Name: MCL Management: A Paradigm Shift?
Uploaded: 2021-11-19T00:00:00Z
Channel: Arthrex
Description: Armando F. Vidal, MD (Vail, CO), explains his rationale for treating MCL injuries.

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<p>Armando F. Vidal, MD (Vail, CO), explains his rationale for treating MCL injuries.</p>

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VID1-002892-en-US | A | MCL Management: A Paradigm Shift?

Armando F. Vidal

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MCL Management: A Paradigm Shift?

My first talk is to talk a little bit about MySQL management and a paradigm shift. And I was reflecting a little bit on it. And you know, this talk is not going to be about internally bracing every MySQL you see or doing allograft reconstructions, but rather it's going to be about thinking of the MySQL in a different way. I think the orthopedic dogma for so long has been all mcls heal. You can ignore them, just treat the other cruciates or just leave them alone. And I think that, you know, we always talk about the lateral side of the knee being, you know, the dark side. But I would argue, I think the medial side is becoming the dark side. I think that we lack a lot of understanding about the anatomy. What are the critical structures. And we lack the understanding of reconstructive techniques that are successful. And we're just beginning to gain that understanding. We're pretty much where we were with the lateral side of the knee, maybe I'd say 5 or 10 years ago, where lapradd, etc. have really expanded our knowledge. So we're going to talk about I just want you if there's any take home point from this talk, is to think about the medial side of the knee differently than the way we're all taught in residency, which is they all heal and leave them all alone. So as we know, the MCL is the most common ligament injury in the knee. We see it in all of our collision athletes. We take care of a lot of skiing population and as you can imagine, I'd say every ACL we see is an ACL, MCL and the majority of these injuries can be treated non-operatively. Thankfully, the medial structures, the medial complex is very vascular, has great intrinsic healing capacity. But again, the paradigm shift, in my opinion, is to think of it as a more complex structure, not just a superficial MCL, which is what we're all trained to think about, but the posterior oblique ligament, and to think of it as a medial complex. Right? The deep MCL, the superficial MCL, the capsule, the medial meniscus and the posterior oblique ligament. Because they're clearly I think all of us in this room have seen MCL injuries that were like, there is no way that's going to heal. Or you examine that patient and they open up in full extension 30 degrees and you're thinking, I know I've been told to leave these things alone, but there's no way that MCL is going to heal on its own or this knee is so unstable. I need to do something about it. And because the orthopedic dogma for so long has been leave them alone again, we lack an understanding of what the best reconstructive or repair options are in that setting. So when you think of an MCL injury, I want you to think of it as a medial complex injury. And I have a talk later on the lateral side. That's where the lateral side is now. Right? We talk about the FCL, the Popliteus, the ligament, etc.. I think you need to think of the medial side the same way, because clearly some of these more severe injuries that involve the pol don't have the same intrinsic healing capacity, I would argue, as just a superficial MCL injury. And there's controversy about what to do in the multi ligament injury, specifically ACL, MCL. But clearly in a more complex injury like Doctor Hatch presented, there's no ambiguity about what to do for those injuries. So very briefly, I don't want to spend too much time discussing the anatomy, but the top part of this slide is critical. So there's a superficial MCL. We all are familiar with that structure. There's a deep MCL which is really the meniscal attachments in the capsular thickening. And then there's the posterior oblique ligament, which is that that oblique structure that comes across. And that has an important role in restraining valgus, but also has an important role in the In the rotational stability of that tibia. There are a variety of medial dynamic stabilizers. But these higher grade injuries, these injuries that open up ten millimeters or so, often involve injury to the superficial MCL as well as the posterior oblique ligament. So part of the challenge is that all the papers you see, and there are tons of papers in MCL management in isolation, there are tons of prospective randomized trials looking at ACL with MCL and treating the grade three MCL, Operatively or Non-operatively. But the challenge is that they all rely on this AMA grading, which is back from the 60s. And so the AMA grading, as we all know, it's, you know, five, 5 to 10 greater than ten is grade one, two and three. But the challenge is notoriously inaccurate. It relies on your subjective exam, but more importantly, has no correlation with treatment or outcome. Right. So Jack Huston in the 90s said, well, maybe we should add an endpoint to that, to that grading system. But it does beg the question whether or not that correlates with outcomes. So a lot of us at this point have looked at stress radiography. So Doctor Laprad really has popularized that for