Simultaneous Reconstruction of the Anterior Cruciate Ligament and Medial Collateral Ligament in Patients With Chronic ACL-MCL Lesions: A Minimum 2-Year Follow-up Study

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.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries-Which Is Best? A Systematic Review and Meta-analysis

BACKGROUND

Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries.

PURPOSE

To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach.

RESULTS

In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength.

CONCLUSION

Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

High Prevalence of Superficial and Deep Medial Collateral Ligament Injuries on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Tears

PURPOSE

To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears.

METHODS

Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears.

RESULTS

In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P = .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P = .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P = .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001).

CONCLUSIONS

The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5% + 24.8% = 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness.

METHODS

This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries.

RESULTS

Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.).

CONCLUSION

Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured.

LEVEL OF EVIDENCE

Level IV.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review

PURPOSE

To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up.

METHODS

A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria.

RESULTS

A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively.

CONCLUSIONS

MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries

BACKGROUND

The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary.

RESULTS

Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01).

CONCLUSION

In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.

Combined Anterior Cruciate Ligament and Medial Collateral Ligament Reconstruction Shows High Rates of Return to Activity and Low Rates of Recurrent Valgus Instability: An Updated Systematic Review

Purpose

To examine the clinical outcomes and return to sport rates after treatment of combined, complete (grade III) injuries of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL).

Methods

A literature search of the following databases was completed using key words related to combined ACL and (MCL) tears: MEDLINE, Embase, Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, and SPORTDiscus. Level I-IV studies that examined patients with complete tears of the ACL and grade III tears of the MCL, diagnosed by either magnetic resonance imaging or clinical examination of valgus instability, were included. Study inclusion was determined by 2 independent reviewers. Patient demographics, treatment choices, and patient outcomes, including clinical examination (i.e., range of motion, hamstring strength) and subjective assessments (i.e., International Knee Documentation Committee, Lysholm scores, Tegner activity scores) were collected.

Results

Six possible treatment combinations were assessed. Good or excellent outcomes related to range of motion, knee stability, subjective assessments, and return to play were reported after ACL reconstruction regardless of MCL treatment. Those with combined ACL and MCL reconstruction returned to their previous level of activity at a high rate (range, 87.5%-90.6%) with low rates of recurrent valgus instability. Triangular MCL reconstruction with a posterior limb that serves to reconstruct the posterior-oblique ligament best-restored anteromedial rotatory stability of the knee when compared with anatomic MCL reconstruction (90.6% and 65.6%, respectively). Nonsurgical management of the ACL injury, regardless of MCL treatment, demonstrated low return to activity (29%) and frequent secondary knee injuries.

Conclusions

High rates of return to sport with low risk of recurrent valgus instability have been demonstrated after MCL reconstruction, and triangular MCL reconstruction can more effectively restore anteromedial rotatory instability compared with MCL repair. Restoration of valgus stability can be common after reconstruction of the ACL with or without surgical management of the MCL, although patients with grade III tibial-sided or mid-substance injuries were less likely to regain valgus stability with nonoperative treatment than femoral-sided injuries.

Level of Evidence

Level IV; systematic review of Level I-IV studies.

Unhappy triad of the knee: What are the current concepts and opinions?

The association between injuries to the anterior cruciate ligament, medial collateral ligament, and medial meniscus (MM) has been known to orthopedic surgeons since 1936; O'Donoghue first used the term "unhappy triad" of the knee to describe this condition in 1950. Later studies revealed that involvement of the lateral meniscus is more common than MM in these cases, leading to a change in the definition. Recent studies have revealed that this triad may be primarily linked to knee anterolateral complex injuries. Although there is not a definite management protocol for this triad, we try to mention the most recent concepts about it in addition to expert opinions.

The Association Between Bone Bruises and Concomitant Ligaments Injuries in Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis

Background

Bone bruises and concomitant ligament injuries after anterior cruciate ligament (ACL) injuries have attracted attention, but their correlation and potential clinical significance remain unclear.

Purpose

To assess the relationship between bone bruises and concomitant ligamentous injuries in ACL injuries.

