VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

Revisiting ACL Repairs in An Athlete with Combined Grade III Medial Collateral Ligament and High-Grade Posterolateral Anterior Cruciate Ligament Tear: A Case Report Muir SM BS, Lucas J MD, Sadowski E PA, McDermott JD MD. Spartanburg Regional Healthcare System, Sports Medicine, Spartanburg, SC.

Abstract # CBR-27



Case Presentation

Introduction: Operative versus non-operative management of a grade III medial collateral ligament injury in athletes is controversial. Furthermore, anterior cruciate ligament tears are historically treated by reconstruction, although primary anterior cruciate ligament repairs are being revisited due to advancements in novel surgical techniques. We describe a grade III tibial sided tear with partial femoral avulsion of the medial collateral ligament and tear of the posterolateral bundle of the anterior cruciate ligament that were both surgically repaired, in a competitive high school athlete. Case Presentation: A 17-year-old male presented to the Sports Medicine Clinic after injuring his left knee in a football game. Radiographs revealed normal skeletal anatomical alignment with no acute fractures. A magnetic resonance imaging suggested partial injury of the femoral attachment of the medial collateral ligament and a grade III medial collateral ligament tear where it attached to the tibia. An arthroscopic evaluation of the knee revealed a posterolateral anterior collateral ligament tear. Operative management included surgical repair of the grade III tibial sided medial collateral ligament tear and the posterolateral anterior cruciate ligament tear. Conclusion: New surgical techniques provide new opportunities for operative repair of medial collateral ligament tears compared to nonoperative management due to decreased risk of reinjury, increased stability, and decreased return to playtime in athletes. They also provide alternative approaches for anterior cruciate ligament repair in situations wherein anterior cruciate ligament reconstruction may not be necessary. This case report describes the surgical management of a grade III medial collateral ligament tear and an anterior cruciate ligament tear in a high school football athlete. .

Anterior Cruciate Ligament

References 1. Acevedo J, Boden AL, Greif DN, et al. Distal Medial Collateral Ligament Grade III Injuries in Collegiate Football Players: Operative Management, Rehabilitation, and Return to Play. J Athl Train . 2021;56(6):565 2. Holuba K, Vermeijden HD, Yang XA, O’Brien R, van der List JP, DiFelice GS. Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous. Arthroscopy: The Journal of Arthroscopic & Related Surgery . Published online July 8, 2022. 3. van der List JP, DiFelice GS. Primary Repair of the Medial Collateral Ligament With Internal Bracing. Arthrosc Tech . 2017;6(4):e933-e937. 4. Büchler L, Regli D, Evangelopoulos DS, et al. Functional recovery following primary ACL repair with dynamic intraligamentary stabilization. Knee . 2016;23(3):549-553. 5. DiFelice GS, Villegas C, Taylor S. Anterior Cruciate Ligament Preservation: Early Results of a Novel Arthroscopic Technique for Suture Anchor Primary Anterior Cruciate Ligament Repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery . 2015;31(11):2162-2171. 6. van der List JP, DiFelice GS. Primary repair of the anterior cruciate ligament: A paradigm shift. The Surgeon . 2017;15(3):161-168. This project was approved by Spartanburg Regional Healthcare System. The authors would like to thank Edward Via College of Osteopathic Medicine and their team for their support and editorial revisions, Arthrex® for primary ACL repair images, and William Muir, DVM. PhD. for his poster and abstract guidance. Acknowledgements • Non-operative treatment has been shown to increase return to play time, increased reinjury, and decreased field time after return to play in elite level athletes. • Acevedo et al. was one of the first to demonstrate the success of operative management with an appropriate post-operative protocol in Division I football athletes with grade III MCL tears combined. • Holuba et. al. demonstrated that nonoperative management of the MCL tears with operative reconstruction of the ACL produced poor results due to an increase in valgus laxity, increased return to play time, and further risk of intra articular damage. The same authors also suggested that treatment algorithms of MCL-ACL injuries need to be revisited based upon historical outcomes. • Lastly, Van der list et. al. attributed successful repair of MCL-ACL injuries with primary MCL repair and ACL reconstruction to the prevention of muscle atrophy, valgus instability, and a maintenance of proprioception. • Historically ACL repair was abandoned because of high rates (2-20 percent) of reinjury however there has been a paradigm shift when thinking about ACL injuries in athletes. ACL repair is being reconsidered due to the advancements in surgical techniques and new technologies. • A one year follow study has demonstrated successful functional recovery and low refracture rates in a primary ACL repair using dynamic intraligamentary stabilization. In addition, DiFelice et al. have demonstrated short term success of proximal avulsion type tears treated with arthroscopic primary ACL repair technique. • As primary ACL repair becomes increasingly popular, definitive protocols, indications, and contraindications need to be established for select patient populations that may benefit from these surgeries. • This case presents the successful surgical management of an ACL posterolateral tear in a high-level high school football athlete. Primary ACL repair should be considered in athletes with partial ACL tears. Operative management is recommended for athletes with MCL-ACL injuries especially those with tibial sided MCL tears.

