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Medial knee pain is commonplace in clinical practice and ultrasound assessment of the tibial collateral ligament-medial meniscus complex is increasingly becoming a valuable examination tool in the outpatient setting. In the pertinent literature, basic sonographic protocols have been proposed to evaluate the medial compartment of the knee joint. Using high-frequency ultrasound probes and high-level ultrasound machines; we matched the histo-anatomical features of the tibial collateral ligament-medial meniscus complex and its different sonographic patterns in physiological/pathological conditions to define a standardized (layer-by-layer) sonographic approach. Moreover, high-sensitive power Doppler assessments have also been performed to evaluate the nearby microcirculation. Modern ultrasound equipment appears to provide optimal "sonographic dissection" of the tibial collateral ligament-medial meniscus complex for its various physiological/pathological patterns. Likewise, high-sensitive power Doppler allows clear visualization of the microcirculation as regards the local ligamentous and capsular structures. In clinical practice, using adequate technological equipment, a detailed sonographic assessment of the tibial collateral ligament-medial meniscus complex can be performed. High-frequency B-mode ultrasound imaging and high-sensitive power Doppler perfusion patterns can be matched/integrated with the clinical findings to optimize the management of patients with medial knee pain.

Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. Purpose/Hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. Results: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group ( P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) ( P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] ( P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) ( P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) ( P = .184). Conclusion: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

To evaluate the degree of correlation between MRI and clinical gradings of medial collateral ligament (MCL) injuries and assess for associated structures on MRI which may influence the clinical perception of MCL laxity. All knee MRIs with acute MCL injuries between 2016 and 2020 at our centre were retrospectively reviewed by two blinded musculoskeletal radiologists. The clinic notes were reviewed for clinical gradings. One hundred and nineteen MRIs included. Forty-eight percent (57/119) agreement between MRI and clinical gradings (κ = 0.21, standard error (SE) 0.07). MRI grades: I 29% (34/119), II 50% (60/119), III 21% (25/119). Clinical grades: I 67% (80/119), II 26% (31/119), III 7% (8/119). In patients with clinical grade III MCL injury, there was waviness of the superficial MCL on MRI in 100% (8/8), deep meniscofemoral ligament tear in 75% (6/8), anterior cruciate ligament (ACL) partial or complete tear in 75% (6/8) and posteromedial corner (PMC) injury in 100% (8/8); compared with 0% (0/111), 34% (38/111), 44% (49/111) and 41% (46/111) respectively in clinical grade I or II injuries (p

INTRODUCTION This study aimed to describe an anatomic medial knee reconstruction technique for combined anterior cruciate ligament (ACL) and grade III medial collateral ligament (MCL) injuries and to assess knee function and stability restoration in patients who underwent primary MCL reconstruction compared with primary repair. METHODS A total of 105 patients who had undergone anatomic ACL reconstruction between 2008 and 2017 were enrolled in this retrospective study and divided into two groups according to concomitant MCL ruptures. Group A included patients with isolated ACL ruptures without MCL injuries. Group B included patients with both ACL and MCL injuries, and it was subdivided into three groups according to the severity of the MCL injury and treatment modality: B-1, grade I or II MCL injury treated conservatively; B-2: grade III MCL injury treated by primary MCL repair; and B-3: grade III MCL injury treated by primary reconstruction. Knee stability was measured via Telos valgus radiography at 6-month and 2-year postoperative. The Lysholm score, Tegner activity level, Likert scales (satisfaction), and return to previous sports were evaluated at 2-year postoperative. RESULTS At 6-month postoperative, there was no significant difference in medial laxity between the B-2 and B-3 groups. However, at 2-year postoperative, medial laxity were significantly higher both at 30° of flexion (5.2° versus 2.2°, p = 0.020) and at full extension (3.4° versus 1.1°, p

Introduction The primary aim of this investigation was to systematically review relevant literature of various imaging modalities (magnetic resonance imaging (MRI), stress radiography and ultrasonography) in the assessment of patients with a medial collateral ligament (MCL) injury. Materials and methods A systematic literature review of articles indexed in PubMed and Cochrane library was performed. Original research reporting data associated with medial gapping, surgical, and clinical findings associated with MCL injuries were considered for inclusion. The methodological quality of each inclusion was also assessed using a verified tool. Results Twenty-three imaging studies (magnetic resonance imaging (MRI) n = 14; ultrasonography n = 6; radiography n = 3) were ultimately included into the review. A total of 808 injured, and 294 control, knees were assessed. Interobserver reliabilities were reported in radiographic and ultrasonographic investigations with almost perfect agreement. MRI studies demonstrated agreement ranging between substantial to almost perfect. Intraobserver reliability was only reported in radiographic studies pertinent to medial gapping and was found to be almost perfect. Correlation of MRI with clinical findings was moderate to strong (65–92%). Additionally, MRI imaging was more sensitive in the detection of MCL lesions when compared to clinical examination. However, when compared to surgical findings, MRI underestimated the grade of instability in up to 21% of cases. Furthermore, MRI showed relatively inferior performance in the identification of the exact MCL-lesion location when compared to surgical findings. Interestingly, preoperative clinical examination was slightly inferior to stress radiography in the detection of MCL lesions. However, clinical testing under general anaesthesia performed similar to stress radiography. The methodological quality analysis showed a low risk of bias regarding patient selection and index testing in each imaging modality. Conclusion MRI can reliably diagnose an MCL lesion but demonstrates limitations in its ability to predict the specific lesion location or grade of MCL instability. Ultrasonography is a widely available, radiation free modality, but is rarely used in clinical practice for detecting MCL lesions and clinical or surgical correlates are scarce. Stress radiography findings correlate with surgical findings but clinical correlations are missing in the literature. Level of evidence IV.

