The Presence of the Arthroscopic "Floating Meniscus" Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury

Trilogy of isolated deep medial collateral ligament injuries of the knee: A set of three cases and overview of the literature

The authors present three unique cases of isolated deep medial collateral ligament (dMCL) injuries and comprehensively review the current literature. An isolated dMCL injury is often overlooked in clinical practice, and a consensus on the most adequate treatment is needed. Three male patients were examined at our institution directly following the trauma. The first patient experienced isolated soft-tissue avulsion of the dMCL, the second patient had a bony avulsion from the femoral insertion of the dMCL, and the third patient presented with an isolated "reverse Segond" fracture, which has not previously been described in the literature. All three injuries resulted from a violent external knee joint rotation. The treatment regime included a knee brace for up to 5 weeks and a physical therapy regimen for up to 3 months. All three patients reported satisfactory outcomes regarding restored knee function, absence of symptoms, and early return to activities at the final follow-up. STUDY DESIGN: Case report; Level of evidence V.

Does Combined Reconstruction of the Medial Collateral and Anterior Cruciate Ligaments Provide Better Knee Function? A Systematic Review and Meta-Analysis

Objective: This study aimed to determine if medial collateral ligament reconstruction (MCLR) alongside anterior cruciate ligament reconstruction (ACLR) preserves knee functionality better than isolated ACLR in combined ACL and MCL tears. Methods: MEDLINE, EMBASE, Scopus, CENTRAL, and Web of Science were searched systematically on 31 March 2023. Studies reporting post-operative function after ACLR and ACLR + MCLR in combined injuries were included. Outcomes included International Knee Documentation Committee (IKDC) score, side-to-side difference (SSD), Lysholm, and Tegner scale values. Results: Out of 2362 papers, 8 studies met the criteria. The analysis found no significant difference in outcomes (MD = 3.63, 95% CI: [-5.05, 12.3] for IKDC; MD = -0.64, 95% CI: [-3.24, 1.96] for SSD at 0° extension; MD = -1.79, 95% CI: [-4.61, 1.04] for SSD at 30° extension; MD = -1.48, 95% CI: [-16.35, 13.39] for Lysholm scale; MD = -0.21, 95% CI: [-4.29, 3.87] for Tegner scale) between treatments. Conclusions: This meta-analysis found no significant difference in outcomes between ACLR and ACLR + MCLR, suggesting that adding MCLR does not provide additional benefits. Due to the heterogeneity and quality of the included studies, further high-quality randomized controlled trials are needed to determine the optimal treatment for combined severe MCL-ACL injuries.

Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis

» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.

Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

BACKGROUND

Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques.

PURPOSE

To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury.

STUDY DESIGN

Controlled laboratory study.

METHODS

Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system.

RESULTS

sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion.

CONCLUSION

In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion.

CLINICAL RELEVANCE

In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness

Purpose

To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up.

Methods

A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR).

Results

A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0).

Conclusions

In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up.

Level of Evidence

Level IV, therapeutic case series.

Contribution of the Medial Hamstrings to Valgus Stability of the Knee

Background

Multiligament knee injuries involving the medial side are common. When performing surgical reconstruction, use of the medial hamstrings (HS) as grafts remains controversial in this setting.

Purpose

To determine the role of the medial HS in stabilizing the valgus knee for different types of medial-sided knee injury.

Study Design

Controlled laboratory study.

Methods

A biomechanical study on 10 cadaveric knees was performed. Valgus load (force moment of 10 N/m) was applied at 0°, 30°, and 60° of flexion, and the resultant rotation was recorded using an optoelectronic motion analysis system. Measurements were repeated for 4 different knee states: intact knee, superficial medial collateral ligament (sMCL) injury, deep medial collateral ligament (dMCL) injury, and posterior oblique ligament (POL) injury. For each state, 4 loading conditions (+ loaded; - unloaded) of the semitendinosus (ST) and gracilis (GRA) tendons were tested: ST+/GRA+, ST+/GRA-, ST-/GRA+, and ST-/GRA-.