Study design

Systematic review.

Methods

A comprehensive search of PubMed, Embase, Web of Science, and Cochrane Library was completed from inception to October 20, 2021. All articles that evaluated the relationship between bone bruises and related ligaments injuries were included. Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessment as well as Review Manager 5.3 was used for data analysis.

Results

A total of 19 studies evaluating 3292 patients were included. After meta-analysis, anterolateral ligament (ALL) injuries were associated with bone bruising on the lateral tibial plateau (LTP) (RR = 2.33; 95% CI 1.44-3.77; p = 0.0006), lateral femoral condyle (LFC) (RR = 1.97; 95% CI 1.37-2.85; p = 0.0003) and medial tibial plateau (MTP) (RR = 1.62; 95% CI 1.24-2.11; p = 0.0004); Moreover, medial collateral ligament (MCL) injuries were associated with bone bruising on the femur (RR = 1.49; 95% CI 1.17-1.90; p = 0.001), and no statistical significance was found between bone bruising on the MTP and Kaplan fiber (KF) injuries (RR = 1.58; 95% CI 1.00-2.49; p = 0.05). Nonetheless, the current evidence did not conclude that bone bruises were associated with lateral collateral ligament (LCL) injuries.

Conclusion

For individuals with an ACL injury, bone bruises of the LTP, LFC, and MTP can assist in the diagnosis of ALL injuries. Furthermore, femoral bruising has potential diagnostic value for MCL injuries. Knowing these associations allows surgeons to be alert to ACL-related ligament injuries on MRI and during operations in future clinical practice.

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.

Medial Collateral Ligament Reconstruction for Anteromedial Instability of the Knee: A Biomechanical Study In Vitro

BACKGROUND

Although a medial collateral ligament (MCL) injury is associated with anteromedial rotatory instability (AMRI) and often with an anterior cruciate ligament (ACL) injury, there has been little work to develop anteromedial (AM) reconstruction to address this laxity.

PURPOSE

To measure the ability of a novel "anatomic" AM reconstruction technique to restore native knee laxity for isolated AM insufficiency and combined AM plus posteromedial insufficiency.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 12 cadaveric knees were mounted in a kinematic testing rig that allowed the tibia to be loaded while the knee flexed-extended 0° to 100° with 88-N anteroposterior translation, 5-N·m internal rotation-external rotation (ER), 8-N·m valgus, and combined anterior translation plus ER to simulate AMRI. Joint motion was measured using optical trackers with the knee intact, after superficial MCL (sMCL) and deep MCL (dMCL) transection, and after AM reconstruction of the sMCL and dMCL with semitendinosus autografts. The posteromedial capsule (PMC)/posterior oblique ligament (POL) was then transected to induce a grade 3 medial injury, and kinematic measurements were repeated afterward and again after removing the grafts. Laxity changes were examined using repeated-measures analysis of variance and post-testing.

RESULTS

sMCL and dMCL deficiency increased valgus, ER, and AMRI laxities. These laxities did not differ from native values after AM reconstruction. Additional PMC/POL deficiency did not increase these laxities significantly but did increase internal rotation laxity near knee extension; this was not controlled by AM reconstruction.

CONCLUSION

AM reconstruction eliminated AMRI after transection of the dMCL and sMCL, and also eliminated AMRI after additional PMC/POL transection.

CLINICAL RELEVANCE

Many MCL injuries occur in combination with ACL injuries, causing AMRI. These injuries may rupture the AM capsule and dMCL. Unaddressed MCL deficiency leads to an increased ACL reconstruction failure rate. A dMCL construct oriented anterodistally across the medial joint line, along with an sMCL graft, can restore native knee ER laxity. PMC/POL lesions did not contribute to AMRI.

A Triple-Strand Anatomic Medial Collateral Ligament Reconstruction Restores Knee Stability More Completely Than a Double-Strand Reconstruction: A Biomechanical Study In Vitro

BACKGROUND

There are many descriptions of medial collateral ligament (MCL) reconstruction, but they may not reproduce the anatomic structures and there is little evidence of their biomechanical performance.

