KNEE LIGAMENT INJURIES

AND
MENISCAL INJURIES
Static stabilizers Dynamic Stabilizers

• Capsule • Quadriceps femoris

• Ligaments • IT band
• Extensor retinaculum
• Popliteus
• Pes anserinus
• Hamstring
• Gastrocnemius
 Ligaments
Extracapsular ligaments or external ligaments
• Patellar ligament
• Medial collateral ligament
• Lateral collateral ligament
• Oblique popliteal ligament
• Arcuate popliteal ligament

The intra-articular ligaments or Internal Ligaments

• Anterior cruciate ligament
• Posterior cruciate ligament
• Meniscofemoral ligament
 Classification
 Grade I
– The fibers of the ligamemt are stretched but there is no tear
– The knee does not feel unstable
 Grade II
– The fibers of the ligament are partially torn
– The joint may feel unstable and ‘give out’ during activity
 Grade III
– The ligament is completely torn
– The ligament cannot control knee movements
 Clinical Features
• Severe knee pain
• Swelling of the knee within 48 hours
• Stiffness of the knee
• Tenderness when pressing on knee joint line
• Popping or clicking within the knee
• Loss of range of motion of the knee joint
• Feeling of instability or ‘give away’ with weight
bearing
 Anterior cruciate ligament injury
• ~4,00,000 ACL reconstructions / year
 Anatomy
• Goes from lateral femoral condyle to
anterior tibia between the
intercondylar eminence of the tibia
 ACL Function
• Provides 85% of the stability to
prevent anterior translation of the
tibia relative to the femur
• Restraint to tibial rotation and
varus/valgus rotation
• Prevents hyperextention of the knee
 ACL Blood supply : middle geniculate artery

 ACL Innervation : posterior articular nerve

• Anteromedial bundle
– more isometric behaviour
– tightest in flexion
– 1° responsible for
restraining anterior tibial
translation
– prone to injury with knee in
flexion
• Posterolateral bundle
– greater length changes
– tightest in extension
– 1° responsible for
rotational stability
– risk for injury in
hyperextension and
internal rotation place
 Gender
• Female athletes are more susceptible to ACL injuries. The factors
responsible for the increased occurrence of ACL injury in females are
• The difference in landing biomechanics
– Females land with their knees in more extension and valgus due to
the hip internal rotation
• Structural Differences
– smaller notches
– smaller ACL size
• Cyclic hormonal levels
– Greater risk for injury during the first half (preovulatory phase) of the
menstrual cycle
• Neuromuscular Differences
– Lower hamstring quadriceps ratio
• Weaker core stability
• Genetic
– underrepresentation of COL5A1 gene sequence, which is collagen
producing, in females with ACL ruptures.
 Mechanism of Injury
• Contact :
blow to the lateral
knee or valgus force
due to twisting injuries
in sports or RTA

• Non contact:
(70%) either due to
hyperextension or
valgus force + internal
rotation of tibia.
 ACL injuries usually combined

• meniscus(50%)
• articular cartilage(30%)
• collateral ligaments(30%)
• O Donoghue’s unhappy
triad-injuries to the ACL,
the MCL and the medial
meniscus.
when lateral force to knee
while the foot is fixed on
the ground.

O Donoghue’s unhappy triad

 Physical Exam
Anterior drawer test
• influenced by hamstring spasm in acute injuries, least reliable.
• patient supine and the knee flexed to 90°.
• examiner sit on patient’s foot and grasp patient’s calf with both hands.
• anterior force is applied
• tibial excursion is compared to the unaffected knee.
 Lachman test
• knee in 20-30° of flexion
• femur is stabilized with a nondominant hand
• Anteriorly-directed force is applied to the proximal calf.
• Asymmetry in side-to-side laxity or a soft endpoint is
indicative of an ACL tear.
 Pivot shift test

• extension to flexion:
reduces at 20-30° of
flexion
• patient must be
completely relaxed
(easier to elicit
under anesthesia)
• mimics the actual
give away event
 Investigation

 Segond fracture : Avulsion fracture of proximal lateral tibia due to bony avulsion by
the anterolateral ligament (ALL)
Deep sulcus (terminalis) sign :
Depression on the lateral femoral condyle at the terminal sulcus, a junction between the
weight bearing tibial articular surface and the patellar articular surface of the femoral
condyle.
A 40 year-old female presents after a skiing
injury with a partial ACL tear
 Treatment
• Nonoperative
– patients who are not involved in any type of sport activity
– whose jobs are sedentary
• bracing for 1 to 2 weeks with ice, elevation, NSAIDs
• physical therapy
• functional sports brace