Results

At 0° of flexion, combined unloading of the ST and GRA (ST-/GRA-) increased valgus laxity on the intact knee compared with the ST+/GRA+ condition (P < .05). For all medial-sided injury states (isolated sMCL; combined sMCL and dMCL; and combined sMCL, dMCL, and POL damage), ST-/GRA- increased valgus laxity at 0° and 30° of flexion versus ST+/GRA+ (P < .05 for all). The absolute value of valgus laxity increased with the severity of medial-sided ligament injury. Isolated ST unloading increased valgus laxity for the intact knee and the MCL-injured knee (combined sMCL and dMCL) at 0° of flexion (P < .05 vs ST+/GRA+). Isolated unloading of the GRA had no effect on valgus knee stability.

Conclusion

The medial HS tendons contributed to the stabilization of the knee in valgus, and this was even more important when the medial side was severely affected (POL damage). This stabilizing effect was greater between 0° and 30°, in which the POL is the main valgus stabilizer.

Clinical Relevance

When deciding on graft selection for multiligament knee injury reconstruction, the surgeon should be aware of the effect of harvesting the medial HS tendon on valgus laxity.

Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous

Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Case Study: Management of Anterior Cruciate Ligament Injuries

Considering the frequency of anterior cruciate ligament (ACL) tears, optimal management of these injuries was the subject of a 2022 clinical practice guideline update from The American Academy of Orthopaedic Surgeons (AAOS) with input from representatives from the American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Orthopaedic Society for Sports Medicine, the American Medical Society for Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American College of Emergency Physicians. The eight recommendations and seven options to guide orthopaedic surgeons and other physicians managing patients with these anterior cruciate ligament injuries are based on the best current available evidence. The cases presented in this article are examples designed to demonstrate the clinical application of these guidelines.

Comparative study of superficial medial collateral ligament reconstruction combined with posterior oblique ligament reconstruction or posteromedial capsule advance in grade III injuries of the medial compartment in a complex knee injury scenario

BACKGROUND

The purpose of this study was to compare the combined reconstruction of the superficial medial collateral ligament (sMCL) and the posterior oblique ligament (POL) with the reconstruction of the sMCL associated with the advancement of the posteromedial capsule in a complex knee injury scenario. We hypothesized that both techniques would present similar knee stability and failure rates.

METHODS

This is a retrospective case-control study designed to compare the results of the two reported techniques for grade III MCL instability. Patients undergoing MCL reconstruction associated with anterior cruciate ligament, posterior cruciate ligament, or both, from 2010 to 2019, were included. The following parameters were evaluated: demographic data, type of graft, time from injury to surgery, associated meniscus injuries, follow up time, mechanism of trauma, postoperative objective IKDC, subjective IKDC and Lysholm scales, range of motion, reconstruction failure and complications.

RESULTS

Seventy-eight patients were evaluated, 37 of whom underwent reconstruction of the sMCL and POL, and 41 of whom underwent reconstruction of the sMCL with advancement of posteromedial structures. There was no difference in any preoperative variable. Patients undergoing reconstruction of the sMCL + advancement had greater loss of flexion (Group 1 3.4 ± 4.6 vs Group 2 8.4 ± 7.9; P = 0.002) and more individuals with flexion loss greater than 10° (Group 1, seven patients (18.9%) vs Group 2, 17 patients (41.5%); P = 0.031). Postoperative knee stability, failures and complications were similar between groups.

CONCLUSION

Both techniques presented good functional results and low rates of complications. However, the advancement technique showed greater flexion loss, which should be considered when choosing the best surgical option.

The management of combined ACL and MCL injuries: A systematic review

Background

The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies.

Methods

A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score.

Results

52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury.

Conclusions

Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.

The value of magnetic resonance imaging in the preoperative diagnosis of tibial plateau fractures: a systematic literature review

Purpose

The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated.

Methods

A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles’ reference lists and the ePublication lists of leading orthopedic and trauma journals.

Results

A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found.

Conclusion

At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.

Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability

The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.

An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review

PURPOSE

The posterior tibial slope (PTS) is considered a risk factor for anterior cruciate ligament (ACL) injury. However, the influence of PTS on graft failure following ACL reconstruction remains relatively unknown. Therefore, this systematic review was conducted to investigate whether PTS could be a potential risk factor for graft failure after ACL reconstruction.

METHODS

PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure Database, and Wanfang Database were comprehensively searched from inception to March 31, 2021. Observational studies reporting the associations of medial tibial plateau slope (MTPS) or lateral tibial plateau slope (LTPS) with graft failure after ACL reconstruction were evaluated.