To investigate the incidence of bone bruising with isolated medial collateral ligament injury and to assess whether the presence of bone bruising is related to the injury grade. Patients who sustained an acute isolated medial collateral ligament injury demonstrated on knee MRI between 2016 and 2020 were included in this study. Patient’s characteristics and injury classification (clinical and radiological) were reviewed from clinical notes and imaging. The patients were divided into two groups, based on the presence of bone bruising. Fisher’s exact test was used for dichotomous variables and odds ratios were computed in areas of clinical significance. Sixty patients with a median age of 37.6 ± 13.8 were included. Twenty-eight (46.7%) had bone bruising demonstrated on MRI scan. The bone bruising group were 7 times (95% CI [1.4;36.5]) more likely to have a complete disruption of the superficial medial collateral ligament and MRI grade III injury. Injury to the deep medial collateral ligament was more often observed in this group (p

Intraoperative medial collateral ligament (MCL) injury during total knee arthroplasty (TKA) is a serious complication. External bracing and/or conversion to a constrained implant has previously been studied. The technique of using an internal high-strength suture brace to augment an MCL repair has been evaluated in the nonarthroplasty patient and could provide an alternate solution. The goal of this study was to determine whether MCL repair with internal suture bracing restores stability of the implanted knee joint. A robotic simulator completed laxity testing on 5 cadaveric knee specimens in 4 sequential phases: (1) intact knee, (2) after implantation with TKA, (3) after sectioning of the MCL, and (4) after MCL repair with suture brace augmentation. Laxity was compared between the different test phases throughout range of motion. Subsequently, the internal brace was tested to failure under valgus load. The MCL repair with internal bracing was effective at restoring laxity in varus-valgus, internal-external, and medial-lateral degrees of freedom through midflexion, with limited support at deeper flexion angles and in anterior-posterior laxity. Rotational laxity was not significantly different than intact knee laxity. Generally, medial-lateral translations were less and anterior-posterior translations were greater and were significantly different at 30° to 45° and 90°, respectively. The mean failure moment was 46.4±9.1 Nm, with the primary mode of failure being MCL repair. Primary MCL repair with internal bracing using a high-strength suture augment showed the potential to provide adequate stability and strength to correct MCL incompetence in TKA without the use of an external knee brace or constrained implants. [ Orthopedics . 2022;45(5):e269–e275.]

Medial Collateral Ligament (MCL) injury may require operative treatment. Marx et al. described the latest technique for reconstruction of MCL. While good results have been reported using the Marx technique, some issues have been observed. To address the mentioned issues, a modification to the Marx technique has been devised. Eleven patients were enrolled and their ligaments were repaired by the fixation of allograft on the proximal and distal attachment footprints of the superficial MCL. For preventing loss of knee ROM, MCL and other ligaments were reconstructed in 2 separate stages. At the last follow up the ROM, knee ligament laxity and functional outcome scores, subjective (IKDC) and Lysholm score were evaluated and recorded. Knee motion was maintained in all cases. Two cases demonstrated 1+ valgus instability at 30 degrees of knee flexion. Both were treated for combined MCL and PCL tear, the rest were stable. The average IKDC-subjective score was 93 ± 4 and the average Lysholm score was 92 ± 3. All patients were satisfied and returned to their previous level of activity. In this technique, the superficial MCL was recon- structed closer to its anatomical construct. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Also reconstructing the ligaments in 2 stages helped to preserve the knee motion. Level of Evidence : Level IV therapeutic.

Purpose We aim to determine a reference data set for normal medial collateral ligament (MCL) stiffness values using shear wave elastography (SWE). Methods Quantitative stiffness of the MCL was measured at three levels: the proximal (MCL area from the level of the medial meniscus to the level of the femoral attachment), the middle (MCL area at the level of the medial meniscus), and the distal (MCL area from the level of the medial meniscus to the level of the tibial attachment) segments of the MCL at a knee position of 0 degrees. Results A total of 60 MCL of 30 healthy volunteers (15 female, 15 male) were examined. The mean stiffness values of the proximal, middle, and distal MCL for observer 1 were 32.25 +/- 6.44, 34.25 +/- 6.84, and 35.47 +/- 6.98, respectively. The mean stiffness values of the proximal, middle, and distal MCL for observer 2 were 33.56 +/- 6.76, 35.44 +/- 6.91, and 36.32 +/- 7.04, respectively. Conclusion SWE has a strong potential to be a method of choice for evaluating MCL stiffness. Our study participants were healthy volunteers and the data can be used as reference data for future studies.

© 2021, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). Purpose: Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. Methods: This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. Results: Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18–52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24–72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). Conclusion: Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. Level of Evidence: IV

Aim of this study was to compare outcomes of a newer technique of pie-crusting of the femoral origin of medial collateral ligament (MCL) with the conventional medial release, for correcting varus deformity during total knee arthroplasty. Null hypothesis was that there is no difference in clinical outcomes between these two techniques. All patients requiring an additional medial release after excision of osteophytes and release of deep MCL during total knee arthroplasty were allocated into two groups, alternately. Each group composed of 40 patients. Pie-crusting with a needle was done near the femoral attachment of superficial MCL in group-1, whereas the group-2 underwent classic sub-periosteal release of the tibial insertion of superficial MCL. All the patients were assessed for any laxity (more than 3 mm opening) intraoperatively or at one-year follow-up, pain score at 12 and 24 h after the surgery, Knee Society Score, Western Ontario and McMaster Universities Arthritis Index and range of motion 12 months after the surgery. None of the patients showed any signs of laxity or failure at one-year follow-up. Pain scores were slightly better (not statistically significant) in the group-1. However, no differences were noted in functional outcomes scores. Pie-crusting of superficial MCL is a safe, controlled and less invasive approach for medial soft tissue release. When knee deformity is not correctable with initial soft tissue release, this is an appropriate next surgical step. There does not appear to be a risk of over-release during the surgery or afterward. Non-randomized controlled trial, Level II.