both the medial and lateral side. I use it pretty extensively, but it's hard to do it in acute injury and opening in full extension. So we're all taught that opening in full extension means that there's a cruciate and a collateral. But I would argue if you have a patient like this, this is a guy I saw on Tuesday. This is this is a severe injury. He actually is getting his MRI today. I haven't even seen the severity of his injury. But I can almost guarantee that this is going to be an operative MCL. And I'm sure he's got a cruciate ligament as well. And when they open up in full extension and you've got to be it's challenging because sometimes these acute knees you can't get into full extension. But if they open up in full extension that's a more severe injury typically is going to involve the superficial MCL, the deep MCL and the posterior oblique ligament. The controversy, again, is because a lot of these and we're part of this paper, part of the moon group. We looked at our outcomes of grade three MCL with ACLs didn't really show a significant difference in outcome if they were operatively repaired, but again, a lot of them are based on archaic grading systems. And just in the interest of time, I think if you abide by the rule that you know this, that all mcls can be treated non-operatively. What do you do when you encounter this injury? Right. So this is an injury. You can see the MCL. I don't know if I have a pointer here. But the MCL where the Arrow is, is pulled off the tibia. It's rolled up. It's intra-articular. This is clearly not an injury that's going to heal. So you need to be able to manage these injuries that are more severe. You know, you have to have techniques that work. So in my mind, if it's a combined injury with posterior oblique ligament involvement and posteromedial corner injury, and I'm going to define that either by stress radiography with greater than ten millimeters of opening compared to their contralateral side, or opening in full extension. That's somebody that at least I'm going to take a more critical approach to and consider operative intervention. If it's a tibial site lesion, especially if it's a stenner lesion. So, you know, you guys are all familiar with the center lesion in the thumb. But if it pulls off the tibia and it's sitting superficial to the peasants tendons, that's an injury that's not going to heal and is challenge. That's one that I'm going to consider intervention, especially if I'm there for an ACL where I'm going to have the anteromedial aspect of aspect of the knee exposed in one way or another, whether it's a BTB or even just for my Anteromedial or sorry for my tibial drilling. Obviously, if there's intra-articular, ligament entrapment, symptomatic chronic injuries, and debatable whether or not in high level athletes or in patients who are already constitutionally and valgus and have high grade injuries, whether or not they should be treated. But these are all areas of controversy. And again, it's I think the debates are what's what are the structures that need to be addressed. What's the best classification system that's going to predict management options and outcome. And then what are the do these high grade injuries with posterior oblique ligament involvement heal the same as the injuries that we've all been told? Heal well just like a isolated superficial MCL. So this is where the controversy lies. And this is where the paradigm is shifting, because there's increasing biomechanical and clinical data that these higher grade injuries probably do need to be addressed or should be considered for surgical intervention. These are all cases that I've done in the last two months. So again, our skiing population has a high incidence of medial sided injuries. So this is a 20 year old kid, high grade ACL, MCL opening in full extension. I don't have the entirety of his MRI here, but you can clearly see he's got a tibial sided lesion. This is a true center lesion. He's got opening in full extension. You can do an ACL in isolation in this group, and you'd get away with it probably 90% of the time. But this is a lesion that I would argue is not going to heal well and should be addressed when they have good tissue quality. And I can primarily repair them, as you've seen in several other talks in other conditions. I do repair them, and I like to support them with an internal brace. So in my hands this is a BTB ACL. I think you can make an argument about a quad or some other graft, but clearly an autogenous graft. I would not harvest a hamstring, as Rachel indicated in her talk earlier with a high grade MCL. And it's subtle, but you can see a little lucency at the base of my screw there where I have my SwiveLock, and I'll show you how I like to do these internal braces with repair. The reason I use an internal brace in this context is that there is clear biomechanical data, and you've seen it with other Conditions that they are structurally better than repair alone and approach more normal kinematics. And I think the morbidity of adding an internal brace if you're doing a repair is pretty low. And for anybody here that's done an MCL repair, you know, it's like an Achilles. Right. So that thing pulls off. It's not like it's clearly pulled off. You just sock it back down. It's shredded. The tissue is hard to get suture in. So I think augmenting it in this context with SutureTape augmentation makes sense with very low morbidity. This is from