RESULTS

Twenty studies involving 12 case-control studies, 4 retrospective studies and 4 cross-sectional studies including 5326 patients met the final inclusion criteria. The high heterogeneity and the characteristics of nonrandomized controlled trials limited data synthesis. Fifteen of the 20 included studies detected a significant association between increased PTS and ACL graft failure, while 5 studies concluded that increased PTS was not associated with ACL graft failure. Ten studies suggested that MTPS is associated with ACL graft failure, and six studies suggested that LTPS is associated with ACL graft failure. The mean MTPS values for nonfailure group ranged from 3.5° ± 2.5° to 14.4° ± 2.8°. For the graft failure group, MTPS ranged from 4.71° ± 2.41° to 17.2° ± 2.2°. The mean LTPS values for nonfailure group ranged from 2.9° ± 2.1° to 11.9° ± 3.0°. For the graft failure group, LTPS ranged from 5.5° ± 3.0° to 13.3° ± 3.0°. The reported PTS values that caused ACL graft failure was greater than 7.4° to 17°.

CONCLUSION

Based on the current clinical evidence, increased PTS is associated with a higher risk of ACL graft failure after ACL reconstruction. Despite various methods of measuring PTS have high reliability, there is still vast disagreement in the actual value of PTS.

LEVEL OF EVIDENCE

IV.

Knee anteromedial compartment dissection: Final results and anterior oblique ligament description

The anteromedial region of the knee is little explored in the literature and may play an important role in anteromedial rotatory instability. The purpose of this study is to describe a ligamentous structure in the anteromedial region of the knee identified in a series of anatomical dissections of cadaveric specimens. Twenty-one cadaveric knees were dissected to study the medial compartment. Exclusion criteria were signs of trauma, previous surgery, signs of osteoarthritis, and poor preservation state. The main structures of this region were identified during medial dissection. After releasing the superficial medial collateral ligament of the tibia, the anterior oblique ligament (AOL) was isolated. The morphology of the structure and its relationship with known anatomical parameters were determined. For the statistical analysis, the means and standard deviations were calculated for continuous variables. A 95% confidence interval was defined as significant. Student's t-tests were used for continuous variables. After dissection, a distinct ligamentous structure (AOL) was found in the medial region of the knee. This structure was found in 100% of the cases, was located extracapsularly and originated in the anterior aspect of the medial epicondyle, running obliquely toward the tibia. When crossing the joint, the ligament presented a fan-shaped opening, exhibiting a larger area at the tibial insertion. The AOL had a mean thickness of 6.83 ± 1.51 mm at its femoral origin and 13.39 ± 2.64 at its tibial insertion. It had a significantly (p = 0.0001) longer mean length with the knee at 90° of flexion (35.27 ± 6.59 mm) than with the knee in total extension (27.89 ± 5.46 mm), indicating that the ligament is tensioned in flexion. A new structure was identified in the anteromedial compartment of the knee with a ligamentous appearance. Further studies are necessary to identify its importance on knee stability. This study demonstrates the anatomy of a new medial structure of the knee. As a result, there will be a better understanding of the stability of the knee.

The post-traumatic meniscal extrusion, sign of meniscotibial ligament injury. A case series

BACKGROUND

Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings.

HYPOTHESIS

The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL.

PATIENTS AND METHODS

Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity.

RESULTS

All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15-57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (ρ=-0.270; p=0.202). Neither between having more than 3mm of extrusion and gender (χ²=0.80; p=0.371), acute/chronic lesion (χ²=0.91; p=0.341) and primary/revision reconstructions (χ²=0.83; p=0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up.

DISCUSSION

A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes.

LEVEL OF EVIDENCE

IV, retrospective case series.

Current concepts on management of medial and posteromedial knee injuries

Traditionally, while managing ligament injuries around the knee, medial side injuries are frequently overlooked or considered 'benign' with very little influence on overall knee stability outcomes. However, much has changed in the recent past, and like the lateral side of the knee, it is gaining considerable attention. It is now well known that the Medial collateral ligament and Posteromedial corner are fundamentally two distinct structures that differ in anatomy and biomechanics. When it comes to decision making between conservative versus operative approach for medial side injuries, treating orthopaedic surgeons are subjected to walking on a thin line trying to balance between potential residual laxity and joint stiffness. This review will delve into some of the recent works focusing on the medial side injuries and discuss the evolving concepts.