PurposeThe purpose of this study was to examine the length change patterns of the native medial structures of the knee and determine the effect on graft length change patterns for different tibial and femoral attachment points for previously described medial reconstructions.MethodsEight cadaveric knee specimens were prepared by removing the skin and subcutaneous fat. The sartorius fascia was divided to allow clear identification of the medial ligamentous structures. Knees were then mounted in a custom-made rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights. Threads were mounted between tibial and femoral pins positioned in the anterior, middle, and posterior parts of the attachment sites of the native superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). Pins were also placed at the attachment sites relating to two commonly used medial reconstructions (Bosworth/Lind and LaPrade). Length changes between the tibiofemoral pin combinations were measured using a rotary encoder as the knee was flexed through an arc of 0–120°.ResultsWith knee flexion, the anterior fibres of the sMCL tightened (increased in length 7.4% ± 2.9%) whilst the posterior fibres slackened (decreased in length 8.3% ± 3.1%). All fibre regions of the POL displayed a uniform lengthening of approximately 25% between 0 and 120° knee flexion.The most isometric tibiofemoral combination was between pins placed representing the middle fibres of the sMCL (Length change = 5.4% ± 2.1% with knee flexion). The simulated sMCL reconstruction that produced the least length change was the Lind/Bosworth reconstruction with the tibial attachment at the insertion of the semitendinosus and the femoral attachment in the posterior part of the native sMCL attachment side (5.4 ± 2.2%). This appeared more isometric than using the attachment positions described for the LaPrade reconstruction (10.0 ± 4.8%).ConclusionThe complex behaviour of the native MCL could not be imitated by a single point-to-point combination and surgeons should be aware that small changes in the femoral MCL graft attachment position will significantly effect graft length change patterns. Reconstructing the sMCL with a semitendinosus autograft, left attached distally to its tibial insertion, would appear to have a minimal effect on length change compared to detaching it and using the native tibial attachment site. A POL graft must always be tensioned near extension to avoid capturing the knee or graft failure.

The aim of this study was to assess the outcomes and complications, such as tibiofemoral instability and recurrence of valgus deformity, of total knee arthroplasty for valgus knees with a new technique preserving the deep layer of the medial collateral ligament.In this study 33 (4 male and 29 female) patients, and a total of 36 (26 knees with osteoarthritis and 10 with rheumatoid arthritis) knees with a standing femorotibial angle (FTA) of170° were included. Posterior Stabilized (PS) implants were used in 34 knees, rotating hinged knee implants were used in 2 knees. The procedures were carried out by a single surgeon protecting the deep layer of the medial collateral ligament. The patients' average age at the time of the operation was 67.6 ± 12 years, and the average follow-up period was 9.0 ± 3 years (range, 4-15 years). The Japanese Orthopaedic Association (JOA) knee score, range of motion (ROM) (extension/flexion; measured in degrees), FTA (measured in degrees) and complications were investigated.The Japanese Orthopaedic Association knee score significantly improved from an average of 51 ± 12 points before the operation to 86 ± 9 points after the operation (P0.001). The extension ROM and flexion ROM improved from, -13 ± 13° to a postoperative average of -2 ± 4°, and 115 ± 25° to a postoperative average of 125 ± 18° respectively (P0.001). The standing FTA significantly improved from 158 ± 9° to an average of 173 ± 2° after the operation (P0.001). Thirty-four knees with severe valgus deformity were operated on using pos- terior stabilised implants, while only two knees required constrained implants. During follow-up, no complications, such as tibiofemoral instability, recurrence of valgus deformity, patellar necrosis, deep infection, wound problems, or peroneal nerve paralysis were observed.This study has shown us that after performing TKA while preserving the d-MCL for valgus knee deformity good clinical results were obtained and no complications were observed.Level IV, Therapeutic Study.

Background: Medial-sided knee injuries can lead to symptomatic valgus laxity or anteromedial rotatory instability and may require surgery, particularly in the setting of cruciate tears and tibial-sided medial collateral ligament (MCL) avulsions. The LaPrade (LP) technique utilizes 2 free grafts to reconstruct the superficial MCL (sMCL) and the posterior oblique ligament (POL). An alternative MCL reconstruction devised by the senior author comprises an anatomic single-bundle reconstruction using a free graft to reconstruct the sMCL with advancement and imbrication of the posteromedial capsule/POL (MCL anatomic reconstruction with capsular imbrication [MARCI] technique). These techniques have not been biomechanically compared with one another. Purpose: To identify if one of these reconstruction techniques better restores valgus and rotational medial knee stability throughout the range of motion. Study Design: Controlled laboratory study. Methods: A total of 20 fresh-frozen, male (mean age, 43.7 years [range, 20-63 years]), midfemur-to-toe-matched cadaveric knees were utilized. All reconstructions were performed by a single fellowship-trained sports medicine surgeon. Left and right specimens within matched pairs were randomized to 1 of the 2 treatment groups: LP or MARCI. Each specimen was tested in 3 phases: (1) intact knee, (2) destabilized (MCL and POL completely severed), and (3) reconstructed (post-LP or post-MARCI reconstruction). We quantified valgus angulation defined by medial joint line opening, as well as internal and external tibial rotation at 0°, 20°, 30°, 60°, and 90° of knee flexion under applied external moments/torques at each phase. Results: There were significant differences between the MARCI and LP reconstruction groups in valgus stability compared with the intact state ( P = .021), with the MARCI reconstruction more closely approximating the intact knee. There was no overall difference between the MARCI and LP reconstruction techniques for internal rotation ( P = .163), with both closely resembling the intact state. For external rotation, the effect of the reconstruction technique was dependent on the knee flexion angle ( P < .001). At the highest angles, there were no differences between reconstructions; however, for lower knee flexion angles, the MARCI technique more closely resembled the intact state. Conclusion: Although both techniques improved knee stability compared with destabilized conditions, the MARCI technique better approximated intact stability during valgus at knee flexion angles from 0° to 90° and external rotation loads at knee flexion angles ≤30° in a cadaveric model. Clinical Relevance: The MARCI technique provides an alternative option to improve valgus stability throughout the range of motion. It utilizes a POL advancement without the potential limitations seen in the LP technique, such as multiple tunnel complexity and collision, particularly in the multiple ligament–injured knee.

