with POL. Direct surgical repair or reconstruction, therefore, should be done for these two ligaments as both play an important role in static medial knee stability. A biomechanically validated approach is to reconstruct both POL and the two sMCL divisions.
Cries of Severe Intelligence
Surgery involving direct repair (with or without augmentation from hamstring autograft), among previously used techniques, has not been tested biomechanically. The reconstruction of the anatomy of sMCL and POL has been validated biomechanically.
Chronic Instability
The underlying cause of chronic medial knee instability should be identified before surgical reconstruction is performed. More specifically, patients with genus valgum (knock-kneed) alignment should be evaluated and treated with osteotomy (s) to establish a balanced force in the knee ligaments, preventing premature failure of reconstruction of the cruciate ligaments simultaneously. These patients should be rehabilitated after osteotomy heals before it can be verified that they still have no functional limitations. Once proper alignment is achieved, reconstruction can be performed.
Anatomic Medial Knee Reconstruction
This technique, described in detail by LaPrade et al., Uses two grafts in four separate tunnels. The incision is made above medial knee 4 cm medial to the patella, and extended 7 to 8 cm across the joint line, directly above the anserin pes plexus.
Within the distal boundary of the incision, the semitendinosus and gracilis tendons are found beneath the sartorius muscle fascia. The distal tibial appendix of sMCL can be found beneath this identified tendon, making the floor of anserine burst, 6 cm distal to the joint line. Once identified, the remaining soft tissues will be removed from the attachment site. A hole pin is then drilled through the transverse attachment site through the tibia, ensuring the starting point lies in the posterior aspect of the site to ensure better biomechanical results. At the eyepiece pin, a 7-mm enhancer (6 mm is considered in a smaller patient) is named to a depth of 25 mm. Once prepared, attention is directed to preparing the reconstruction tunnel for the installation of the POL tibial. Above the attachment of the anterior arm of the semimembranosus muscle tendon, the attachment of the POLP central arm tibia is identified. This attachment is exposed by making a small incision parallel to the fibers along the posterior edge of the anterior arm of the semimembranosus tendon. After exposure, the hole pins are drilled through the tibia to Gerdy's tubercle (anterolateral tibia). After verifying the correct pin placement of the anatomical hole, a 7-mm reamer is used above the pin to drill a 25 mm tunnel depth.
Moving to the femoral ligament attachment, the first step is to identify the adductor magnus muscle tendon, and the appropriate attachment site, near the adductor tubercle. Only distal and slightly anterior to the tubercle is the superiority of the bone of the medial epicondyle. The sMCL attachment site can be identified slightly proximal and posterior to the epicondyle. A hole pin can now be passed across the femur on this site. Tunnels at this location, however, should be drilled after identifying the POL attachment site.
The next step to identify the POL femoral attachment is by placing the gastrocnemius tubercle (2.6 mm distally and 3.1 mm anteriorly to the attachment of the medial gastrocnemius tendon on the femur). If the posteromedial capsule is not intact, the POL attachment site is located 7.7 mm distally and 2.9 mm anterior to the gastrocnemius tubercle. With an intact capsule, however, an incision is made along the posterior aspect of sMCL, parallel to the fiber. The center arm of POLRI can be found at its femoral attachment site. Once identified, the hole pin is passed across the thigh bone. The distance between the femoral attachment sites of POL and sMCL (average, 11mm) should now be measured to verify that the anatomical attachment site has been correctly identified. Once this is done, the femoral tunnel for sMCL and POL can be reamed to a depth of 25 mm using a 7-mm reamer.
The next aspect of surgery is the preparation and placement of the reconstruction graft. Preparation can be done while other steps are being completed by a surgeon or another physician's assistant. The semitendinosus tendon can be harvested using a hamstring stripper to be used as an autograft reconstruction. Autograft divided into 16-cm long for sMCL reconstruction and 12 cm long for POL reconstruction. This length is also used if the operation is performed with cadaver allograft. The sMCL and POL grafts are drawn into each femoral tunnel and each is secured with a cannulated bioabsorption screw. The grafts are passed distally along their original program to the tibial attachment. SMCL is passed under sartorius fascia (and remaining sMCL fiber). Both grafts are passed (but not yet secured) to each tibial tunnel using the existing hole pins. If simultaneous cruciate ligament surgery is in progress, cruciate reconstruction is secured before securing the medial ligament.