MCL Reconstruction Using a Flat Tendon Graft for Anteromedial and Posteromedial Instability

The main principles of the present medial collateral ligament (MCL) reconstruction techniques are (1) to approximate the natural anatomy and (2) to restore the main passive restraining structures in anteromedial and posteromedial knee instability. Therefore, we describe a technique using a flat tendon graft instead of tubular grafts with point-to-point bone fixation. Moreover, we address the deep MCL, a relevant restraint to anteromedial instability.

Do Clinical Outcomes and Failure Rates Differ in Patients With Combined ACL and Grade 2 MCL Tears Versus Isolated ACL Tears?: A Prospective Study With 14-Year Follow-up

Background:

A combined injury to the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) is a common injury pattern encountered during clinical practice. Recent systematic reviews have found no consensus on the optimal method of managing this combined ligament injury pattern, and no long-term studies with modern techniques are available in the literature.

Purpose:

To compare 2 groups of patients who underwent isolated ACL reconstruction in terms of failures and clinical scores at long-term follow-up. In the first group were patients with isolated ACL tears (ACL group), while the second was composed of patients with combined ACL and MCL grade 2 tears (ACL + MCL group).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 57 patients (37 in the ACL group and 20 in the ACL + MCL group) underwent isolated ACL reconstruction with a double-bundle technique between January and December 2005. Patients were contacted for scores on the International Knee Documentation Committee subjective form, Western Ontario and McMaster Universities Osteoarthritis Index, and Tegner activity scale as well as data regarding ipsilateral or contralateral revision ACL surgery. A 2-way analysis of variance for repeated measures was used to statistically assess the differences between the groups.

Results:

Overall, 49 patients (86%) completed the survey and were therefore included in the study. The minimum follow-up was 14.6 years (range, 14.1-15.2 years). There was a significant reduction in both groups of all the outcome scores between the intermediate and final-follow-up. The number of failures was 3 of 31 (9.7%) in the ACL group and 1 of 18 (5.5%) in the ACL + MCL group; this difference was not significant. Moreover, there were no clinical differences between the groups in terms of graft failures, contralateral lesions, and clinical scores.

Conclusion:

At 14-year follow-up, no clinical difference or increased failure rate was observed between the study groups, suggesting that isolated ACL reconstruction could represent an appropriate treatment for a combined ACL and MCL grade 2 lesion.

Semimembranosus Tendon Advancement for the Anteromedial Knee Rotatory Instability Treatment

Injury to the medial compartment of the knee is the most common ligament injury to this joint. The medial approach must consider the presence of associated anteromedial instability. Untreated injury of these instabilities can result in failure of the other reconstructed ligaments. As treatment is usually associated with other ligaments, it is relevant that the technique could save grafts and synthetic material. This article aims to describe a technique for the treatment of anteromedial instabilities through semimembranosus tendon tenodesis in a more anterior and distal position, promoting the tensioning of the posteromedial structures.

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

Purpose

To provide an overview of all published randomized controlled trials (RCTs) in anterior cruciate ligament reconstruction (ACLR) summarizing the available evidence.

Methods

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane FIGCentral Register of Controlled Trials, Ovid MEDLINE, and Embase for RCTs of ACLR from their inception to August 26, 2020. Outcome measure was whether RCTs reported statistically significant findings. RCTs were then classified according to their intervention groups in a narrative synthesis of the evidence.

Results

In total, 299 RCTs met the inclusion criteria and were included with a total number of 25,186 patients. Only 30 RCTs (10%) reported significant differences between the intervention and the control groups. These included 101 RCTs on grafts, 20 RCTs on tunnel placements, 48 RCTs on graft fixation, 42 RCTs on single-bundle compared with double-bundle reconstructions, 11 RCTs on additional procedures, 11 RCTs on graft tensioning, 5 RCTs on timing of surgery, 25 RCTs on technical variations from standard techniques, 6 RCTs on ACL repair, 5 RCTs on navigation, 16 RCTs on perioperative management, and 9 RCTs on other aspects of ACLR. Only 14 RCTs (4.7%) reported outcomes beyond 10 years with greater allograft failures compared with autografts, high incidence of osteoarthritic changes in reconstructed knees (22%-100%), with no significant differences in outcomes between bioabsorbable or metal screws for graft fixation, patellar versus hamstrings or single- versus double-bundle reconstructions.