PURPOSE

To investigate the ability of "anatomic" MCL reconstruction to restore native stability after grade III MCL plus posteromedial capsule/posterior oblique ligament injuries in vitro.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric knees were mounted in a kinematic testing rig to impose tibial displacing loads while the knee was flexed-extended: 88-N anteroposterior translation, 5-N·m internal-external rotation, 8-N·m valgus-varus, and combined anterior translation plus external rotation (anteromedial rotatory instability). Joint motion was measured via optical trackers with the knee intact; after superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament transection; and then after MCL double- and triple-strand reconstructions. Double strands reproduced the sMCL and posterior oblique ligament and triple-strands the sMCL, dMCL, and posterior oblique ligament. The sMCL was placed 5 mm posterior to the epicondyle in the double-strand technique and at the epicondyle in the triple-strand technique. Kinematic changes were examined by repeated measures 2-way analysis of variance with posttesting.

RESULTS

Transection of the sMCL, dMCL, and posterior oblique ligament increased valgus rotation (5° mean) and external rotation (9° mean). The double-strand reconstruction controlled valgus in extension but allowed 5° excess valgus in flexion and did not restore external rotation (7° excess). The triple-strand reconstruction restored both external rotation and valgus throughout flexion.

CONCLUSION

In a cadaveric model, a triple-strand reconstruction including a dMCL graft restored native external rotation, while a double-strand reconstruction without a dMCL graft did not. A reconstruction with the sMCL graft placed isometrically on the medial epicondyle restored valgus rotation across the arc of knee flexion, whereas a reconstruction with a more posteriorly placed sMCL graft slackened with knee flexion.

CLINICAL RELEVANCE

An MCL injury may rupture the anteromedial capsule and dMCL, causing anteromedial rotatory instability. Persistent MCL instability increases the likelihood of ACL graft failure after combined injury. A reconstruction with an anteromedial dMCL graft restored native external rotation, which may help to unload/protect an ACL graft. It is important to locate the sMCL graft isometrically at the femoral epicondyle to restore valgus across flexion.

High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury

PURPOSE

In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures.

METHODS

Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests.

RESULTS

Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury.

CONCLUSION

The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment.

LEVEL OF EVIDENCE

III.

Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG)

Background:

Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined.

Purpose:

To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL.

Study Design:

Consensus statement.

Methods:

Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests.

Results:

The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements.

Conclusion:

The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.

Comparison between single- and double-bundle anterior cruciate ligament reconstructions for knee with grade 2 medial collateral ligament injury

This research discussed clinical outcomes of anterior cruciate ligament reconstruction accompanied by conservative treatment for grade 2 medial collateral ligament injury, and comparison was performed between double-bundle and single-bundle anterior cruciate ligament reconstruction.Clinical information was retrospectively collected for 41 cases suffering anterior cruciate ligament injuries accompanied by grade 2 medial collateral ligament injuries. Within 14 days after their injuries 22 cases received single-bundle anterior cruciate ligament reconstruction (SB group), while 19 were treated with double-bundle medial collateral ligament reconstruction (DB group). Physical statuses were estimated based on International Knee Documentation Committee (IKDC) and Lysholm scores, Lachman, pivot shift and manual valgus test, and range of motion (ROM), while side-to-side difference was estimated through KT 2000 arthometer.Anterior cruciate ligament reconstruction accompanied by conservative treatment showed significantly improved anteroposterior, rotational and valgus stability, and IKDC and Lysholm scores (in comparison to pre-operative status, P < .05). Incidence of pivot shift was dramatically lower in DB group (2/19) than in SB group (7/22 and 2/22; P = .028). No substantial dissimilarity existed between DB and SB groups either in Lachman and valgus tests, KT 2000, ROM, IKDC, or Lysholm scores.Anterior cruciate ligament reconstruction accompanied by conservative treatment could achieve outstanding stability and functional manifestations for cases facing anterior cruciate ligament injury accompanied by grade 2 medial collateral ligament injury. Moreover, double-bundle anterior cruciate ligament reconstruction is superior to single-bundle operation in treating rotational instability of the knee.Level of evidence: Retrospective comparative study, Level III.

