0:00

So, um, these cases are inclusive of both the medial

0:04

and lateral ligaments, uh,

0:06

because I just spoke to you about,

0:08

uh, the lateral ligaments.

0:09

There's gonna be a little bit

0:10

of a bias towards the lateral side,

0:11

but we'll also talk about the medial

0:13

side in some of these cases.

0:15

And, um, I'm not going to go through all the findings, some

0:19

of these cases, um, uh, they do have multiple findings.

0:22

I just wanna hit some of the highlights.

0:24

So certainly you have them to review on your own

0:27

and hopefully you've done so beforehand so

0:29

that we can review them, uh, together.

0:32

So the first case is a, uh, 37-year-old woman who presented,

0:36

uh, with a knee dislocation while running on the beach.

0:39

She actually presented in the er, uh, dislocated

0:42

and was subsequently reduced.

0:45

So we'll just show the first radiograph here.

0:48

Obviously there's a malalignment of the knee.

0:51

There's, uh, anterior dislocation of the tibia relative

0:54

to the femur proximal override.

0:57

And if you just kind of think about in your mind

0:59

what could be injured, knowing where the footprints

1:03

of various ligamentous structures are, we know

1:05

that the ACL lives at the roof of the nickon

1:07

or notch up here.

1:09

It should attach somewhere here.

1:10

So, you know, A ACL that's approximately three

1:13

to four centimeters in length probably is not gonna survive

1:15

this kind of injury.

1:17

Likewise, the PCL probably disrupted,

1:19

but more importantly, when you're thinking about this

1:21

patient from a clinical standpoint,

1:23

what is their neurovascular status?

1:26

And of course our clinical colleagues will also be thinking

1:28

about this as well.

1:31

Um, so as far as re regards to neurovascular status,

1:34

this patient did undergo a CTA examination

1:38

and we can see that the popal artery, in fact,

1:41

is patent down

1:42

to its trifurcation into the tibial peroneal trunk.

1:47

This patient, of course, was subsequently reduced,

1:49

as I alluded to in the history,

1:51

and as breast neck showed you earlier, uh, an example

1:55

of this patient has clearly had a prior injury.

1:58

So this is an example of pellegrin Sada.

2:01

So this is gonna change the way we interpret the MCL when we

2:04

look at the subsequent MRI.

2:08

So here it is, the subsequent MRI.

2:10

We'll first look at that MCL

2:12

and without the knowledge of knowing that

2:15

that pellegrini data exists, you might be hard pressed

2:18

to even call any ossification in this media,

2:21

epicon perhaps here.

2:23

But we saw how robust that ossification was

2:26

and it didn't really have, um, sort

2:28

of bone marrow signal intensity.

2:29

And that's why we're not really seeing, I think this is akin

2:32

to looking for OPLL in the spine on your spine.

2:36

MRI sometimes can be difficult,

2:38

but certainly we can see a background of thickening

2:40

of this MCL reflecting her history of a more remote injury.

2:44

But if we look into the intercondylar notch,

2:47

we can see certainly that there's a complete disruption

2:50

of the mid portion of the anterior cruciate ligament.

2:53

And as we surmise,

2:54

the posterior cruciate ligament too is also completely vols

2:57

from its femoral attachment.

3:01

As we start to look at the lateral supporting structures

3:04

of the knee, as we move from front to back here,

3:07

we find the ileal tibial band attaching to ileal, uh,

3:10

gerdes tubercle, which is intact.

3:12

We now start to encounter the antral lateral ligament,

3:15

or if you want to call it the mid third

3:16

lateral capsular ligament.

3:18

And we can see the inferior meniscal tibial portions intact,

3:21

but superiorly it's vols.

3:23

And as we become more posteriorly,

3:25

we encounter the fibular collateral ligament.

3:28

Now you'll notice here as we see the more inferior portions

3:31

of the fibular collateral ligament, it's wavy and redundant.

3:34

So why is that? As we scroll back

3:35

and forth, we can see actually it's, there's a peel off

3:39

of the ligament from the bone here, which again, we could,

3:43

we correlate this

3:44

and, uh, cross reference with our axial images.

3:47

We can see here that it's pulled off the bone.

3:50

So this is a complete avulsion

3:51

of a fibular collateral ligament.

3:53

We're not quite done yet.

3:54

We need to look at the papa tendon.

3:57

And here also the papilla tendon.

3:59

While it's a vols not complete, it's not, uh, uh,

4:03

not separated too much from the PTL groove

4:06

of the, uh, distal femur.

4:08

But indeed at surgery this was, uh, found to be uls

4:10

of the distal femur.

4:12

Finally, as we move even more posteriorly,

4:14

we wanna make sure we interrogate the biceps fems tendon.

4:18

We can see a little bit of increased intrasubstance signal,

4:21

but no major fiber disruption in this example.

4:25

So if anything, maybe a low grade sprain

4:27

of those distal fibers, but we can see them attaching to

4:30

the fibular head.

4:34

So, um, just to summarize, uh, this patient, uh, under, uh,

4:39

went under, uh, exam under anesthesia.

4:41

They were grossly, um, unstable

4:43

and they had a lot of, um, injuries, both their A-C-L-P-C-L

4:47

and their poster lateral corner.

4:48

Um, so they had an extensive, um,

4:51

poster lateral Corona reconstruction, ACL

4:54

and uh, PCL reconstruction.

4:56

And let me see if I can pull up.

4:58

This is her postoperative plane film,

5:01

and you can see multiple interference screws, um,

5:03

from those multiple ligament reconstructions.

5:07

One thing I forgot to mention too, patients with this degree

5:11

of severity of ligament injury,

5:13

you always wanna make sure you check neuro uh, nerves too.

5:17

And she did, um, have some nerve injury,

5:20

at least on clinical exam.

5:21

But the peroneal nerve is definitely at risk,

5:23

so you wanna make sure you follow it.

5:25

Um, a little bit difficult in this situation,

5:27

given the edema.