Conclusions

The evidence indicates that a standard arthroscopic single- or double-bundle ACLR with hamstrings/patella autografts, transportal technique, and fixation techniques familiar to the surgeon leads to comparable results. This evidence offers surgeons the flexibility to use standard and cost-effective techniques and achieve comparable outcomes.

Level of Evidence

Level II; systematic review of Level I-II randomized controlled trials.

Lower Failure Rates and Improved Patient Outcome Due to Reconstruction of the MCL and Revision ACL Reconstruction in Chronic Medial Knee Instability

Background:

Concomitant lesion of the medial collateral ligament (MCL) is associated with a greater risk of anterior cruciate ligament (ACL) graft failure.

Purpose:

The aim of this study was to compare two medial stabilization techniques in patients with revision ACL reconstruction (ACLR) and concomitant chronic medial knee instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

In a retrospective study, we included 53 patients with revision ACLR and chronic grade 2 medial knee instability to compare medial surgical techniques (MCL reconstruction [n = 17] vs repair [n = 36]). Postoperative failure of the revision ACLR (primary aim) was defined as side-to-side difference in Rolimeter testing ≥5 mm or pivot-shift grade ≥2. Clinical parameters and postoperative functional scores (secondary aim) were evaluated with a mean ± SD follow-up of 28.8 ± 9 months (range, 24-69 months).

Results:

Revision ACLR was performed in 53 patients with additional grade 2 medial instability (men, n = 33; women, n = 20; mean age, 31.3 ± 12 years). Failure occurred in 5.9% (n = 1) in the MCL reconstruction group, whereas 36.1% (n = 13) of patients with MCL repair showed a failed revision ACLR (P = .02). In the postoperative assessment, the anterior side-to-side difference in Rolimeter testing was significantly reduced (1.5 ± 1.9 mm vs 2.9 ± 2.3 mm; P = .037), and medial knee instability occurred significantly less (18% vs 50%; P = .025) in the MCL reconstruction group than in the MCL repair group. In the logistic regression, patients showed a 9-times elevated risk of failure when an MCL repair was performed (P = .043). Patient-reported outcomes were increased in the MCL reconstruction group as compared with MCL repair, but only the Lysholm score showed a significant difference (Tegner, 5.6 ± 1.9 vs 5.3 ± 1.6; International Knee Documentation Committee, 80.3 ± 16.6 vs 73.6 ± 16.4; Lysholm, 82.9 ± 13.6 vs 75.1 ± 21.1 [P = .047]).

Conclusion:

MCL reconstruction led to lower failure rates in patients with combined revision ACLR and chronic medial instability as compared with MCL repair. MCL reconstruction was superior to MCL repair, as lower postoperative anterior instability, an increased Lysholm score, and less medial instability were present after revision ACLR. MCL repair was associated with a 9-times greater risk of failure.

Arthroscopic Anterior Cruciate Ligament Injury in Clinical Treatment of Joint Complications and CT Observation

Arthroscopy is the gold standard for diagnosing ACL injuries. It is a dual clinical technique for examination and treatment, which can effectively target the injury site for repair and treatment and can also accurately identify the lesion site and determine the degree of ligament injury through visual and three-dimensional observation of ligament injuries that are difficult to detect on imaging. However, this technique is invasive, so the clinic still needs to improve the related auxiliary imaging examination. In this paper, we performed MPR and VRT on patients with ACL injury and postprocessed the data. The diagnostic compliance rate of dual-source CT was 91.67% (33/36), the true positive rate was 93.33% (28/30), the missed rate was 6.67% (2/30), the true negative rate was 83.33% (5/6), and the misdiagnosis rate was 83.33% (5/6). The rate of true negative was 83.33% (5/6), and the rate of false diagnosis was 16.67% (1/6). Kappa analysis of the consistency between dual-source CT and arthroscopy showed a Kappa value of 0.719, indicating a high degree of consistency between the two examinations. In conclusion, MPR and VRT images are of clinical value for the diagnosis of ACL injury. In addition, dual-source CT can measure the CT value of the ACL and the thickness of each segment by MPR and VRT postprocessing techniques to diagnose the ligament injury in an objective, quantitative, and noninvasive way and can use dual-energy staining techniques to predict the ligament injury in a more intuitive way, which is not available in some arthroscopes.