Background: A “Stener-like” lesion of the knee is defined as a distal avulsion of the superficial medial collateral ligament (sMCL) with interposition of the pes anserinus between the ligament and its tibial insertion—a displacement impeding anatomic healing. Because of the scarcity of these injuries, the literature is limited to case reports and small case series. Purpose: To assess the effect of surgical repair of acute Stener-like lesions of the sMCL on the following outcomes: return to preinjury level of sporting function; time to return to preinjury level of sporting function; functional performance; injury recurrence; and any other complications. Study Design: Case series: Level of evidence, 4. Methods: This prospective single–surgeon study included 23 elite athletes with a mean age of 27.2 years (range, 19-37 years). Of the participants, 20 were men (87%) and 3 were women (13%). The mean body mass index was 23.1 ± 2.3. A total of 16 athletes were soccer players (70%) and 7 were rugby players (30%), with isolated acute, traumatic Stener-like lesions of the sMCL of the knee confirmed on preoperative magnetic resonance imaging. Surgical repair was undertaken with primary suture anchor repair with ligament repair or reconstruction system (LARS) augmentation. Predefined outcomes were recorded at regular intervals after surgery. The minimum follow–up time was 24 months (range, 24-108 months) from the date of surgery. Results: The mean time from injury to surgical intervention was 9 days (range, 3-28 days). Overall, 15 (65%) athletes had isolated distal sMCL injuries requiring anatomic suture anchor repair at the distal tibial insertion site only, and 8 (35%) athletes had concomitant injuries of the proximal and distal sMCL and required anatomic suture anchor repair at the proximal and distal attachment sites. Ten athletes required LARS augmentation at the time of the index operation. All study patients returned to their preinjury level of sporting activity in professional soccer or rugby. The mean time from surgical intervention to return to full sporting activity was 16.8 ± 2.7 weeks. At 6 and 24 months’ follow–up, all patients had Tegner scores of 10. At a 2–year follow–up, all study patients were still participating at their preinjury level of sporting activity. Three patients developed complications around the LARS that required further surgery to remove synthetic material; however, this did not affect function. Conclusion: Surgical repair of acute Stener-like lesions of the sMCL is associated with a high return to preinjury level of sporting function, excellent functional performance, and a low risk of recurrence at short–term follow-up in elite athletes.

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.

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.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.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.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 current study was aimed at reviewing the literature systematically to educe enhanced understanding of various techniques, sequels, as well as complications after percutaneous MCL lengthening through the procedure of arthroscopy of the knee; moreover, we utilize this clinical data that will help surgeons to encompass this technical gesticulation into their day-to-day surgical practice.The inclusion criteria were framed as per the internationally standardized PICOS framework, as recommended by PRISMA guidelines. The study population included adults who underwent arthroscopic knee surgery for sMCL lengthening.After evaluation of 69 papers, only 9 studies were ascertained for analysis after these papers fulfilled both inclusion and exclusion criteria. The patient's age varied from 13 to 60 years at the time of commencement of surgery. There was no record of any perioperative complications in relation to iatrogenic chondral damage, fracture, and there was no report of any additional meniscal injury. The requirement of postoperative bracing was reported in 2 studies, and that was required for a time period of about 4 weeks after lengthening, while various other authors reported no use of postoperative bracing. Furthermore, in relation to postoperative pain, mild pain at the medial needle tract site was experienced by patients in two that lasted up to 15 days. None of the studies reported any case of saphenous vein or saphenous nerve injury. The duration of the final follow-up after surgery varied from 3 weeks to 24 months. No incidence of subjective instability was accounted for.Thus, the present study concludes that percutaneous lengthening is effective with well-documented benefits with minimum allied risks and can be recommended for surgeons' who perform arthroscopy of the posteromedial compartment of the knee in the presence of a tight medial compartment. Furthermore, data reveal that healing is not impaired, or the risk of postoperative complications does not upsurge without the use of bracing.

This paper presents an alternative method of surgical treatment in patients with late-diagnosed knee dislocation. The treatment involves anterior cruciate ligament reconstruction with an autogenic graft and the use of synthetic Fibertape bracing to ensure normal medial structure healing. The paper includes case presentation, indications for use, a description of the surgical technique and conclusions.

