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PubMed1984

Rotatory instability of cadaver knees after transection of collateral ligaments and capsule.

The importance of the medial and lateral compartment ligaments of the knee in relation to valgus-varus and axial rotation instability was investigated. Mobility patterns were drawn from 20 osteoligamentous knee preparations after successive transections of the structures. Cutting of the medial collateral ligament resulted only in slight valgus instability and modest anteromedial instability. When the medial posterior joint capsule was also cut, both types of instability increased, and moreover, the knee became posteromedially unstable. Cutting of the lateral collateral ligament produced only a little varus instability and anterolateral rotatory instability, but varus instability increased considerably when the posterior lateral capsule was also transected. In this latter situation, even marked posterolateral rotatory instability was found. Isolated transection of the medial or lateral collateral ligament did not cause any major valgus or varus instability, but when the posterior capsule was also transected, a considerable degree rotatory instability could be found even though the cruciate ligaments were intact.

Biomechanical Phenomena↗
PubMed1981

[Surgical treatment of lesions of the cruciate and collateral ligaments of the knee].

The paper describes a number of patients operated for recent lesions of cruciate anterior ligament associated with lesions of internal collateral ligament. Patients were controlled after a time from operation of a 4 months- 4 years. For an exact functional valuation, a personal protocol was used, elaborated from the methods of the Orthopedic School of Lion. In the majority of cases, the trauma was secondry to sport practice, expecially sky. The technique used were the O'Donoghue one for cruciate ligament and the Vigliani one for collateral. Results were in all cases very good.

Humans↗
PubMedDate not supplied

Surgical treatment of bi- and trimalleolar ankle fractures: should the medial collateral ligament be sutured or not?

In Weber type A, B, and C fractures there is no census or whether or not to suture the ruptured medial collateral ligament. From May 1990 to December 1994, operations were performed on 48 patients with such lesions. Thirty-three cases were reviewed, 29 males and four females, with an average age of 39 years (range, 15-73 years). In 22 cases there was an isolated fracture of the lateral malleolus, and in 11 cases the fracture was associated with a posterior malleolus fracture. There were tibiotalar dislocations in nine cases. Fifty-eight percent of the injuries were caused by sports activities and 27% by an ordinary fall. After a preoperative external reduction, the lateral and posterior (if necessary) fractures were anatomically and rigidly fixed (plate, pins, and wire) without any suture of the medial ligament. Medial tibiotalar and tibiofibular diastasis were totally reduced as shown during intraoperative radiographs. The follow-up at time of review was 27 months on average (range, 9 months-5 years). Functional results were excellent and good in 82.5% of cases, with a return to sports activities at a mean time of 4.3 months. X-rays were considered as normal in 73% of cases, with an anterior impingement syndrome in 15% and calcifications of the medial collateral ligament in 12%. Stress radiographs in valgus talar tilt (n = 24) were normal in all cases. The authors suggest new surgical guidelines in ankle fractures with a medial collateral rupture, based on fracture stabilization, with ligament tears left unexplored (medial, tibiofibular, and syndesmotic ligaments), and early mobilization.

Adolescent↗
PubMed1994

Snow skiing combined anterior cruciate ligament/medial collateral ligament disruptions.

Recent reports indicate that combined anterior cruciate ligament/medial collateral ligament (ACL/MCL) knee injuries are usually associated with a lateral meniscus tear. In our center, snow skiing is the athletic activity most frequently associated with this double-ligament injury complex. A sports-specific analysis was undertaken to evaluate the hypothesis that the snow skiing ligament injury is different from similar injuries caused by other athletic activities. Of a total of 64 acute arthroscopically confirmed tears of both the MCL and ACL, 23 were caused by snow skiing and 41 by nonskiing activities. There were fewer lateral meniscus tears in skiers (43%) when compared with the nonskiers (88%). Skiers also had fewer medial meniscus tears (13%) than did nonskiers (37%). No medial meniscus tears occurred in the absence of a lateral meniscus tear. Although 78% of the skiers were women, only 12% of the nonskiers were women. Skiers were older (average age 35 years) than the nonskiers (average age 28 years). The right knee was injured almost twice as frequently as the left. These data suggest that the double (ACL/MCL) ligament injury in skiers might be distinctly different from that in nonskiers.

Adolescent↗
PubMed1997

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor.

Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.

Acute Disease↗
PubMed2003

Subject-specific finite element analysis of the human medial collateral ligament during valgus knee loading.

The objectives of this study were (1) to develop subject-specific experimental and finite element (FE) techniques to study the three-dimensional stress-strain behavior of ligaments, with application to the human medial collateral ligament (MCL), and (2) to determine the importance of subject-specific material properties and initial (in situ) strain distribution for prediction of the strain distribution in the MCL under valgus loading. Eight male knees were subjected to varus-valgus loading at flexion angles of 0 degrees, 30 degrees, and 60 degrees. Three-dimensional joint kinematics and MCL strains were recorded during kinematic testing. Following testing, the MCL of each knee was removed to allow measurement of the in situ strain distribution and to perform material testing. A FE model of the femur-MCL-tibia complex was constructed for each knee to simulate valgus loading at each flexion angle, using subject-specific bone and ligament geometry, material properties, and joint kinematics. A transversely isotropic hyperelastic material model was used to represent the MCL. The MCL in situ strain distribution at full extension was used to apply in situ strain to each MCL FE model. FE predicted MCL strains during valgus loading were compared to experimental measurements using regression analysis. The subject-specific FE predictions of strain correlated reasonably well with experimentally measured MCL strains (R(2)=0.83, 0.72, and 0.66 at 0 degrees, 30 degrees, and 60 degrees, respectively). Despite large inter-subject variation in MCL material properties, MCL strain distributions predicted by individual FE models that used average MCL material properties were strongly correlated with subject-specific FE strain predictions (R(2)=0.99 at all flexion angles). However, predictions by FE models that used average in situ strain distributions yielded relatively poor correlations with subject-specific FE predictions (R(2)=0.44, 0.35, and 0.33 at flexion angles of 0 degrees, 30 degrees, and 60 degrees, respectively). The strain distribution within the MCL was nonuniform and changed with flexion angle. The highest MCL strains occurred at full extension in the posterior region of the MCL proximal to the joint line during valgus loading, suggesting this region may be most vulnerable to injury under these loading conditions. This work demonstrates that subject-specific FE models can predict the complex, nonuniform strain fields that occur in ligaments due to external loading of the joint.

Adult↗
PubMed2000

Proteoglycan metabolism during repair of the ruptured medial collateral ligament in skeletally mature rabbits.

The metabolism of the chondroitin/dermatan sulfate (CS/DS) proteoglycans (PGs) decorin and biglycan is markedly altered during short-term (3-6 weeks) and long-term (40 weeks-2 years) repair of surgically ruptured medial collateral ligaments from mature rabbits. A PG-rich extracellular matrix accumulates in injury gaps by 3 weeks postsurgery and extends into tissue regions containing the original ligaments, and elevated PG levels remain apparent up to 2 years postinjury. CS/DS PGs were prepared from such ligaments and identified after SDS-polyacrylamide gel electrophoresis by Alcian blue staining or immunoblotting. In normal ligaments, decorin is the most abundant proteoglycan (accounting for approximately 80% of the total); the remainder is biglycan and a large PG, possibly versican. In repairing ligaments, decorin is barely detected, but instead a large proteoglycan and abundant amounts of biglycan accumulate. Biglycan is present in two forms in repairing ligaments, and they can be separated on SDS-PAGE into 200- and 140-kDa forms. The slower migrating species is absent in normal ligaments and may represent a different glycoform (containing either a single or two short chondroitin/dermatan sulfate chains) of biglycan. Alteration in PG expression and posttranslational processing during medial collateral ligament repair are similar to those reported for repair and scar formation of other connective tissues. The accumulation of biglycan observed here may interfere with proper collagen network remodeling and may lead to persistent inflammatory and matrix turnover processes, thus preventing restoration of a long-term functional ligament tissue.

Animals↗
PubMed2003

The two-level ulnar collateral ligament injury of the metacarpophalangeal joint of the thumb.

Ulnar collateral ligament injuries of the thumb may present as avulsion fractures of the bone or as ligamentous tears. Displaced fracture fragments or Stener lesions demand operative management. Occasionally, both fracture and ligamentous tears may occur simultaneously, and the management of the ligamentous aspect may be overlooked in cases with undisplaced fractures leading to failure of non-operative treatment. It is important in cases with a relatively undisplaced fracture fragment to exclude a simultaneous ligamentous tear and Stener lesion by careful clinical examination and by examining the radiographs for telltale displaced flecks of bone.

