All right, so let's take a look at the medial side of the knee. So this talk is relatively new, so bear with me because I'm not exactly sure how long it's going to go. There are no conflicts with this particular presentation. So just a few slides on anatomy and biomechanics. I think it's important to know, and a lot of this comes from Pittsburgh, so I pulled out this old slide to pay tribute to Freddy Fu and Savio Wu standing right in the front there. And you can see by the type of dress code, and I have this white collar on a blue shirt, it's clearly the 90s. Long time ago, but a lot of good studies came out of that lab using the robot, and you obviously know that the MCL is the most important restraint there to valgus rotation. And then these numbers are just good to know, three, I don't know, 9.8 is very hard for me to even get knees that have that much opening. But I would argue that if a knee opens even two or maybe two and a half millimeters, you might need to do something, especially when you talk about multiligaments, right? And so there's a lot of good work out of our laboratory on animal models that back in the old days we used to do quite a bit. You know that when the ACL is torn, the MCL won't heal as well. When the MCL is torn, the ACL graft will stretch out. So this is all knowledge back from the early 2000s. And especially in soccer, maybe not the most important sport in this country, certainly not when you lose to Panama in overtime, in penalties, I mean, come on, guys. But in soccer, the MCL is absolutely crucial because you kick with your inseam because you plant your foot in such a way. And so this study shows that if you use a brace, you have a longer layoff. Now it's probably some bias there because you put a brace on and there's a higher grade injury to begin with. But I'm going to show you a case where when I walked into this guy, now this is not this particular player, but that size, right? So you're talking 280 pounds, super mobile. You know how defensive ends are. And then you see a complete avulsion, this MRI, of the tibial side of the MCL. Even if isolated, you would probably think you need to fix this, right guys? Maybe? No, this guy refused fixation. So we did early rehab. We protected him in the brace for six weeks. And in the end, it healed. You can see all the braces there. This is sort of August 1st in my training room. But it works. Now how do you diagnose the MCL? Obviously you examine an extension, you compare side to side. If you open up an extension, you have a problem. Now this MRI is not compatible with a non-operative management, obviously. And here you open extension and inflection. And you have also multi-ligament injury in it. And I use stress x-ray there. This is just one case with a very similar MCL. You can see the image. And an interesting fact is that in this particular player, on the right side, we had an MRI a year earlier for something else. You know that this is a very abnormal MCL, obviously. And a fixation you can do here is like a triple row type of fixation, with two anchors near the joint line, with two more anchors, four centimeters distal. And then like a footprint type of double row construct you would do on a rotator cuff, more distally. And it works actually really well. And so treatment options, so operative management is really reserved for avulsions, for maybe persistent grade 3 injuries, you know, chronic stuff. You just hate when players come back and you have a re-injury, right? You want to just avoid that, you know? You can do that with the hamstrings, but maybe not with MCL. So if you have these persistent grade 3s, you treat them. And injuries, of course, multiligaments and these so-called steno lesions where the hamstring tendons are interposed between the bone and the MCL. Now most of the time, I like repairing. I'm not a big fan of reconstruction, but you know, it's coming more and more into the forefront. I'll show you some cases. So here is your considerations, you know, acute versus delayed, and we already saw some start trial slides up there. So we can talk about that a little bit later. You know, two-stage, I think, is a good option, especially when you're early in your practice, just to kind of see how things go. And the best thing about a two-stage is you learn about your patient after that first surgery. Can they handle it? You know, are they ready for more steps? Otherwise, economically, you know, it's a huge burden for everyone. So you try to do it all in one stage. And it's important to tell the patient, maybe we do two stages so there are no surprises. You don't want to come out and say, well, I couldn't finish it and do it in six weeks. That's not a good look. Repair reconstruction, you know, your grafts, you know, I like using either hamstrings or peroneal tendons, but allografts, and then synthetics is a huge question too. And then when do we go in acutely? Obviously I'm very biased because every MRKR that comes in, I give them the option of early surgery, I give them the option of delayed surgery, and I give them the option of the star trial, and then they can choose. And if you really openly discuss it that way, they can make that choice. Now avulsions, peel-off injuries, you see that picture on the upper left with this fleck of bone next to the medial joint, well, that's that piece of cartilage with the fleck of bone. I don't think you can wait very long on this. That's half of the plateau. You know, interposition of the MCL, the standard lesions, et cetera. Now this is a horrible injury on a professional at 16 years old, but already professional football player, and you can see sort of the amount of valgus they're having there. So there's an acute grade three ACL, PCL, and MCL completely avulsed off the tibia with the entire posterior medial corner capsule, everything off. So what do you do with a person like that with a hugely swollen knee and just a bum that went off? And maybe more importantly, the cartilage injury in the meniscus. And so here you can see all these medial injuries. So ACL, in this case, got BTB autograft reconstruction. You can argue in a multiligament just do all allografts, but it's very interesting when you think about it, the ACL obviously has very clear negative outcome from allografts in young people. So I recently switched back to autograft. Also internationally, I mean, this is the US, we use allograft. If you go internationally, nobody uses allograft, it's just not available everywhere. So the PCL, you can sometimes repair. So you can see here in the middle picture, there's a suture in the PCL, and if that holds really well, you can just drill a little tunnel and pull that back up. So in that case, that's what we did. And then in professional players, I like getting MRIs later on, so you can see your grafts and all this and how things are healing. And then here's some early rehab pictures. This is about five years later, with a nice, stable medial site, the negative posterior drawer, not much anterior drawer, and