Objective To describe the technique of primary repair of medial collateral ligament (MCL) insufficiency using a screw and rectangular spiked washer in a case series of 14 patients. Methods Fourteen patients undergoing MCL repair by a screw and rectangular spiked washer during TKA between March 2018 and March 2019 were retrospectively reviewed. Among them, half injuries were avulsion of the femoral origin, and the other half were MCL laxity. There were 12 women and two men included in the study, with an average age of 63.6 years (range, 49–79 years) at the time of surgery. This series were followed up with a focus on range of motion (ROM), coronal alignment, Hospital for Special Surgery (HSS) knee scores, their subjective sense of joint instability, and related complications. At the last follow‐up, function of the MCL was assessed by manually applying a valgus stress to the knee at both 0° and 30° of knee flexion. Results The mean follow‐up time for all patients was 15.6 months (range, 13–20 months). Repair of the MCL was successful in all patients. ROM improved from a mean of 70.7° ± 35.1° before surgery to 103.9° ± 6.8° at latest follow‐up (P = 0.001). All patients were able to perform a half squat easily, but none were able to do full squatting. The mean preoperative HSS score was 43.6 ± 13.4 and increased to a mean of 85.6 ± 3.8 postoperatively (P, We have repaired medial collateral ligament (MCL) insufficiency using a screw and rectangular spiked washer in 14 patients during total knee arthroplasty (TKA). Half injuries were avulsion off the femoral origin, and the other half were MCL laxity. Repair of the MCL was successful in all patients. ROM improved from a mean of 70.7° ± 35.1° before surgery to 103.9° ± 6.8° at latest follow‐up. No patient required revision and manipulation under anesthesia following the index arthroplasty. No patient reported subjective instability of the knee. Upon physical examination, no patient was found to have laxity in the coronal plane in either 30° of flexion or full extension. In conclusion, the screw and rectangular spiked washer is a simple and effective method for treating MCL sufficiency in TKA.

The concept of medial stabilizing technique total knee arthroplasty (MST-TKA) is to minimize the medial release without the superficial layer of medial collateral ligament (MCL). However, it is unclear at what stage the proper medial laxity is obtained during surgery. The purpose of this study was to investigate the implication of deep layer of MCL (dMCL) and osteophyte resection on medial laxity during MST-TKA. A total of 103 consecutive patients who underwent cruciate-retaining TKA using the navigation system were included. The intraoperative hip–knee–ankle (HKA) angle was recorded under three conditions (no stress, valgus, and varus stress) at four time points after the resection of the anterior cruciate ligament (ACL) and meniscus (1st evaluation), after the dMCL release (2nd evaluation), and after osteophyte resection on both the femoral and tibial side (3rd evaluation). To assess valgus laxity, the differences in intraoperative HKA angle between 1st and 2nd evaluation (stage 1) and between 2nd and 3rd evaluation (stage 2) were calculated. Under the valgus stress condition, the intraoperative HKA angle change in stage 2 was significantly larger than that in stage 1 in full extension (stage 1; − 0.5 ± 1.0°, stage 2; − 2.0 ± 1.3°, p

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

Constraint choice in revision total knee arthroplasty depends on the stability of the collateral ligaments and on the severity of bone loss, but the least degree of constraint necessary is recommended. The purpose of this retrospective matched-paired study was to compare clinical results, radiographic outcome and the survival of a stemmed medial pivot revision implant in aseptic revision TKA vs. medial pivot implant in primary TKA.Records were reviewed for 69 cases of aseptic revision TKA using Advance® Medial Pivot Stemmed Revision Knee system between 2002 and 2016. These patients were then matched in a 1:2 ratio control group of patients who received a primary TKA with Advance® Medial Pivot system. American Knee Society Score and Visual Analogue Scale pain score were recorded. Alignment, loosening, and incidence of radiolucent lines were evaluated on X-rays. Implant survival was assessed by Kaplan-Meier survival analysis.The primary TKA group had significant superior AKSS clinical and functional score at baseline (52.3 and 68.2 points, respectively) and at last follow up (84.6 and 68.6 points) compared with the revision TKA group (47.9 and 40.9 points; 78.4 and 59.9 points; P 0.05). No significant difference was observed in the mean change from baseline to last follow up of AKSS score between the two groups (P 0.05). Radiographical outcome and implant survival were similar in the two groups (P 0.05).The authors support the use of this revision system in knees with collateral ligaments competence and mild-to-moderate bone defect.

A knee dislocation that involves at least 2 of the 4 major ligament groups-such as the anterior cruciate ligament, the posterior cruciate ligament, or the posterolateral corner-is a catastrophic event for an athlete or trauma patient. Careful evaluation of these patients is needed to avoid disastrous outcomes. Surgeons must be cognizant of a number of key treatment concerns-such as tunnel crowding, controversies over graft fixation methods, and sparsity of level I clinical data-to make proper ligament repair decisions. This manuscript will review treatment principles that govern high-quality care of this complex injury.

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.

An understanding of knee ligament anatomy and biomechanics is foundational for physicians treating knee injuries, especially the more rare and morbid multiligamentous knee injuries. This chapter examines the roles that the cruciate and collateral anatomy and morphology play in their kinematics. Additionally, the biomechanics of the ACL, PCL, MCL, and LCL are discussed as they have surgical and reconstructive implications.

The multiple ligament injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurological status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends upon the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.