Adult↗
PubMed1986

Reconstruction of the ulnar collateral ligament in athletes.

Reconstruction of the ulnar collateral ligament using a free tendon graft was performed on sixteen athletes. All participated in sports that involved throwing (mostly professional baseball), and all had valgus instability of the elbow. After reconstruction and rehabilitation, ten of the sixteen patients returned to their previous level of participation in sports, one returned to a lower level of participation, and five retired from professional athletics. Despite precautions, there was a high incidence of complications related to the ulnar nerve. Two patients had postoperative ulnar neuropathy (one late and one early) that required a secondary operation, but they eventually recovered completely. Three others reported some transient postoperative hypoesthesia along the ulnar aspect of the forearm that resolved after a few weeks or months.

Adult↗
PubMed1997

Biomechanical evaluation of the medial collateral ligament of the elbow.

UNLABELLED: Anatomical dissection and biomechanical testing were used to study twenty-eight cadaveric elbows in order to determine the role of the medial collateral ligament under valgus loading. The medial collateral ligament was composed of anterior, posterior, and occasionally transverse bundles. The anterior bundle was, in turn, composed of anterior and posterior bands that tightened in reciprocal fashion as the elbow was flexed and extended. Sequential cutting of the ligament was performed while rotation caused by valgus torque was measured. The anterior band of the anterior bundle was the primary restraint to valgus rotation at 30, 60, and 90 degrees of flexion and was a co-primary restraint at 120 degrees of flexion. The posterior band of the anterior bundle was a co-primary restraint at 120 degrees of flexion and a secondary restraint at 30 and 90 degrees of flexion. The posterior bundle was a secondary restraint at 30 degrees only. The reciprocal anterior and posterior bands have distinct biomechanical roles and theoretically may be injured separately. The anterior band was more vulnerable to valgus overload when the elbow was extended, whereas the posterior band was more vulnerable when the elbow was flexed. The posterior bundle was not vulnerable to valgus overload unless the anterior bundle was completely disrupted. The intact elbows rotated a mean of 3.6 degrees between the neutral position and the two-newton-meter valgus torque position. Cutting of the entire anterior bundle caused an additional 3.2 degrees of rotation at 90 degrees of flexion, where the effect was greatest. CLINICAL RELEVANCE: Physical findings in a patient who has an injury of the anterior bundle may be subtle, and an examination should be performed with the elbow in 90 degrees of flexion for greatest sensitivity. As the anterior bundle is the major restraint to valgus rotation, reconstructive procedures should focus on anatomical reproduction of that structure. Parallel limbs of tendon graft placed from the inferior aspect of the medial epicondyle to the area of the sublimis tubercle will simulate the reciprocal bands of the anterior bundle. Temporary immobilization with the elbow in flexion may relax the critically important anterior band of the reconstruction during healing.

Biomechanical Phenomena↗
PubMed2006

Physical examination and imaging of the medial collateral ligament and posteromedial corner of the knee.

The medial side is one of the most commonly injured areas of the knee. The anatomy, diagnosis, and treatment of medial collateral ligament and posteromedial corner (PMC) injuries can be challenging. Understanding the mechanism of injury and performing a thorough physical examination and radiographic evaluation is essential. Frequently, there are concomitant meniscal and other ligament injuries associated with medial-side injuries. Correct identification of all injured structures is important, as missed diagnoses can lead to significant disability. Unrecognized PMC injuries have been implicated in anteromedial rotary instability and failed anterior cruciate ligament reconstructions. Valgus stress testing is the cornerstone for the identification of medial-side knee injuries. Coronal sequences from magnetic resonance imaging are the most useful tool to view the medial collateral ligament and posteromedial structures. Stress x-rays and ultrasound may also be helpful. Thorough physical examination and imaging of injuries to the PMC should dictate the appropriate treatment for optimal results.

Angiography↗
PubMed1998

Engineering the healing of the rabbit medial collateral ligament.