DonJoy ACL everyday knee support ACL knee brace for ACL tear or injury
 Operative
ACL reconstruction
 It involves taking a suitable tendon graft and reconstruction of the
ligament.
 Delayed atleast 3 weeks following injury
 Indications
– younger, more active patients including children
– older active patients
– prior ACL reconstruction failure
– associated injuries
• MCL injury – allow MCL to heal and then ACL reconstruction is
done
• Meniscal tear – Both operated at the same time
• Posterolateral corner injury– Simultaneous reconstruction or
repaired in the first stage before ACL surgery
The grafts used
 Autografts(patient’s own
tissues)
• Bone-patella-bone
• Hamstring tendon
• Quadriceps tendon

 Allograft(from a cadaver)
• Patellar tendon
• Achilles tendon
• Semitendinosus
• Gracilis, or posterior tibialis
tendon
 Surgical Techniques
• Femoral tunnel placement
• Tibial tunnel placement
• Graft placement
• High tibial osteotomy
Post ACL Reconstruction surgery X-Ray AP and lateral view
 Ligament Repair
• Bridge-enhanced anterior cruciate ligament repair (BEAR) combines suture repair of
ACL with a specific extracellular matrix scaffold (the BEAR scaffold) that is placed
in the gap between the torn ends of the ACL to facilitate ligament healing.
 Complications
 Graft Failure
 Missed diagnosis
 Infection
 Infrapatellar contracture syndrome
 Loss of motion & arthrofibrosis
 Patella fracture
 Patella Tendon Rupture
 Overaggressive rehab
 Cyclops Lesion
• Here the fibroproliferative tissue(painful anterior knee mass) blocks
extension
 Late arthritis [related to meniscal integrity]
 Local nerve irritation [saphenous nerve]
 Complex regional pain syndrome
 Posterior Cruciate Ligament injury
 5-20% of all knee ligamentous injuries
 Anatomy
• PCL originates from posterior tibial sulcus
and inserts in anterolateral medial
femoral condyle
• PCL has two bundles
– anterolateral bundle
• tight in flexion
• strongest and most important for
posterior stability at 90° of flexion
– posteromedial bundle
• tight in extension
 Blood supply-
branches of the middle geniculate artery
 Mechanism
– direct blow to proximal tibia with a flexed knee (dashboard
injury)
– noncontact hyperflexion with a plantar-flexed foot
– hyperextension injury
 Pathoanatomy
– primary restraint to posterior tibial translation
– prevents hyperflexion/sliding
– isolated injuries cause the greatest instability at 90° of
flexion
 Associated conditions
– combined PCL and posterolateral corner (PLC) injuries
– multiligamentous knee injuries
– knee dislocation
 Classification
• Based on posterior subluxation of tibia relative to femoral condyles (with
knee in 90° of flexion)
• Grade I (partial)
– 1-5 mm posterior tibial translation
– tibia remains anterior to the femoral condyles
• Grade II (complete isolated)
– 6-10 mm posterior tibial translation
– complete injury in which the anterior tibia is flush with the femoral
condyles
• Grade III (combined PCL and capsuloligamentous)
– >10 mm posterior tibial translation
– tibia is posterior to the femoral condyles and often indicates an
associated ACL and/or PLC injury
 Physical Exam
 Posterior sag sign
• Patient lies supine with hips and knees flexed to 90°
• examiner supports ankles and observes for a posterior shift of the
tibia as compared to the uninvolved knee
Posterior drawer test (at 90° flexion)
• with the knee at 90° of flexion, a posteriorly-directed
force is applied to the proximal tibia and posterior
tibial translation is quantified
 Varus/ valgus stress
• Laxity at 0° indicates MCL and PCL injury.
• But laxity at 30° alone indicates of Medial or lateral collateral
ligament injury only.

