Consideration of growth factors and bio-scaffolds for treatment of combined grade II MCL and ACL injury

Abstract

The literature suggests that a Grade II medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury will heal naturally and not compromise patient outcome following ACL reconstruction. Evidence based on bone-patella tendon-bone autograft use is stronger than evidence supporting anatomically placed soft tissue graft use. Current ACL reconstruction practices make greater use of soft tissue grafts, differing fixation methods, and anatomically lower placement on the inner wall of the lateral femoral condyle. Anatomical graft placement aligns the femoral bone tunnel more directly with valgus knee loading forces. Differences in the soft tissue graft-bone tunnel integration and ligamentization timetable following ACL reconstruction also increase concerns regarding residual Grade II MCL laxity and functional deficiency during accelerated functional rehabilitation. MCL dysfunction may increase susceptibility to early ACL graft slippage, elongation, outright failure, and medial femoral condyle lift-off with valgus knee loading. This concept paper discusses the potential role of growth factors and bio-scaffolds for improving Grade II MCL injury healing and mechanical integrity when the injury occurs in combination with an ACL injury that is reconstructed with a soft tissue graft and an anatomical surgical approach.

Permanent knee sensorimotor system changes following ACL injury and surgery

“…This trend is occurring in direct association with a growing appreciation for lesion healing potential, preserving both natural ACL mechanoreceptor and enthesis function [51, 116]. Some have recommended ACL repair augmentation with collagen‐coated suture, submucosa, or magnesium ring scaffolding [9, 46, 124, 125]. The knowledge base regarding biologically mediated tissue healing enhancement has prompted a surgical management “pendulum swing” away from a solely mechanocentric focus of ACL reconstruction to greater consideration of a biocentric repair approach [126, 127].…”

“…The complete ACL insertional remnant debridement that enables precise graft placement, and then drilling through the entheses for reconstruction, creates a structure that differs greatly from the natural ligament. Solely focusing on ACL biomechanics during surgery may also contribute to an under appreciation for concomitant CL injuries and neurosensory impairments to synergistic tissues [9, 45, 46]. Healing that culminates in residual knee laxity, and/or poorly organized, weakened, or lesser quality collagen fibre type or orientation may be directly related to impaired mechanoreceptor function.…”

Anterior cruciate ligament reconstruction, rehabilitation, and return to play: 2015 update

“… 37 – 39 Internal bracing also provides an additional option for repairing adjacent knee tissues that function in synchrony with the ACL, such as the medial collateral ( Figure 2 ) and anterolateral ligaments. 2 , 38 , 40 With more ACL repair or reconstruction options, the previous “mechano-centric” surgical and rehabilitative focus will likely evolve to a greater decision-making balance between both mechanical and neurosensory function restoration, surgically preserving and enhancing the function of as much viable, proprioception-enhancing tissue as possible through insightful rehabilitation approaches. 41…”

Platelet-Rich Plasma: From Laboratory to the Clinic

“…PRP injection for grade I and grade II MCL sprains for faster recovery may be suggested in daily practice. Also at the end of the procedure of percutaneous MCL reefing combined with ACL regularization, PRP may be injected over the MCL (Anoka et al 2012;Doral et al 2013) (Fig. 4).…”