Treatment of medial-sided injuries in patients with early bicruciate ligament reconstruction for knee dislocation

PURPOSE

In knee dislocation with bicruciate ligament and medial side injury (KDIIIM), treatment method of medial side injuries is controversial. The purpose of this study was to evaluate the outcomes of non-operative treatment of proximal and midsubstance and operative treatment of distal avulsion medial collateral ligament (MCL) ruptures in patients with early bicruciate reconstruction.

METHODS

One-hundred and forty-seven patients with a knee dislocation and bicruciate ligament injury (KDII-KDV) were identified. Sixty-two patients had KDIIIM injury. Of these, 24 patients were excluded and 13 were lost to follow-up. With a minimum of 2 years of follow-up, IKDC2000 (subjective and objective), Lysholm and Tegner scores and stress radiographs were recorded.

RESULTS

Twenty-five patients were available for follow-up: 18 had a proximal or midsubstance grade-III MCL rupture (proximal MCL group) and 7 had a distal MCL avulsion (distal MCL group). In the proximal MCL and distal MCL groups, respectively, median IKDC2000 subjective scores were 80 (range 57-99) and 62 (range 39-87), and median Lysholm scores were 88 (range 57-99) and 75 (range 40-100). The median medial opening (side-to-side difference) was 2.4 mm (range 0.1-9.2) in the proximal MCL group and 2.5 mm (range 0.2-4.8) in the distal MCL group.

CONCLUSION

We found acceptable recorded outcomes in patients who underwent non-operative treatment of proximal and midsubstance grade-III MCL rupture and operative treatment of distal MCL avulsion with early bicruciate ligament reconstruction.

LEVEL OF EVIDENCE

Level IV.

Results of Treatment of the Multiple Ligament Injured (Dislocated) Knee

Knee dislocations leading to multiligament knee injuries are associated with a wide variety of bony, ligamentous, soft tissue, and neurovascular injury patterns. Numerous management strategies have been proposed including nonoperative treatment and surgical repair or reconstruction. In recent years, an emphasis has been placed on anatomic repair and reconstruction principles, which have shown superior outcomes compared with older techniques. However, despite these advances, clinical outcomes continue to vary widely, with many patients experiencing chronic pain, stiffness, loss of range of motion, instability, and failure to return to work or sports. The purpose of this chapter is to review clinical outcomes following combined anterior and posterior cruciate ligament, medial collateral ligament, and posterolateral corner injuries sustained during a knee dislocation. Understanding the available treatment options and reported outcomes will allow surgeons to individualize management to address each patient's specific injury pattern and functional goals.

Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players

BACKGROUND

For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation.

HYPOTHESIS

There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP.

RESULTS

A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone-patellar tendon-bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant.

CONCLUSION

The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

The medial ligaments and the ACL restrain anteromedial laxity of the knee

PURPOSE

The purpose of this study was to determine the contribution of each of the ACL and medial ligament structures in resisting anteromedial rotatory instability (AMRI) loads applied in vitro.

METHODS

Twelve knees were tested using a robotic system. It imposed loads simulating clinical laxity tests at 0° to 90° flexion: ±90 N anterior-posterior force, ±8 Nm varus-valgus moment, and ±5 Nm internal-external rotation, and the tibial displacements were measured in the intact knee. The ACL and individual medial structures-retinaculum, superficial and deep medial collateral ligament (sMCL and dMCL), and posteromedial capsule with oblique ligament (POL + PMC)-were sectioned sequentially. The tibial displacements were reapplied after each cut and the reduced loads required allowed the contribution of each structure to be calculated.

RESULTS

For anterior translation, the ACL was the primary restraint, resisting 63-77% of the drawer force across 0° to 90°, the sMCL contributing 4-7%. For posterior translation, the POL + PMC contributed 10% of the restraint in extension; other structures were not significant. For valgus load, the sMCL was the primary restraint (40-54%) across 0° to 90°, the dMCL 12%, and POL + PMC 16% in extension. For external rotation, the dMCL resisted 23-13% across 0° to 90°, the sMCL 13-22%, and the ACL 6-9%.