 Dial test
• prone or supine position
• done at 30° and 90° of flexion
• The external rotation at the
knee joint is noted by
measuring the foot-thigh
angle.
 Investigation

16-year-old male. Both knee AP (A) and lateral (B, C) radiograph show displaced
bony avulsion fracture of the posterior cruciate ligament
Lateral stress views
of the knee reveal
increased posterior
sag on posterior
drawer in the left
knee compared to
the right
• Magnetic Resonance
Imaging
– confirmatory study
for the diagnosis of
PCL injury
– identify whether
the tear is
complete or
incomplete and
whether the PCL
injury is isolated or
associated with
injury to other
structures.
 Treatment
Nonoperative
• PRICE for immediate treatment
• relative immobilization in extension for 2-4 weeks
• Indication
– Grade I (partial)
– Grade II injuries
– Grade III injuries with associated PLC injury or
intra-articular damage
• extension bracing with limited daily ROM exercises
• immobilization followed by quadriceps
strengthening
• it may take up to 6 weeks for a
sufficient recovery without surgery
 Operative
 PCL repair of bony avulsion fractures or reconstruction
 Indications
– combined ligamentous injuries
• PCL + ACL or PLC injuries
• PCL + Grade III MCL or LCL injuries
– isolated Grade II or III injuries with bony avulsion
– isolated chronic PCL injuries with a functionally unstable knee
– Persistent pain, instability, or disability despite conservative treatment
 Techniques
– Can be transtibial [arthroscopic technique] or tibial inlay [open
technique]
– Graft used could be single bundle or double bundle
– Graft options include - Achilles, bone-patellar tendon-bone,
hamstring, and anterior tibialis
a) Trans-tibial tunnel technique.
b) Tibial inlay technique.
High tibial osteotomy
• indications
– chronic PCL deficiency
• Medial wedge osteotomy to treat both varus
malalignment and PCL deficiency
 Complications
• Popliteal artery injury
– at risk when drilling the tibial tunnel
– lies just posterior to PCL insertion on the tibia,
separated only by posterior capsule
• Patellofemoral pain/arthritis
– due to chronic PCL deficiency
 Medial Collateral Ligament Injury
• Anatomy
The MCL originates from the medial
femoral epicondyle and inserts on the
anteromedial tibia
– Superficial MCL-
 primary valgus stabilizer
 tibial external rotation and
anterior/posterior tibial
translation stabilizer
– Deep MCL-
 2° stabilizer to valgus stress
• Vascular supply -superior medial and
inferior medial geniculate arteries
• Nerve supply - saphaneous nerve
 Mechanism of Injury
• Contact - direct blow to the lateral knee with valgus force(complete tear.)
• Noncontact - deceleration or pivoting activities with valgus and external rotation
force (partial tears)
• Associated injuries
 Anterior cruciate ligament (ACL) tear - most common
 Meniscus tear - medial > lateral
 Pellegrini-Stieda syndrome
– calcification at the medial femoral insertion site
– results from chronic MCL deficiency
 Classification of MCL Injury
 O’Donoghue classification
• Grade I (mild)
– MCL has few torn fibers but no loss of ligamentous integrity.
• Grade II (moderate)
– MCL is partially torn, mild pathological laxity
• Grade III (severe)
– MCL is completely disrupted, significant pathological laxity of the knee
with valgus stress.
 Physical Exam

Valgus Stress Test

• Done in full knee extension
and 30 degrees of flexion.
• force the leg at the knee
into valgus
• If the knee is seen to open up
on the medial side, indicative
of MCL damage
• When performing the test at
30°, the MCL is the primary
stabilizer
Investigation
 Treatment
Non operative
• Indications
– Grade I
– Grade II
– Grade III
• if stable to valgus stress in full
extension
• no associated cruciate injury
• NSAIDs, rest, therapy
• immobilizer for comfort for 1-2
weeks
• hinged knee brace for ambulation
Operative