The superficial medial collateral ligament is the major restraint to anteromedial instability of the knee

PURPOSE

The purpose of the present study was to determine how the medial structures and ACL contribute to restraining anteromedial instability of the knee.

METHODS

Twenty-eight paired, fresh-frozen human cadaveric knees were tested in a six-degree of freedom robotic setup. After sequentially cutting the dMCL, sMCL, POL and ACL in four different cutting orders, the following simulated clinical laxity tests were applied at 0°, 30°, 60° and 90° of knee flexion: 4 Nm external tibial rotation (ER), 4 Nm internal tibial rotation (IR), 8 Nm valgus rotation (VR) and anteromedial rotation (AMR)-combined 89 N anterior tibial translation and 4 Nm ER. Knee kinematics were recorded in the intact state and after each cut using an optical tracking system. Differences in medial compartment translation (AMT) and tibial rotation (AMR, ER, IR, VR) from the intact state were then analyzed.

RESULTS

The sMCL was the most important restraint to AMR, ER and VR at all flexion angles. Release of the proximal tibial attachment of the sMCL caused no significant increase in laxity if the distal sMCL attachment remained intact. The dMCL was a minor restraint to AMT and ER. The POL controlled IR and was a minor restraint to AMT and ER near extension. The ACL contributed with the sMCL in restraining AMT and was a secondary restraint to ER and VR in the MCL deficient knee.

CONCLUSION

The sMCL appears to be the most important restraint to anteromedial instability; the dMCL and POL play more minor roles. Based on the present data a new classification of anteromedial instability is proposed, which may support clinical examination and treatment decision. In higher grades of anteromedial instability an injury to the sMCL should be suspected and addressed if treated surgically.

Arthroscopic Primary Medial Collateral Ligament Repair With Suture Anchor

A medial collateral ligament (MCL) tear is common in cases of isolated injury or in those combined with anterior cruciate ligament injury. Although conservative treatment for an MCL tear is popular, some cases result in residual instability. Thus, the treatment approach of grade III MCL injury remains controversial. In this Technical Note, we present the technique of arthroscopic primary MCL repair with suture anchor. With this technique, proximal MCL injuries can be repaired with minimal invasion. This technique improves valgus stability and enables early rehabilitation, including range of motion and weight-bearing exercise.

Arthroscopy Annual Awards: The "Old Normal"

With sincere thanks to the Arthroscopy Association of North America Education Foundation for their support, we are pleased to announce the Annual Awards for our best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2020, as well as the Most Downloaded and Most Cited papers published 5 years ago. We proudly introduce new members of our editorial team, and your editors update their disclosures of potential conflicts of interest.

[Clinical observation of arthroscopic all-inside combined with outside-in "suture loop" repair for meniscus bucket-handle tear]

OBJECTIVE

To investigate the effectiveness of arthroscopic all-inside combined with outside-in "suture loop" repair for meniscus bucket-handle tear (BHT).

METHODS

Between August 2016 and May 2019, 44 case of meniscus BHT were treated with arthroscopic all-inside combined outside-in "suture loop". There were 29 males and 15 females with an average age of 26.6 years (range, 18-42 years). The causes of injury included sports injury in 31 cases, falling injury in 7 cases, and sprain in 6 cases. There were 32 cases of medial meniscus posterior horn tears and 12 cases of lateral meniscus posterior horn tears. The disease duration ranged from 6 weeks to 3 months. Thirty-three cases were complicated with anterior cruciate ligament rupture. All patients had normal lower limb alignment. The preoperative Lysholm score was 42.1±9.1. According to the evaluation criteria of MRI and Barrett et al., the healing of meniscus was evaluated, and the effectiveness was evaluated by Lysholm score.

RESULTS

All the 44 patients were followed up 8-36 months with an average of 16.8 months. At last follow-up, according to the evaluation criteria of Barrett et al., 39 cases were clinically healed, 5 cases were not healed, the clinical healing rate was 88.6%; according to MRI evaluation, 32 cases were completely healed, 7 cases were partially healed, and 5 cases were not healed, the total healing rate was 88.6%, and the complete healing rate was 72.7%. Lysholm score was 87.8±4.8, which was significantly different from that before operation ( t=31.060, P=0.000).