CONCLUSION

The dMCL is the largest medial restraint to tibial external rotation in extension. Therefore, following a combined ACL + MCL injury, AMRI may persist if there is inadequate healing of both the sMCL and dMCL, and MCL deficiency increases the risk of ACL graft failure.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Weave Technique for Reconstruction of Medial Collateral Ligament and Posterior Oblique Ligament: An Anatomic Approach Using Semitendinosus Tendon

Medial collateral ligament (MCL) is the most commonly injured ligament in knee. The majority of MCL tears can be managed conservatively, and reconstruction or augmentation is required in few selected cases. Anatomic MCL and posterior oblique ligament reconstruction have good functional outcome, but it requires 2 tunnels each in the tibia and femur, which may be a limitation in cases in which multiligament reconstruction is required. Several studies report the use of semitendinosus tendon with intact tibial attachment for MCL reconstruction. Since the attachment of semitendinosus is anterior to MCL footprint, it is non-anatomic and anisometric, which may lead to increased laxity of the reconstructed ligament in due course of time. To prevent the laxity in long term, the reconstruction has to be isometric and anatomic. We, hereby, are reporting our unique technique of MCL and posterior oblique ligament reconstruction using intact semitendinosus at tibial attachment and re-routing to the MCL which makes the reconstruction anatomic and isometric. A supplemental video demonstration of the technique is attached with this article.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction

PURPOSE

Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions.

METHODS

A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified.

RESULTS

The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue.

CONCLUSION

The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue.

LEVEL OF EVIDENCE

IV.

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

PURPOSE

To compare the outcomes of patients with an arthroscopic floating meniscus sign at 24-month follow-up when treated with and without medial compartment reconstruction surgery. Another aim of the present study was to compare magnetic resonance imaging and arthroscopic findings directly related to the characterization and localization medial collateral ligament (MCL) injuries.

METHODS

A total of 112 patients diagnosed with combined anterior cruciate ligament (ACL)-MCL grade II injuries to be treated with ACL reconstruction surgery were included in the study. During arthroscopy, patients diagnosed with the "floating meniscus" sign were divided into 2 groups: group 1 (n = 58) was treated with ACL and medial compartment reconstruction surgery and group 2 (n = 54) was treated with ACL reconstruction and nonsurgical medial compartment treatment. Return to competitive sports (Tegner score), Lysholm scores, ACL reconstruction failure, and residual MCL laxity were evaluated 6, 12, and 24 months after surgery.

RESULTS

After 24 months, patients from group 1 (n = 58) had an average Tegner score of 8.98 and Lysholm score of 89.67; 2 patients presented with ACL reconstruction failure and none presented with residual MCL laxity. Patients from group 2 (n = 54) had an average Tegner score of 6.7 and Lysholm score of 78.12; 16 patients presented with ACL reconstruction failure and 13 presented with residual MCL laxity.

CONCLUSIONS

In the presence of a floating meniscus arthroscopic sign, patients with combined ACL and grade II MCL injuries treated with ACL and MCL reconstruction surgery had significantly lower frequency of ACL reconstruction failure, residual MCL laxity, and better Tegner and Lysholm scores at 24 months' follow-up (P < .05). Additionally, magnetic resonance imaging and arthroscopy differed significantly (P < .05) in their ability to identify mid-substance and tibial site MCL injuries.

LEVEL OF EVIDENCE

Level I, randomized clinical trial.

Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry

PURPOSE

To determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction.

METHODS

Patients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively.

RESULTS

A total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41-0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3-23.9], p = 0.005).

CONCLUSION

Non-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction.

LEVEL OF EVIDENCE

Cohort study, Level III.

Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury

PURPOSE

The purpose of this study was to compare knee kinematics and graft forces in anterior cruciate ligament (ACL) reconstruction combined with one of two superficial medial collateral ligament (sMCL) reconstruction techniques (parallel or triangular vector sMCL reconstruction).