Secure POL graft is done with full knee extension. The graft is drawn tight and fixed using a bioabsorbable screw. Knee then bent to 20 Â °. Ensuring the tibia remains in neutral rotation, the varus force is used to ensure there is no knee medial compartment gap. The sMCL graft is then fastened and fixed with a bioabsorbable screw.
The final step of ligament reconstruction is the proximal tibial installation of sMCL. This soft tissue attachment can be reproduced with an anchor of the seams placed 12.2 mm distal to the medial joint line (median location), directly medial to the anterior arm of the semibembranosus tibial attachment. After this aspect of sMCL is secured to the stitching anchor, the knee is inserted through various tests of motion by the physician to determine the "safe zone" of knee motion used during the first postoperative rehabilitation (below).
Rehabilitation
- Nonoperative Rehabilitation As mentioned in the Nonoperative Treatment section, the principles of rehabilitation are to control swelling, protect the knee (strengthen), reactivate the quadriceps muscle , and restore the range of motion. Early weightbearing is recommended as tolerable, using as few crutches as possible, with the aim of walking without limping. Stationary cycling is the preferred range of motion exercises, stimulating the ligaments to recover faster. The time on the bike and the resistance should be increased as tolerated by the patient. Side-to-side movement should be limited to 3 to 4 weeks to allow for adequate healing. Proprioceptive and balance activities may develop after clinical examination or radiographic valgus stress reveals healing. Athletes can often resume full activity within 5 to 7 weeks after an isolated sMCL injury. Postoperative rehabilitation The postoperative rehabilitation protocol for reconstruction or improvement of knee medial injury focuses on protecting ligaments/grafts, managing swelling, reactivating the quads, and setting the range of motion. A variety of safe movements ("safe zones") should be measured by intraoperative surgeons and forwarded to rehabilitation specialists to prevent excess ligament suppression during rehabilitation. The ideal passive range of motion is 0 to 90 Â ° flexion in one postoperative day after surgery and should be followed for 2 weeks, as tolerated, with a goal of 130 Â ° flexion at the end of week 6. To protect the newly reconstructed ligaments, a hinged knee brace should be used. Swelling should be managed with cryotherapy and compression. Patellofemoral mobilization, quadriceps reactivation, and ankle pumps are often also used right after surgery to prevent arthrofibrosis. The non-heavy bearings to the dimming weight pads are recommended for the first 6 weeks, continuing into the closed kinetic chain exercises thereafter. Light-duty stationary cycling also starts at 2 weeks and can be increased as tolerated. The mechanical way of walking is aimed when the patient is able to hold their weight completely. The patient should be able to walk without a limp or develop swelling in the joints. Rehabilitation can only move as fast as tolerance and effusion should be monitored and managed at all times to ensure good results. After movement, strength, and balance again, plyometric and agility exercises begin at 16 weeks. Fast roads for 1 to 2 miles should be well tolerated before the patient starts the jogging program. Back to sports can be assessed at this time, without any functional deficits or stability present. Rehabilitation should be supervised by a professional specialist working with the surgeon. The protocol may be adapted for the concurrent ligament reconstruction or osteotomy. Valgus stress AP radiography (mentioned above) is an excellent and cost-effective way to monitor results and post-operative follow-up.
History
During the Troubles in Northern Ireland, paramilitaries consider themselves law enforcers in their own territory. They use the shooting of limbs to punish the petty criminals and others whose conduct is considered unacceptable. If the crime was considered a grave, the victim was also shot in the ankle and elbow, leaving them with six gunshot wounds (colloquially known as a six pack). Around 2,500 people became victims of this shooting during the conflict. Those who are attacked carry social stigma with them.
The Red Brigade, an Italian militant organization, used the shooting of this punishment to warn their opponents. They used this method to punish at least 75 people until December 1978. Recently a type of shoot-out has been used by Hamas in the Gaza Strip to silence their political opponents.
Bangladesh police have begun beatings in the country since 2009 to punish opposition and prevent them from participating in protests against the government. Human Rights Watch (HRW) has published a report on kneecap in Bangladesh.
Further research
Future research with regard to medial knee injury should evaluate the clinical outcomes between different reconstructive techniques. Determining the advantages and disadvantages of these techniques will also be useful for optimizing treatment.
References
Source of the article : Wikipedia
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