A biological approach to improve healing of the medial collateral ligament (MCL) was investigated by exploring the use of therapeutic growth factors based on in vitro and in vivo experiments. The in vitro cell culture studies involved screening a variety of growth factors to select those that exhibit the most positive effects on cell proliferation and extracellular matrix synthesis. The selected growth factors were applied in vivo to a rabbit model where the MCL was ruptured. Biomechanical and histological evaluations are performed to determine whether the selected growth factors can enhance the properties of the healed MCL, whether these improvements are dose dependent, and whether combinations of growth factors can enhance MCL healing to a greater extent than individual growth factors. In vitro studies showed that epidermal growth factor (EGF) and platelet derived growth factor-BB (PDGF-BB) have the greatest effect on ligament fibroblast proliferation, whereas transforming growth factor-beta 1 (TGF-beta 1) superiorly promotes extracellular matrix synthesis. These growth factors were then applied in vivo at different dosages, in isolation and in combination, and the ligaments were evaluated six weeks post-operatively. Tensile testing of the femur-MCL-tibia complexes (FMTCs) revealed that the specimens treated with a high dose of PDGF-BB have ultimate load, ultimate elongation and energy absorbed to failure values that are significantly greater than those from the other groups. The high dose of PDGF-BB was more effective than the low dose, indicating a dose dependency. The addition of TGF-beta 1 to PDGF-BB did not lead to any further increases in the structural properties of the FMTC. These encouraging results suggest that PDGF-BB may be a potential growth factor to enhance the quality of the healing ligament.

Animals↗
PubMed1987

Metacarpophalangeal joint motion and the role of the collateral ligaments.

A three stage study of the metacarpophalangeal joint was performed. First, a triaxial goniometer was designed which allowed direct measurement of joint motion in living and cadaveric hands. Then, based on the above data, a computer simulated model of the joint was developed. This permitted an analysis of the orientation of the joint for any given point in the axis of motion, the effects of the collateral ligaments and their contribution to joint motion and stability. Finally the metacarpal head was analysed using a shadow profilometer and anatomical dissections. From 0 degree to 70 degrees, the metacarpal head demonstrated a curved configuration. At approximately 70 degrees, the metacarpal head assumed a bicondylar shape which produced a bony block to lateral deviation. Dissection of the collateral ligaments demonstrated that they ran diagonally from the metacarpal head to the proximal phalanx. We conclude that the metacarpophalangeal joint has an instant axis. From 0 degree to 70 degrees of flexion, in any given hand, the angle of lateral deviation is constant. Beyond 70 degrees there is a marked decrease in lateral deviation. The joint has two degrees of freedom and the collateral ligament is taut in all positions.

Female↗
PubMed2006

Medial collateral ligament healing in macrophage metalloelastase (MMP-12)-deficient mice.

Medial collateral ligament (MCL) injuries heal by a wound repair scar response controlled by a complex cellular and cytokine environment. Many enzymes participate in wound repair, particularly the matrix metalloproteinases. We hypothesize macrophage metalloelastase (MME/MMP-12) deficiency results in impaired healing of MCL injury. One hundred fifty MME-deficient and 150 WT (MME+/+) mice underwent knee MCL transection with the opposite knee as a sham operated control. Mice were sacrificed at 3, 7, 28, 42, and 56 days. At each of the five time points, 15 mice were utilized for biological and 15 were utilized for biomechanical testing. Outcome measures were the presence of macrophages to represent the inflammatory phase of wound healing, collagen synthesis to assay for matrix repair, and biomechanical testing for repair strength. Immunohistochemistry demonstrated significantly fewer macrophages in cut MCLs from MME-deficient mice versus wild-type (WT) mice at 3, 7, 28, and 42 days (all p<or=0.04). In situ hybridization to Col1a1 mRNA in the MME-deficient cut MCLs at 7, 28, and 42 day time points showed a decreased level of type I pro-collagen mRNA compared to the WT cut MCLs (p<0.05). Biomechanical testing revealed cut ligaments from MME-deficient mice had significantly lower ultimate force and stiffness compared to cut ligaments from WT mice (p<0.001), with maximal differences of 40% at 7 days for ultimate force and 28 days for stiffness (p<0.05 by Tukey post hoc test). We conclude MME is important in the multifactorial cascade of knee MCL injury healing, showing significant differences in both the early inflammatory and in the matrix tissue synthesis phases.

Animals↗
PubMed1992

Healing of the medial collateral ligament following a triad injury: a biomechanical and histological study of the knee in rabbits.