METHODS

Twenty porcine knees were divided into two groups (n = 20), parallel or triangular vector sMCL reconstruction, with both groups having anatomic single-bundle ACL reconstruction. The knees were tested under (1) an 89-N anterior tibial load, (2) 4 Nm internal and external rotational tibial torques, and (3) a 7 Nm valgus torque.

RESULTS

With ACL/sMCL co-injuries, single-bundle ACL reconstruction alone does not restore anterior, valgus, and internal stability. Triangular vector sMCL reconstruction better restored anterior stability, and parallel sMCL reconstruction better restored valgus stability.

CONCLUSION

This study showed that single-bundle ACL reconstruction alone was not able to restore anterior tibial translation, valgus rotation, and external rotation of the intact knee with combined ACL and sMCL injuries and sMCL reconstruction was also required. The combined ACL and parallel sMCL reconstruction better restored valgus and external rotation stability, while the combined ACL and triangular vector method better restored anterior tibial translation. With combined ACL and severe sMCL injury, both ligaments should be reconstructed. The two sMCL reconstruction techniques exhibited slightly different kinematics and graft force; however, there was not enough difference to recommend one over the other.

An in vitro analysis of medial structures and a medial soft tissue reconstruction in a constrained condylar total knee arthroplasty

PURPOSE

The aim of this study was to quantify the medial soft tissue contributions to stability following constrained condylar (CC) total knee arthroplasty (TKA) and determine whether a medial reconstruction could restore stability to a soft tissue-deficient, CC-TKA knee.

METHODS

Eight cadaveric knees were mounted in a robotic system and tested at 0°, 30°, 60°, and 90° of flexion with ±50 N anterior-posterior force, ±8 Nm varus-valgus, and ±5 Nm internal-external torque. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were transected and their relative contributions to stabilising the applied loads were quantified. After complete medial soft tissue transection, a reconstruction using a semitendinosus tendon graft was performed, and the effect on kinematic behaviour under equivocal conditions was measured.

RESULTS

In the CC-TKA knee, the sMCL was the major medial restraint in anterior drawer, internal-external, and valgus rotation. No significant differences were found between the rotational laxities of the reconstructed knee to the pre-deficient state for the arc of motion examined. The relative contribution of the reconstruction was higher in valgus rotation at 60° than the sMCL; otherwise, the contribution of the reconstruction was similar to that of the sMCL.

CONCLUSION

There is contention whether a CC-TKA can function with medial deficiency or more constraint is required. This work has shown that a CC-TKA may not provide enough stability with an absent sMCL. However, in such cases, combining the CC-TKA with a medial soft tissue reconstruction may be considered as an alternative to a hinged implant.

Medial Collateral Ligament Reconstruction in Patients With Medial Knee Instability: A Systematic Review

Background:

The medial collateral ligament (MCL) is the most frequently injured ligament of the knee, but it infrequently requires surgical treatment. Current literature on MCL reconstructions is sparse and offers mixed outcome measures.

Purpose/Hypothesis:

The purpose of this study was to compare the outcomes of isolated MCL reconstruction and multiligamentous MCL reconstruction. Our hypothesis was that in selective patients, MCL reconstruction would significantly improve objective and subjective patient knee performance measures, those being baseline valgus laxity, range of motion, objective and subjective International Knee Documentation Committee (IKDC) scores, Tegner score, and Lysholm knee activity scores.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and utilizing 3 computer-based databases. Studies reporting clinical outcomes of patients undergoing MCL reconstruction due to chronic instability or injury with mean follow-up of at least 2 years and levels of evidence 1 to 4 were eligible for inclusion. All relevant subject demographics and study data were statistically analyzed using 2-sample and 2-proportion z tests.