• ACL reconstruction is the current standard of care for MCL-ACL and isolated ACL tears and involves using a patellar, quadriceps, or hamstring tendon autographed to rebuild the ACL ligament. • Although ACL reconstruction is the standard of care, ACL repair has recently resurfaced as a viable surgical alternative in select patients. • Historical data suggested that the risk of reinjury following ACL repair was as high as 20% and the procedure was abandoned. • Detailed review of past studies and recent research has shown ACL repair can be beneficial and produce low failure rates, particularly in younger patients, for specific femoral avulsions and isolated posterolateral bundle tears. • A 17-year-old male athlete presented to the Sports Medicine Clinic after injuring his left knee in a football game. His left foot was planted when he was hit causing his knee to hyperextend. There was no “pop” noted during the incident, however he immediately observed swelling. No endpoint with valgus stress was noted during sideline examination. • Ultrasound guided aspiration of the left knee joint produced 30mL of blood colored fluid. The MRI confirmed a grade III MCL tear at its attachment to the tibia with partial injury of the femoral attachment. A partial tear of the ACL involving the anteromedial (AM) bundle was also noted. • Diagnostic arthroscopy confirmed extensive hemarthrosis, probing of the ACL revealed a posterolateral (PL) ACL tear not an AM tear as noted on the MRI report. • A primary ACL repair of the PL bundle was performed using TightRope® per the Arthrex technique guide. The tibial sided MCL tear was also repaired. Clinical Course


Medial Collateral Ligament

• Medial collateral ligament (MCL) injuries are the most common ligamentous injury to the knee and account for approximately eight percent of all athletic knee injuries. • The knee is commonly in flexion during injury and valgus stress or external rotation to the lateral aspect of the knee is the most common cause of ligamentous injury. • There are currently two well-known accepted MCL classification systems; the American Medical Association (AMA) and the Hughston modification of the AMA classification. Table 1 . AMA and Hughston Classification of MCL tears

Image 1 . Primary ACL repair.

Image 2 . 3mo post-op x-rays.

Wilson TC, Satterfield WH, Johnson DL. Medial collateral ligament “tibial” injuries: Indication for acute repair. Orthopedics . 2004;27(4):389-393.

Multi-Ligamentous Injury

• The most common multi-ligamentous knee injuries are medial and anterior cruciate (MCL – ACL) tears. • Grade III MCL injuries can be successfully managed non-operatively, however, most orthopedic sports medicine surgeons recommend repair to limit complications e.g., (chronic pain, instability, reinjury) associated with non-operative management. • Tibial sided MCL tears receive less blood flow than femoral sided tears and are predisposed to delayed or diminished healing requiring operative repair.


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