0:00

Now let's talk a little bit about grading of the medial

0:04

uh, uh, supporting structures.

0:06

This is a grade that you can find.

0:08

This system, I should say,

0:09

is something you can find in the orthopedic literature,

0:13

and it is a clinical system.

0:15

I think it mainly relates to the effects

0:18

that you see on clinical examination,

0:21

which includes stress testing, grades one, two, and three.

0:25

You can see grade one pain, stable to stress, grade two,

0:29

pain unstable, but firm endpoint when stress is applied.

0:34

And then finally, grade three,

0:35

where there is a soft ENG endpoint.

0:38

In many of those cases, there are corresponding MR findings.

0:42

I listed them here and suspected pathologic findings.

0:47

But this is really a clinical grading systems.

0:50

There are no accurate MR imaging grading systems.

0:55

So when I look at abnormalities

0:56

of the medial supporting structures, I often talk in terms

1:00

of not grades, but mild, moderate,

1:03

or severe injury as an overview of

1:06

how much damage is being done.

1:09

This would be of the three examples.

1:11

The most mild, there is site tearing perhaps,

1:15

and thickening of the superficial

1:17

or tibial collateral ligament.

1:19

There's certainly damage

1:20

to the deep medial meniscal femoral ligament

1:23

and to the deep medial meniscal tibial ligament

1:27

with a little bit of fluid within the MCL bursa.

1:30

This looks worse. The degree of damage

1:33

to the tibial collateral ligament

1:35

and deep ligaments is greater.

1:37

And this clearly looks worse.

1:39

It would be a severe injury with disorganization

1:42

of the medial supporting structures.

1:45

Now, there have been attempts in the literature to come up

1:48

with MR classification systems

1:51

and here's one in fact, uh,

1:53

that has been emphasized in a couple of articles.

1:56

And you can see here grade one, grade two and grade three.

2:00

But this in fact assumes that the deep layer fails

2:04

after the superficial layer.

2:06

And there are articles that suggest

2:08

that the deep layer may fail first

2:11

or be the only layer of abnormality.

2:14

It's a shorter structure compared

2:17

to the superficial structure.

2:19

And hence may fail first when tensile force is applied

2:23

to the medial aspect of the knee.

2:25

Well, this according to that

2:27

classification system would be a grade three injury

2:31

with damage to both the superficial

2:34

and deep portions of the medial collateral ligament.

2:39

But what do you do with this when you see an abnormality

2:42

only of the deep portion?

2:44

This is a small avulsion fracture.

2:46

And by the way, I wanna make a comment again about this.

2:50

There is edema here in this case probably related

2:53

to the fracture.

2:54

But remember, the deep medial capsule ligament has a direct

2:58

Attachment.

2:59

So it is not unusual, even with a soft tissue avulsion,

3:04

that you will get marrow edema in the medial

3:07

femoral condyle.

3:08

But here's another example. What grade is this?

3:12

According to that system

3:13

where mainly the deep portion is involved.

3:18

Now there is another grading system

3:20

that has been described in the literature

3:22

and that ignores completely the deep layer.

3:25

You can see the three grades here. Okay?

3:28

So only the superficial layer is considered.

3:31

So that is why I think there's no really good

3:35

currently anyway, good MRI classification system

3:40

for the severity of injuries

3:42

to the medial supporting structures.

3:45

So a number of years ago, I tried to come up with one.

3:48

I'm not recommending this, in fact we don't use this,

3:51

but I tried to figure out what might be grade one

3:55

and I came up with,

3:57

it might involve the superficial fibers alone.

4:00

We could call that A one s with edema here,

4:03

the deep fibers alone, or both superficial and deep fibers.

4:07

So that might be a way of grading the various components.

4:11

Okay? So you could look at something like this

4:14

and say this is a low grade

4:16

or grade one injury involving mainly the superficial portion

4:21

of the medial collateral ligament.

4:24

And you could go further

4:25

and come up with grade two, which is a partial tear.

4:29

It may involve only the superficial fibers

4:32

or only the deep fibers, either proximally or distally,

4:36

or it may involve both.

4:38

So here, by using this complex system,

4:41

a grade two involving the superficial proximal fibers

4:45

and deep or component, the proximal fibers,

4:48

but I'm not recommending this.

4:50

And finally, I show you the last example of

4:53

what might be a grade three injury, where here we deal

4:57

with a complete tear of both the superficial fibers

5:01

and the deep fibers.

5:02

So this would be a grade three superficial proximal portion,

5:07

deep proximal portion.

5:10

And you can see here a similar sort of arrangement.

5:13

So we tried this for a while and it didn't work.

5:16

So I, I do not use this. I use mild, moderate, and severe.

5:21

When you deal with severe problems

5:24

of the medial supporting structures,

5:26

you may get displacement of the meniscus.

5:30

So you might imagine that if you're dealing with a problem

5:33

that is located below LA tibia, that

5:36

that meniscus might move superiorly shown here

5:40

with a distal lesion of the medial collateral ligament.

5:44

Or if the opposite were to occur, the meniscus might move.

5:48

Inferiorly being closer to the medial tibial plateau.