Results:

Ten studies involving 275 patients met our inclusion criteria. Of these patients, 46 underwent isolated MCL reconstruction while another 229 underwent reconstruction of the MCL in addition to a variety of concomitant reconstructions. Overall outcomes for all patients were significant for (1) reducing the medial opening of the knee (8.1 ± 1.3 vs 1.4 ± 1.0 mm; P < .001), (2) improving the patient’s objective IKDC score (1.2% vs 88.4%; P < .001), (3) improving the patient’s subjective IKDC score (49.8 ± 6.9 vs 82.4 ± 9.6; P < .001), and (4) improving the Lysholm knee activity score (69.3 ± 5.9 vs 90.5 ± 6.6; P < .001). No differences existed between concomitant reconstruction groupings except that postoperative Lysholm scores were better for MCL/anterior cruciate ligament reconstruction than MCL/posterior cruciate ligament reconstruction (94.3 ± 4.5 vs 84.0 ± 11.7; P < .001). Normal or nearly normal range of motion was obtained by 88% of all patients.

Conclusion:

The systematic review of 10 studies and 275 knees found that the reported patient outcomes after MCL reconstruction were significantly improved across all measures studied, with no significant difference in outcomes between concomitant reconstructions.

Outcomes at a Minimum of 2 Years After Medial Collateral Ligament Reconstruction Using Partial-Thickness Quadriceps Tendon-Bone Autograft

This study reports outcomes at a minimum of 2 years after a technique using quadriceps tendon-bone autograft for medial collateral ligament reconstruction. This technique effectively restored medial stability in medial collateral ligament-deficient knees. It is particularly valuable when nonirradiated allograft is unavailable or harvesting medial knee restraints (semitendinosus) for medial collateral ligament reconstruction is to be avoided. [Orthopedics. 2017; 40(3):e557-e562.].

Outcomes of surgical stabilization in patients with combined ACL deficiency and patellofemoral instability - A case series

BACKGROUND

The purpose of this study was to assess the disease-specific quality of life, and the objective clinical and functional outcomes of patients with symptomatic ACL deficiency and patellofemoral instability following surgical stabilization of both ligaments.

METHODS

Between February 2010 and August 2013, 22 subjects underwent a combined ACL reconstruction and patellofemoral stabilization. The anterior cruciate ligament quality of life questionnaire (ACL-QOL) was completed pre-operatively and two-years post-operatively. Clinical and functional assessments were performed two-years post-operatively. A paired t-test assessed the difference between the pre- and post-operative ACL-QOL scores. Effect size was calculated manually using the Eta squared formula. A Pearson r correlation coefficient assessed for a relationship between the post-operative ACL-QOL scores and functional tests.

RESULTS

Twenty patients completed the 24-month ACL-QOL, 17/20 completed clinical assessment, and 14/20 completed functional testing. The mean pre-operative ACL-QOL score was 21.20 (SD=7.25, range 5.8 to 31.7) and two-years post-operative it was 65.24 (SD=21.38, range 34.5 to 99.1). The paired t-test demonstrated a statistically significant improvement in ACL-QOL scores; t (19)=9.119, p<.001 (two-tailed). The Eta squared statistic (0.81) indicated a very large effect size. Statistically significant correlations (p<.05) were evident between post-operative ACL-QOL scores and all the operative limb single-leg hop tests.

CONCLUSIONS

Combined ACL reconstruction and patellofemoral stabilization surgery leads to good results. This patient cohort with chronic ACL-MPFL injuries demonstrated a statistically significant change in disease-specific quality of life following surgery. In addition, the patient-reported outcomes and objective functional testing results correlated.

LEVEL OF EVIDENCE

Case series - IV.

Combined Reconstruction of the Medial Collateral Ligament and Anterior Cruciate Ligament Using Ipsilateral Quadriceps Tendon-Bone and Bone-Patellar Tendon-Bone Autografts

The exclusive autograft choice for medial collateral ligament (MCL) reconstruction that has been described until today is the semitendinosus tendon. However, this has some potential disadvantages in a knee with combined MCL-anterior cruciate ligament (ACL) injury, including weakening of the hamstring's anterior restraining action in an already ACL-injured knee and nonanatomic distal MCL graft insertion when leaving the semitendinosus insertion intact at the pes anserinus during reconstruction. Moreover, because some surgeons prefer to use the hamstring for autologous ACL reconstruction, the contralateral uninjured knee hamstring needs to be harvested as a graft source for the MCL reconstruction if autografts and not allografts are the surgeons' preference. We describe a technique for performing combined reconstruction of the MCL and ACL using ipsilateral quadriceps tendon-bone and bone-patellar tendon-bone autografts. This technique of MCL reconstruction spares the hamstring tendons and benefits from the advantage provided by bone-to-bone healing on the femur with distal and proximal MCL tibial fixation that closely reproduces the native MCL tibia insertion.