The effect of a partial medial meniscectomy and anterior cruciate ligament (ACL) transection on medial collateral ligament (MCL) healing was studied in skeletally mature rabbits. Two groups of animals, group I (isolated MCL rupture) and group II (MCL rupture with ACL transection and partial medial meniscectomy), were examined. At 6 and 12 weeks postoperatively, histological examination of the healing MCL and biomechanical evaluation of the varus-valgus (V-V) knee rotation and tensile properties of the femur-MCL-tibia complex (FMTC) were performed. Group II animals experienced substantial joint degeneration by 6 weeks. Progressive osteophyte formation was observed adjacent to the MCL insertions along with proximal migration of the MCL tibial insertion between 6 and 12 weeks. Histologic examination of the healing MCL substance from both groups showed disorganized collagen, inflammation, and fibroblast proliferation that decreased over time. For group II knees, the V-V knee rotation was found to be significantly elevated (4.7 to 5.2 times the contralateral control), and did not decrease with time. In contrast, the V-V knee rotations of the group I specimens were 1.8 times greater than control immediately following injury, and approached control values by 12 weeks. Tensile testing of the FMTCs revealed that the ultimate load increased with time for both groups, but group I had significantly higher values than group II. The linear stiffness in group I was not different than that group II and did not increase with time. For the mechanical (material) properties of the healed MCL substance, the modulus of the healing tissue for group II was only 40% that of group I. The structural properties of the FMTC and the mechanical properties of the MCL substance from both groups at 6 and 12 weeks were significantly different from the contralateral controls. We further demonstrated that immediately after ACL reconstruction, the V-V rotation of group II knees could be restored to group I levels. Recent clinical studies of MCL healing following isolated complete ligament tears have suggested that nonoperative management without immobilization leads to excellent treatment outcome. However, in more severe injuries involving additional tissues, poor quality of the healed ligament tissue and articular degeneration are observed. Our results demonstrate the deleterious effects of an untreated triad injury on the healing of the MCL substance and its insertions. Examination of the MCL substance suggests that a much larger healing mass is formed following a triad injury, which partially compensates for inferior ligament mechanical properties.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1995

Isolated Medial Collateral Ligament Injuries in the Knee.

The management of ligament injuries in the knee has progressed significantly over the past two decades as a result of both laboratory and clinical studies that better define the healing capacity of these supporting structures. The intracapsular ligaments (the anterior and posterior cruciate ligaments) appear to have limited potential for spontaneous healing and frequently require surgical reconstruction. The extracapsular ligaments (the medial and lateral collateral ligaments), however, appear to have a fairly robust potential for healing. As a result, the need for surgical intervention is limited to specific clinical situations.

Journal Article↗
PubMed1993

Abnormal joint mechanics and the proteoglycan composition of normal and healing rabbit medial collateral ligament.

OBJECTIVE: This study investigated the influence that abnormal joint mechanics may have upon the biochemical composition of the joint's own soft tissue holding elements. DESIGN: The investigation used an animal model of ligament injury, the rabbit medial collateral ligament (MCL). The proteoglycan component of the ligament extracellular matrix was extracted, purified and characterized. INTERVENTIONS: The experimental groups consisted of: a) a control group consisting of the MCL from both right and left knees of six animals that had not undergone surgery; b) a group (healing gap injury) of six MCL from right knees in which a segment of tissue had been excised from the anterior cruciate and the MCL of the right knee 3 wk prior to sacrifice; and c) a third group (contralateral gap injury) comprised of the MCL from the six left knees of the same gap injury animals. OUTCOME MEASURES: The MCL water content, total proteoglycan content, hexose and hexuronate-containing proteoglycan and proteoglycan electrophoretic mobility were determined for each group studied. RESULTS: The healing gap injury MCL was found to have a higher water content, a higher total proteoglycan content and a higher proportion of aggregating proteoglycan than MCL from control animals. The nonaggregating proteoglycan fraction from the contralateral MCL (group 3) had a greater electrophoretic mobility and probably, therefore, a smaller molecular weight than that found in the MCL from the same knee of control animals. CONCLUSIONS: Since MCL healing took place in an abnormal mechanical environment, these results suggest that joint biomechanics may be an important factor in mediating connective tissue proteoglycan composition.

Animals↗