• Indications
– multi-ligament knee injury
– entrapment of the torn end in the medial
compartment
– continued instability despite nonoperative
treatment
– >10 mm medial sided opening in full
extension
Techniques
MCL repair
• ligament avulsions should be reattached
with suture anchors in 30 degrees of flexion
• internal brace - to minimize tension on
repair during healing process
MCL reconstruction
InternalBrace augmentation of MCL consists of a 2 mm FiberTape suture spanning the distance
between 2 Knotless anchors. This provides protective reinforcement of a primary MCL repair.
 Complications
• Loss of motion
• Neurological injury
– saphenous nerve
• Laxity
– associated with distal MCL injuries
 Lateral Collateral Ligament Injury
• Originates close to the lateral epicondyle
and inserts onto the fibular head.
Biomechanics
• primary restraint to varus stress at 5° and
25° of knee flexion and in extension
• tight in extension and lax in flexion
Blood supply
superolateral and
inferolateral geniculate arteries
Mechanism of injury
• A direct blow to the anteromedial aspect
of the knee
• Noncontact varus or hyperextension
injury.
• Excessive varus stress, external tibial
rotation
 Physical Exam
Varus stress test
• Apply varus stress to the knee at 30° of flexion.
• Amount of lateral opening should be noted.
• varus instability (lateral opening) at 30° flexion only - isolated LCL injury
• varus instability at 0° and 30° flexion - combined LCL and/or ACL/PCL injuries
Investigation
 Treatment
Nonoperative
• limited immobilization, progressive ROM, and functional rehabilitation
– indications
• isolated grade I or II LCL injury (no instability at 0°)
Operative
– indications
• grade III LCL injury
• rotatory instability involving LCL/PLC
• posterolateral instability at 0°
• Acute LCL repair
– lateral approach to the knee
– techniques
• suture anchors for repair of avulsed ligament
• direct suture repair for midsubstance ruptures
• LCL +/- PLC reconstruction
– Techniques
• single-stranded graft
• fibular-based reconstruction (Larson technique) for LCL
• transtibial double-bundle reconstruction of LCL
Anatomical reconstruction of the posterolateral corner with two free grafts
reconstructing the three major structures, through two femoral tunnels, one
tibial tunnel and one fibular tunnel.
 Menisci Injury
Anatomy
The menisci are C-shaped wedges of
fibrocartilage located between the tibial
plateau and femoral condyles.
Medial meniscus
• C-shaped with triangular cross
section
• most common
Lateral meniscus
• is more circular
• more common in acute ACL tears
• Attachment
– transverse (intermeniscal) ligament
– coronary ligaments
– meniscofemoral ligament
• Blood supply
– middle genicular artery
– Medial inferior genicular artery
– Lateral inferior genicular artery
 Functions
• Force transmission
– increasing congruency
– shock-absorption
– transmits 50% weight-bearing load
in extension, 85% in flexion
• Stability
– posterior horn of medial meniscus
is the main 2° stabilizer to anterior
translation
– become 1° stabilizers in ACL-
deficient knee
Mechanism
• by twisting motions
• valgus force with femur internal rotation causes medial meniscus tear
• varus force with femur external rotationd causes lateral meniscus lesion
• degenerative tears
 Classification
• Based on Location
 Red Zone : Outer third, vascularised
Red-White Zone : Middle third
White Zone : Inner third, avascularised
Classification based on Pattern
 Physical Exam
1) McMurray's test
• flex knee ,place a hand on medial
side of knee
• externally rotate the leg and bring
knee into extension.
• palpable pop / click + pain is a
positive test for medial meniscus
tear.
• For lateral meniscus internally
rotate the lower leg with hand on
posterolateral aspect of knee
 Investigation

X-Ray MRI showing meniscal tear and parameniscal cyst

 Treatment
Non-operative
• P.R.I.C.E, NSAIDS, Rehabilitation
– indications
• 1st line of treatment for degenerative tears
• person with mild symptoms of a meniscal tear and who
do not participate in sports
• A smaller tear and tear on the outer edge of the
meniscus in a stable knee
Operative

Partial meniscectomy
 Remove the torn meniscal
fragment and contour the
peripheral rim, leaving a
balanced, stable rim of
meniscal tissue
 Indications
– tears not amenable to
repair
– repair failure >2 times

 Partial preferred over total meniscectomy

- shorter operating time, faster recovery, better post-op function
 Meniscal repair
 Indications
– peripheral in the red-red zone
– 1-4 mm in length
– Vertical, radial, horizontal, degenerative, bucket handle and root tears
– acute repair combined with ACL reconstruction
 3 important steps:
 Appropriate patient selection
 Tear debridemen and local synovial,meniscal and capsular ablation
 Suture placement
 Meniscal Transplantation
• Indications
* Age <40 yr who had previous meniscectomy
* Symptoms localized to tibiofemoral compartment
* No advanced arthrosis
• Attempts at meniscal replacement with
* Allograft meniscus
* Autograft fascial material
* Synthetic meniscus
 Complications
• Saphenous neuropathy (7%)
• Arthrofibrosis (6%)
• Peroneal neuropathy (1%)
• Superficial infection (1%)
• Deep infection (1%)