Biomechanical Analysis of Internal Bracing for Treatment of Medial Knee Injuries

The internal brace technique uses a high-strength suture tie to augment injured tissues or a primary repair, allowing early rehabilitation. Anatomic repair with internal bracing is a novel and promising treatment for femoral-sided medial knee avulsion injuries of the medial collateral ligament and posterior oblique ligament. Unfortunately, biomechanical and clinical data are lacking. To evaluate this technique compared with other treatment options, 3 assays of 9 cadaveric matched pairs (54 knees) were tested to failure at 30° under valgus load in a biomechanical testing apparatus. The primary outcome measure was moment at failure (Nm), with secondary outcome measures of stiffness (Nm/°), valgus angulation at 10 Nm (°), and valgus angulation at failure (°). Repair with internal bracing was compared with the intact state, repair alone, and allograft reconstruction. The mean moment to failure (62.5±24.9 Nm) for internal bracing was significantly lower than that for intact specimens (107.2±39.7 Nm) (P=.009). Mean moment to failure and valgus angle at failure were significantly greater for internal bracing (95±31.9 Nm) than for repair (73.4±27.6 Nm) (P=.05). Internal bracing was similar to reconstruction for the primary outcome measure (53.5±26.3 Nm vs 66.9±28.8 Nm) (P=.227) and for all secondary outcome measures. These findings indicate that posteromedial knee repair with internal bracing for femoral-sided avulsions is superior to repair alone and is similar to allograft reconstruction for all parameters measured; however, this technique did not recreate biomechanical properties equivalent to the intact state. [Orthopedics. 2016; 39(3):e532-e537.].

Incidence of Manipulation Under Anesthesia or Lysis of Adhesions After Arthroscopic Knee Surgery

BACKGROUND

Arthrofibrosis after knee arthroscopy is a challenging complication. Previous studies reporting incidences of manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after knee arthroscopy are limited by confounders such as small sample size and regional sampling bias.

PURPOSE

To investigate the incidence of MUA or LOA after common arthroscopic knee procedures.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

A national insurance database was retrospectively queried for arthroscopic knee procedures from 2007 to 2011. The incidence of postoperative MUA and LOA within 3 and 6 months postoperatively was determined for each of 13 common arthroscopic knee surgeries, including ligamentous reconstructive procedures, cartilage restoration procedures, and meniscal procedures.

RESULTS

A total of 330,714 unique patients who underwent knee arthroscopy were included in the study. The overall incidence of MUA was 0.06% to 6.00% by 3 months and 0.11% to 8.00% by 6 months postoperatively. The incidence of LOA was somewhat less, ranging from 0.04% to 4.00% by 3 months and 0.06% to 6.00% by 6 months postoperatively. Isolated arthroscopic partial meniscectomy had the lowest incidence of postoperative MUA and LOA, while multiligament reconstructions and meniscal transplants had the highest incidences.

CONCLUSION

The overall incidence of MUA and LOA after arthroscopic knee procedures is low but rises significantly as the number of concomitant procedures or complexity of the procedures increases. This information may be useful in counseling patients on the likelihood of MUA or LOA based on the type of arthroscopic knee procedure that is planned.

Management of Chronic Combined ACL Medial Posteromedial Instability of the Knee

The medial collateral ligament is the most commonly injured ligament in the knee. High-grade medial collateral injuries are associated with injuries to the posteromedial structures of the knee. Chronic medial-sided instability is rare due to the intrinsic capacity of the medial ligamentous structures to heal. However, when combined with anterior cruciate ligament deficiency, significant anterior, valgus, and rotatory laxity of the knee occurs. In this review, we discuss the important biomechanical, clinical, and surgical considerations in the management of chronic combined anterior cruciate ligament, medial, and posteromedial instability of the knee.