Lee from his video on the Arthrex website. I didn't have a video of my own, so I borrowed this and just abbreviated it. But this is how I do it. So the repair is wherever the zone of injury is. In this particular video, it's at the femoral side. I don't like to use swivel locks, actually for my internal braces with mcls on the femoral side, because there's a lot of structure there. And I've seen swivel locks that can irritate patients. I have I took one my slides out in the interest of time, but I have one that's backing out. It's, you know, on this side of the knee, you have the MCL, the mpfl, the adductor, they're all inserting in that area. And a prominent hard anchor could be symptomatic. So this is a is a knotless FiberTak. You essentially create a loop on itself and you can pass your FiberTape through that loop. Now, the benefit of this is that it's a low profile on the femoral side, but you can actually adjust the tension afterward. And I can show you how to do that if you guys want. So it's a knotless FiberTak on the femoral side. Pass deep to the sartorial fascia, deep to the tendons. And then the tibial fixation is exactly what you would expect, which is a SwiveLock I would say a couple pearls on this is I like to put a pin into the tibia and find an isometric point, because obviously this is a static structure and is not very forgiving. Once I identify the static, sorry, the isometric point with a pin and loop my FiberTape over it, I take the pin out and then put a SwiveLock in, and I like to use peak SwiveLock on the tibia because this bone is really, really hard and can be challenging with the biocomposites. So the benefit of this is you put that in, you've achieved your repair, and then you can go back and tension it a little bit more after you've finished your cruciates or whatever other work you're doing. So so again, the key is that you create this blind loop, pass your FiberTape through it, leave five millimeters, do your fixation on the tibia, and then you can go back and readjust your attention. And I'll show you in the lateral side how I use similar techniques to adjust my tension on the collaterals after the fact. This is another injury. So this is a this is a guy. Actually, I just saw him for a six week checkup on Tuesday before I flew out here. Acl, MCL, he hit a tree. And this is a pretty diffuse injury. So clearly all the way back there's injury. There's injury to the superficial MCL, the deep MCL, the posterior oblique ligament young guy as well. Lateral blow to the knee on a tree while skiing. You can see actually the intent of this shot was to look at I use a TightRope FiberTag TightRope when I do these so I can adjust the tension when I do a reconstruction. So you can see that on the femoral side. And what what's interesting about this fluoro shot is I was just checking to make sure my button was deployed on the lateral femoral condyle, but look how much that medial side gaps. And I haven't done anything other than just pass my graph on the femoral side so you can see the drive through on the on the arthroscopic pictures as well. So in my hands this is also a BTB as I like it in these multi ligament injuries because it's such a stiff graft and I get such solid fixation. But with a diffuse injury like that, repair can be challenging because there's not a lot of good tissue. So you had a tibial site of lesion. The mid substance of the lesion or of the MCL is compromised as well. His pol actually was fairly sturdy. So we did a reconstruction. I like to use established fluoroscopic landmarks for that. We used a FiberTag TightRope with an allograft, and I still like to fix it with a post in a spiked washer on the tibia, about six centimeters distal to the joint line. Mike Baraga is a friend of mine in Miami. Likes to dunk it into the tibia using another FiberTag TightRope. And I think that's very reasonable. And we were able to primarily repair the pol, which was a more straightforward injury. But again, thinking of the medial side as a complex, you need to you need to account for all the different aspects of the injury. And this is a fluoro shot after everything's been fixed. And you can see how that medial side is, is clamped down. So I think in summary, not all MCL injuries, especially in the setting of ACL, are benign. Most of them are. And I think the orthopedic dogma that MCL he'll still stands. In terms of the superficial MCL, but if you take anything home from this talk, you need to be more critical in your assessment, evaluation and treatment decisions for these higher grade injuries. Again defined as involvement of the entire medial complex, superficial deep MCL and posterior oblique ligament. And clinically, you want to be aware of opening and full extension to get your attention and have a low threshold to do stress radiography in your office if you need to. For acute lesions, I like to do primary repair. I think you've seen that as a recurrent theme today. Internalbrace is Biomechanically enhances that repair and protects it. And for diffuse, chronic or revision surgery, I still like to do reconstruction and I like to use the FiberTag TightRope. I'll show you my technique on the lateral side which mimics this, which allows for reproducible tensioning after the fact, which can be one of the bigger challenges with collateral ligament surgery. So thank you.

MCL Management: A Paradigm Shift?

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