excellent quad set. So it can work with just repairs. Now when should you do reconstruction? So on the lateral side, I think there's plenty of data and we've already seen it, you know, reconstruction, you should probably augment your repairs on the lateral side. But the LCL is a little more wimpy, if I may say, compared to the MCL. The MCL is a broad, large, long structure, eight centimeters long. If you have enough tissue and you get in there early, you can repair this with all kinds of screws or buttons, whatever you want to do. Now timing, of course, is an issue. And you know, in these studies, you know, this is a systematic review, you know, repair, you have maybe more increased stiffness. I think there's bias again. That's what we're studying in the STAR trial. Will repair early on give you stiffness? I don't really know the answer to this. You probably all have your biases, thinking yes or no. And I think this randomized control study, the STAR trial, will give us some of this data. Now synthetics, okay? This is cool. I love this picture, you know, two of my favorite people ever, Einar Erikson. If you don't know him, you should read about him. He's over 90 now, amazing guy. So you talk to him about synthetics, this is what he will say. It's like a shoelace. What are you putting shoelaces in the knee for? You know, in the 90s, doesn't work. You talk to Freddy, he's like, well, you did all this stuff in the 90s and got like horrible arthrolysis, so don't do it. Well, but not so fast. There are some newer devices out there, or newer, say, synthetics out there with quite interesting properties. So I'll probably try some of this out and see how it works. And maybe we can discuss, and I'm sure some of you have some good, interesting thoughts on this. Here are some of your techniques. What I do is sort of a flat, double bundle type of reconstruction, all different ways how to do this. So here's one way how to do it, shown by Christian Fink. And then this is just a little preview for tonight's case that Al and I will be doing. Hopefully. We'll see. But we basically drill two pins in there, one in the media epicondyle where the MCL inserts. We use three different ones to assess for isometry. And then the distal pin is just above the PES tendons, just like Arvind has just shown. Then we pick the isometric point, fix the graft to the distal anchor, put a second anchor closer to the joint line, about 1.5 centimeters. And then both of these limbs of the semitendinosus tendon, in this case, get docked into an isometric and anatomic tunnel on the femur. And this makes a very nice, stable graft. Here's another professional football player, again, horrible valgus injury. This was an acute ACL, MCL, and patellar dislocation, so knee dislocation and patellar dislocation. By the way, I disagree. I think you can dislocate the knee and pop it back in. This is just a shot from a video where you see everything comes out and comes back in. So this is pretty bad. You can see here the exam, and you can see the valgus not all as well, but it's a big valgus. The PCL is stable, ACL is completely unstable. And so in this particular case, it's a BTB autograft. Now you see the impact that you get on the lateral side from this horrible valgus stress. That's probably the real injury. So here we did a microfracture, which I hate doing, and a big lateral meniscus repair, BTB autograft, ACL reconstruction. And then you spend probably about half an hour just fiddling out this MCL. This is a, if I label it here, I don't know if it projects really well, but I labeled the joint line so you see what's below and above. This is probably 10 days or so out, so it's already all scarred in. But then when you're done with it, you can see how long that MCL is if you take your time and peel it out from underneath the sartorius and from on top of the capsule. Then you can fix it distally. I usually do that with a screw. So the proximal part of the tibia gets anchors. For the deep meniscus tibial fibers, the distal part gets a screw under the PES here to fix that. And then you can reef up the posterior oblique ligament. And so here, some early images. One thing that I like doing when I have the option, this picture on the very right, these are two athletes, obviously very different sizes, but similar injuries. And they were just about six weeks apart from the rehab. So talking to one another and giving mental support, I think is something very, very important to do. And so far, so good on this player. Keywords for rehab, again, I think you may have your biases. Should you go early weight-bearing? Should you delay weight-bearing? Should you protect the range of motion? Maybe put them in a brace? Well, I mean, every case is different, right? So you see here, we're working hard on the range of motion to get it back. So I like to go relatively fast. But again, any multiligament that walks into my office gets the option of early rehab, late rehab, and the STAR trial. And I think we get some really interesting data from this. So this is the STAR trial group. Thanks to everyone in this room and elsewhere that is involved. It's a very, very hard study to do. So I appreciate everyone's work on this. It's been going on since 2016. And hopefully trial two will be done at the end of this year, which is very nice. You know, when you see papers that say they have zero complications, I can say, congratulations. Very proud of you. But if you do an actual study, you can see there are hundreds and hundreds of complications. If you have appendicitis, we report it. If you fall on your wrist after a multiligament, we report it. But these are the most common and most important ones. There's about 20% that have some pain afterwards. The second bullet is what's the most interesting. So 13% decreased range of motion, about 10% underwent MUA, which I think is a relatively common number that you all see in your own practice. Some superficial infections, DVTs, et cetera. We had a few failures yet. One total knee, so that's fun too. And so here's some more slides on outcome. In elite soccer, you know, obviously missing days from practice and game is a huge issue. But with an isolated MCL, people return to the same level. There's some combined studies from the NFL with pretty good return to sport data. So in summary, right, so for multiligaments, I write this out, we'll even write it out tonight on the live demo. I think it's good for everyone in the room to know this is what the plan is. And you know that the plan will never work out, ever. So don't go in a multiligament room thinking, great, I have this plan, just like Musal, we're going to get it done. It's going to be plan B and C and D and just stay relaxed, you know, listen to some Michael Jackson and just go with the flow. But having a good plan certainly is a good idea, I think. So yeah. So with that, I say thanks for listening and we have some cases afterwards too. Thanks. Thank you.

MCL

knee stability

soccer

rehabilitative techniques

multiligament injuries