Background:The most commonly damaged structures of the knee are the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and menisci. Given that these injuries present as either isolated or concomitant, it follows that these events are driven by specific mechanics versus coincidence. This study was designed to investigate the multiplanar mechanisms and determine the important biomechanical and demographic factors that contribute to classification of the injury outcome.Hypothesis:Linear discriminant analysis (LDA) would accurately classify each injury type generated by the mechanical impact simulator based on biomechanical input variables (ie, ligament strain and knee kinetics).Study Design:Controlled laboratory study.Methods:In vivo kinetics and kinematics of 42 healthy, athletic participants were measured to determine stratification of injury risk (ie, low, medium, and high) in 3 degrees of knee forces/moments (knee abduction moment, anterior tibial shear, and internal tibial rotation). These stratified kinetic values were input into a cadaveric impact simulator to assess ligamentous strain and knee kinetics during a simulated landing task. Uniaxial and multiaxial load cells and implanted strain sensors were used to collect mechanical data for analysis. LDA was used to determine the ability to classify injury outcome by demographic and biomechanical input variables.Results:From LDA, a 5-factor model (Entropy R2= 0.26) demonstrated an area under the receiver operating characteristic curve (AUC) for all 5 injury outcomes (ACL, MCL, ACL+MCL, ACL+MCL+meniscus, ACL+meniscus) of 0.74 or higher, with “good” prediction for 4 of 5 injury classifications. A 10-factor model (Entropy R2= 0.66) improved the AUC to 0.86 or higher, with “excellent” prediction for 5 injury classifications. The 15-factor model (Entropy R2= 0.85), produced 94.1% accuracy with the AUC 0.98 or higher for all 5 injury classifications.Conclusion:Use of LDA accurately predicted the outcome of knee injury from kinetic data from cadaveric simulations with the use of a mechanical impact simulator at 25° of knee flexion. Thus, with clinically relevant kinetics, it is possible to determine clinical risk of injury and also the likely presentation of singular or concomitant knee injury.Clinical Relevance:LDA demonstrates that injury outcomes are largely characterized by specific mechanics that can distinguish ACL, MCL, and medial meniscal injury. Furthermore, as the mechanics of injury are better understood, improved interventional prehabilitation can be designed to reduce these injuries.

A large variety of data filtration techniques exist in biomechanics literature. Data filtration is both an 'art' and a 'science' to eliminate noise and retain true signal to draw conclusions that will direct future hypotheses, experimentation, and technology development. Thus, data consilience is paramount, but is dependent on filtration methodologies. In this study, we utilized ligament strain, vertical ground reaction force, and kinetic data from cadaveric impact simulations to assess data from four different filters (12 vs. 50 Hz low-pass; forward vs. zero lag). We hypothesized that 50 Hz filtered data would demonstrate larger peak magnitudes, but exhibit consilience of waveforms and statistical significance as compared to 12 Hz filtered data. Results demonstrated high data consilience for matched pair t test correlations of peak ACL strain (≥ 0.97), MCL strain (≥ 0.93) and vertical ground reaction force (≥ 0.98). Kinetics had a larger range of correlation (0.06-0.96) that was dependent on both external load application and direction of motion monitored. Coefficients of multiple correlation demonstrated high data consilience for zero lag filtered data. With respect to in vitro mechanical data, selection of low-pass filter cutoff frequency will influence both the magnitudes of discrete and waveform data. Dependent on the data type (i.e., strain and ground reaction forces), this will not likely significantly alter conclusions of statistical significance previously reported in the literature with high consilience of matched pair t-test correlations and coefficients of multiple correlation demonstrated. However, rotational kinetics are more sensitive to filtration selection and could be suspect to errors, especially at lower magnitudes.

This study aimed to assess the rate of iatrogenic mid-substance superficial medial collateral ligament (sMCL) tear due to the medial pie-crusting technique during varus deformity total knee arthroplasty and compare the knee society score (KSS), range of motion (ROM), and instability rate of the repaired group to the control group with intact sMCL. For this retrospective series of prospectively collected data, the multiple needle puncturing technique was performed for 653 out of the 1768 knees during algorithmic medial soft-tissue release. Iatrogenic tear was observed in 35 knees (5%); hence, repair with running locking nonabsorbable braided suture was performed. Patients were visited and reviewed both clinically and radiographically at 6 weeks, 3 months, 6 months, 12 months, and annually thereafter. Chi-square, ANOVA, Mann–Whitney, independent and paired t test were used to analyze the variables. P value

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.

Purpose To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. Methods Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. Results The anterior sMCL lengthened with flexion (p p p p p p p p Conclusion The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.

Here we investigated the morphology, quantity, distribution and gene expression of mechanoreceptors in the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), patellar tendon (PaT) and popliteal tendon (PoT) of the knee joint. Twelve 6-month-old rabbits were divided into two groups. In one group, the ACL, PCL, MCL, LCL, PaT and PoT were collected to observe the morphology, distribution and quantity of mechanoreceptors. In another group, the ACL, PCL, MCL, LCL, PaT and PoT of bilateral knee joints were used to determine S100B, CGRP and NEFM gene levels. Five types of mechanoreceptors were observed including Ruffini corpuscles, Pacinian corpuscles, Golgi-tendon bodies, atypical mechanoreceptors and free nerve endings. The total amount of mechanoreceptors was significantly lower in MCL, LCL, PaT and PoT as compared with ACL and PCL (P 0.001). All examined mechanoreceptors were present in ACL, PCL and LCL. However, no Pacinian corpuscles and Golgi-tendon bodies were found in MCL and PoT as well as Pacinian corpuscles were not observed in PaT. The present study indicated that the levels of NEFM was significantly lower in PCL, MCL, LCL, PaT and PoT as compared with ACL (P 0.05), but there was no significant difference in CGRP level between ACL and other ligaments except LCL (P 0.05). Thus, the quantity, type and gene expression of mechanoreceptors are different in various ligaments. Thus, the quantity and distribution of mechanoreceptors may be related to ligament's function.