CONCLUSION

Arthroscopic all-inside combined with outside-in "suture loop" repair is a reliable and effective method for the meniscus BHT, which can obtain good joint function.

Percutaneous Arthroscopic Assisted Knee Medial Collateral Ligament Repair

Medial collateral ligament (MCL) injuries are commonly encountered alongside anterior cruciate ligament injuries. Treatment modalities have ranged from conservative management to surgical repair, augmentation, and reconstruction. Various reports have reported residual valgus instability, especially in higher-grade injuries that have been treated conservatively. The MCL provides valgus stability but also is an element of anterior stability to the tibia in addition to the anterior cruciate ligament. In addition, meniscal "lift-off" and "floating" have been described as consequences after MCL injuries, and meniscal dysfunction has been shown to lead to accelerated joint degeneration; therefore, all efforts should be made to treat these injuries adequately. We describe a simple, minimally invasive technique that involves suturing the deep MCL to the medial joint capsule, allowing better MCL healing, causing less soft-tissue scarring, and preventing meniscal extrusion.

Arthroscopy Annual Awards, a 35th Anniversary…and More

With sincere appreciation to the Arthroscopy Association of North America Education Foundation for their generous support, we announce our 2020 Annual Awards for the best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2019, as well as the Most Downloaded and Most Cited papers published 5 years ago. Our January cover is a throwback in honor of the 35th anniversary of our journal, and our cover will sport a festive banner each month this year. We introduce our 2020 masthead and team, including a new Social Media Board. Finally, our Editor-in-chief, Assistant Editors, and Associate Editors update their disclosures of potential conflicts of interest.

Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction

PURPOSE

The purpose of this study was to carefully analyse the reasons for revision ACLR failure to optimize the surgical revision technique and minimize the risk of recurrent re-rupture. Large studies with a minimum of 2 years of follow-up that clinically examine patients with revision ACLR are rare.

METHODS

Between 2013 and 2016, 111 patients who underwent revision ACLR were included in the retrospective study. All patients were examined for a minimum of 2 years after revision surgery (35 ± 3.4 months, mean ± STD) and identified as "failed revision ACLR" (side-to-side difference ≥ 5 mm and pivot-shift grade 2/3) or "stable revision ACLR".

RESULTS

Failure after revision ACLR occurred in 14.5% (n = 16) of the cases. Preoperative medial knee instability (n = 36) was associated with failure; thus, patients had a 17 times greater risk of failure when medial knee instability was diagnosed (p = 0.015). The risk of failure was reduced when patients had medial stabilization (n = 24, p = 0.034) and extra-articular lateral tenodesis during revision surgery (n = 51, p = 0.028). Increased posterior tibial slope (n = 11 ≥ 12°, p = 0.046) and high-grade anterior knee laxity (side-to-side difference > 6 mm and pivot-shift grade 3, n = 41, p = 0.034) were associated with increased failure of revision ACLR. Obese patients had a 9 times greater risk of failure (p = 0.008, n = 30).

CONCLUSION

This study demonstrates the largest revision ACLR patient group with pre- and postoperative clinical examination data and a follow-up of 2 years published to date. Preoperative medial knee instability is an underestimated risk factor for revision ACLR failure. Additionally, high-grade anterior knee laxity, increased PTS and high BMI are risk factors for failure of revision ACLR, while additional medial stabilization and lateral extra-articular tenodesis reduce the risk of failure.

LEVEL OF EVIDENCE

III.

Editorial Commentary: Don't Float Away-Medial Collateral Ligament and Medial Meniscus Will Protect Your Anterior Cruciate Ligament Reconstruction if You Respect Them

As the understanding of the intrinsic reliance of the anterior cruciate ligament on the medial collateral ligament (MCL) has grown, we have delved further into trying to understand what specific function needs to be restored in their combined injury. At the same time, we have expanded our knowledge of the relation between the MCL and the medial meniscus. It is a great step forward for our knowledge to begin to infer medial stability from the status of the medial meniscus in these complex cases. In my practice, this manifests as understanding that a floating meniscus indicates deep MCL injury, which makes me more likely to treat a moderate MCL injury operatively. I look forward to the continued understanding of the dynamic positioning of the medial meniscus and its treatment in combined anterior cruciate ligament-MCL injuries.