The purpose of this study was to evaluate and compare knee kinematics and kinetics following either single bundle, modified triangular or double-bundle reconstruction of the superficial medial collateral ligament (sMCL) with single bundle anatomic ACL reconstruction. Using a cadaveric model (n = 10), the knee kinematics and kinetics following three MCL reconstructions (single-bundle (SB), double-bundle (DB), modified triangular) with single bundle anatomic ACL reconstruction were compared with the intact and deficient knee state. The knees were tested under (1) an 89-N anterior tibial load, (2) 5 N-m internal and external rotational tibial torques, and (3) a 7 N-m valgus torque. Anatomic ACL reconstruction with SB MCL reconstruction was able to restore anterior tibial translation and external rotation to intact knee values but failed to the internal and valgus rotatory stability. Anatomical DB MCL reconstruction (with SB ACL reconstruction) and the modified triangular MCL reconstruction (with SB ACL reconstruction) restored all knee kinematics to the intact value. This study shows that clinical presentation with combined ACL and severe sMCL injury, single-bundle MCL with single-bundle ACL reconstruction does not restore knee kinematics. Anatomical double-bundle MCL reconstruction may produce slightly better biomechanical stability than the modified triangular MCL reconstruction, but the modified triangular reconstruction might be more clinically practical with the advantages of being less invasive and technically simpler while at the same time can restore a nearly normal knee joint.

Background The aims of this study were to (1) describe our functional stepwise multiple needle puncturing (MNP) technique as the final step in medial ligament balancing during total knee arthroplasty (TKA) and (2) evaluate whether this technique can provide sufficient medial release with safety. Methods A total of 137 patients with 212 consecutive knees who underwent TKAs with or without functional stepwise MNP of superficial medial collateral ligament was recruited in this prospective cohort. Eighty-one patients with 129 knees who performed serial stress radiographs were enrolled in the final assessment. Superficial medial collateral ligament was punctured selectively (anteriorly or posteriorly or both) and sequentially depending on the site and degree of tightness. Mediolateral stability was assessed using serial stress radiographs and comparison was performed between the MNP and the non-MNP groups at postoperative 6 months and 1 year. Clinical outcomes were also evaluated between 2 groups. Results Fifty-five TKAs required additional stepwise MNP (anterior needling 19, posterior needling 3, both anterior and posterior needling 33). Preoperative hip-knee-ankle angle and the difference in varus-valgus stress angle showed significant difference between the MNP and the non-MNP groups, respectively (P = .009, P = .037). However, there was no significant difference when comparing the varus-valgus stress angle between the MNP and the non-MNP groups during serial assessment. Clinical outcomes including range of motion also showed no significant differences between the 2 groups. Conclusion Functional medial ligament balancing with stepwise MNP can provide sufficient medial release with safety in TKA with varus aligned knee without clinical deterioration or complication such as instability. Level of Evidence Level II, Prospective cohort study.

Background As an uncommon but severe complication, medial collateral ligament (MCL) injury in total knee arthroplasty (TKA) may be significantly under-recognized. We aimed to determine whether MCL injury influences postoperative outcomes of patients undergoing TKA. Methods Two independent reviewers searched PubMed, Cochrane Library, and EMBASE from their inception to July 1, 2021. The main outcomes were postoperative function, and secondary outcomes included the incidences of revision and complications. Results A total of 403 articles yielded 15 studies eligible for inclusion with 10 studies used for meta-analysis. This study found that there was a statistically significant difference in postoperative functional scores, range of motion (ROM), complications, and revision rates, with adverse outcomes occurring more commonly in patients with MCL injury. Conclusions This meta-analysis highlights the complexity of MCL injury during TKA and shows the impact on postoperative function, joint mobility, complications, and revision. Surgeons need to prevent and put more emphasis on MCL injury during TKA.

Knee pain is among the most common problems in active patients, with common causes of medial knee pain including meniscal injury, osteoarthritis, medial collateral ligament (MCL) injury, and pes anserine bursopathy/distal hamstring tendinopathy. Some cases of medial knee pain are refractory to standard treatment options and may be caused by rare pathology. We present a case of medial knee pain secondary to medial tibial crest friction syndrome (MTCFS) in a 22-year-old male training for a sprint triathlon after rapidly increasing his training program. Magnetic resonance imaging revealed bone marrow and soft-tissue edema about the MTC deep to the MCL consistent with MTCFS. The patient failed a period of relative rest and activity modification, but improved with corticosteroid injection deep to the MCL in the location of his symptoms. This case highlights a potential management option for MTCFS, a disorder previously described only in radiologic literature.

To analyze the MRI characteristics of distal superficial medial collateral ligament (sMCL) tears and to identify features of tears displaced superficial to the pes anserinus (Stener-like lesion (SLL)). Knee MRI examinations at four institutions were selected which showed tears of the sMCL located distal to the joint line. MRIs were evaluated for a SLL, a wavy contour to the sMCL, and the location of the proximal sMCL stump. Additional coexistent knee injuries were recorded. The study included 51 patients (mean age, 28 years [sd, 12]). A SLL was identified in 20 of 51 cases. The proximal stump margin was located significantly (p < 0.01) more distal and more medial with a SLL (mean = 33 mm [sd = 11 mm] and mean = 6.5 mm [sd = 2.5 mm], respectively), than without a SLL (mean = 19 mm [sd = 16 mm] and mean = 4.8 mm [sd = 2.4 mm], respectively). Medial compartment osseous injury was significantly (p < 0.05) more common with a SLL (75%) than without a SLL (42%). The frequency of concomitant injuries in the group (ACL tear, 82%; PCL tear, 22%; deep MCL tear, 61%; lateral compartment osseous injury, 94%) did not differ significantly between patients with and without a SLL. A distal sMCL tear should be considered when MRI depicts a wavy appearance of the sMCL. Distal sMCL tears have a frequent association with concomitant knee injuries, especially ACL tears and lateral femorotibial osseous injuries. A SLL is particularly important to recognize because of implications for treatment.

To listen to the podcast associated with this article, please select one of the following: iTunes or Google Play. OBJECTIVE. The purpose of this article is to describe Stener-like lesions of the superficial medial collateral ligament (sMCL) of the knee, which, to our knowledge, have not yet been reported in the radiologic literature. This lesion, defined as a distal tear with interposition of osseous or soft-tissue structures between the ligament and its tibial attachment, often requires surgical intervention. MATERIALS AND METHODS. Knee MRI examinations of grade 3 sMCL tears were identified via a search of department imaging and orthopedic case files of medial collateral ligament (MCL) tears for the period of January 2010-April 2017 using the keywords "complete MCL tear" or "near complete MCL tear." Two musculoskeletal radiologists reviewed the MRI examinations. The location of the sMCL tear, presence of a Stener-like lesion, associated ligamentous injuries, and surgical findings were recorded. RESULTS. Review of 65 knee MRI examinations identified 20 cases of distal tibial grade 3 sMCL tear. Of the distal tears, 12 (60%) were Stener-like lesions and six (30%) were borderline lesions. Of these 18 cases, 14 (78%) were associated with multiligament knee injury and nine (50%) underwent MCL repair or reconstruction. Ten of the 12 (83%) Stener-like lesions were displaced superficial to the pes anserinus and two (17%) were entrapped, one in a reverse Segond fracture and one in the femorotibial compartment. CONCLUSION. Stener-like lesions represent a high percentage of tibia-sided sMCL avulsions, are found most often with pes anserinus interposition, and are frequently associated with multiligamentous injury, suggesting high-energy trauma. MRI diagnosis is important because interposition preventing anatomic healing and potential secondary valgus instability often prompt surgical intervention.

Background. Upper partial fibulectomy has been preliminarily proved to have the efficacy for pain alleviation and improvement of function in patients with mild to moderate medial compartment knee osteoarthritis (KOA). However, the previous studies lack the control group with other treatments. The aim of this prospective, randomized controlled study is to compare the clinical and biomechanical effects between upper partial fibulectomy and drug conservative treatment on improvement of clinical pain, function, and gait for patients with mild to moderate medial knee osteoarthritis (KOA) and further discuss its biomechanical mechanism. Methods. From August 2016 to February 2017, 49 and 48 patients with mild to moderate medial KOA were allocated to fibulectomy and drug groups. We assessed the patients’ visual analog scale (VAS) pain score, Hospital for Special Surgery (HSS) knee score, limb alignment, passive flexion/extension range of motion (ROM) of the knee, and 3D gait kinematics and kinetics parameters before and after intervention. Repeated-measures ANOVA with Dunnett’s post hoc assessment and multivariate analysis of variance were applied for intragroup and intergroup comparisons, respectively. Results. The improvement in the fibulectomy group on the VAS pain score, HSS knee score, walking speed, and walking knee range of motion (ROM) was statistically better than that in the drug group. The decreased overall peak knee adduction moment (KAM) (decreased by 16.1%) and hip-knee-ankle (HKA) angle (decreased by 0.99° from a more varus alignment to a more neutral alignment) of the affected and operated side 1 year after surgery were observed in the fibulectomy group. Conclusion. This research demonstrated that as a biomechanical intervention, upper partial fibulectomy can be a better choice in pain relief and function and gait improvement than drug conservative treatment for patients with early-stage knee OA. The long-term clinical outcomes, indication, and rationale for the improvement in clinical symptoms should be investigated further.

Total knee arthroplasty is a challenging task in patients with severe varus deformity. In most of these patients, an extensive medial release is needed that may lead to instability. Medial epicondylar osteotomy may be a better substitute for complete medial collateral release. Fourteen patients with bilateral knee osteoarthritis and severe varus deformity were enrolled in this study. In one side, the patients underwent medial epicondylar osteotomy for mediolateral imbalance if the only option was superficial medial collateral ligament (MCL) release. In contralateral side, the extensive medial release was performed and MCL was released either by pie-crusting technique or by subperiosteally release. The results of the two sides were compared. Patients were followed up for 12 months after the operation. Physical examination, clinical questionnaires, and radiography findings were recorded. Union of the osteotomies fragment and complications was evaluated. The mean varus angle before surgery was 21.6 ± 4.7 degrees, which was corrected to 8.6 ± 2.9 degrees after operation with an extensive medial release. The mean varus angle of contralateral side was 22.6 ± 1.7 degrees, which was corrected to 7.5 ± 2.3 degrees following medial femoral epicondyle osteotomy. There was no significant difference in varus correction (p = 0.1). Medial joint line opening in valgus stress test was 2.7 ± 0.4 mm in the osteotomized side and 3.5 ± 0.9 mm in contralateral side. Mean range of motion for the osteotomized side was 97.8 ± 4.3 degrees and 100.7 ± 2.7 degrees for contralateral side (p = 0.6). Nonunion occurred in a case in the osteotomized side and no medial instability was observed in medial release or osteotomies sides. No statistical difference was recorded based on clinical questionnaires (Oxford and WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index] scores). Medial epicondylar osteotomy is a safe technique with the well-controlled medial extensive release in the patients with severe varus deformity during total knee arthroplasty.