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Purpose: Ruptures of the posterior cruciate ligament (PCL) are often accompanied by posterolateral corner (PLC) and posteromedial corner (PMC) injuries. This study investigates the incidence and impact of PMC and PLC injuries on posterior tibial translation (PTT). It was hypothesized that PMC injuries are more common and impactful than previously reported. Methods: In this retrospective study, all patients with a PCL injury between January 2016 and December 2023 and received magnetic resonance imaging (MRI) within 30 days of trauma were included. Patients with atraumatic PCL instability, missing MRI or additional anterior cruciate ligament (ACL) rupture were excluded. Posttraumatic MRI was analyzed for peripheral injuries. Preoperative stress radiographs for PTT were measured, and the side‐to‐side difference was calculated. The statistical significance level was set at p < 0.05. Results: Ninety‐two patients were included, predominantly male (71.7%) with a mean age of 35.8 ± 15.6 years at injury. The mean time from injury to MRI was 7.3 ± 7.9 days. There were 16 patients (27.4%) with isolated PCL injuries. The prevalence of medial injuries (37.0% superficial medial collateral ligament [sMCL], 66.3% deep medial collateral ligament and 51.1% posterior oblique ligament [POL]) was comparable to lateral injuries (22.8% LCL, 55.4% PLC and 13.0% popliteus tendon). Injuries of the PMC (sMCL ± POL) occurred in 53 patients (57.6%) and of the PLC (POP ± PLC ± LCL) in 59 (64.1%) patients. PTT was significantly increased in the presence of a peripheral‐associated injury compared to isolated PCL injury (p < 0.01). With a combined injury of PMC + PLC the PTT was significantly larger than in the case of a unilateral injury (p < 0.05 compared to PLC; p < 0.05 compared to PMC). Conclusion: PCL injuries are commonly associated with PMC and/or PLC injuries. A PTT of >10 mm is equally caused by PLC and PMC‐associated injuries. Knowledge about the severity and localization of peripheral‐associated injuries is therefore essential for therapeutic decision‐making. Level of Evidence: Level III retrospective cohort study. [ABSTRACT FROM AUTHOR]

Introduction: Multi-ligament knee injuries (MLKIs) are rare and complex knee lesions and are potentially associated with intra-articular injuries, especially meniscal tears. Understanding the meniscal tear patterns involved in MLKI can help the orthopedic surgeon treat these complex injuries. Objective: The purpose of this study was to describe the incidence, classification, and treatment of meniscal injuries in a cohort of patients with MLKIs and carry out an updated review of the evidence available. Materials and methods: Descriptive retrospective study. Patients with a history of reconstructive surgery for MLKI performed between 2013 and 2023 were included. Informed consent was obtained from all patients included in the study. Patient demographics, magnetic resonance imaging (MRI) study, and operative reports were reviewed. Groups were then formed based on ligament injury patterns. Meniscal tears were identified by MRI and through diagnostic arthroscopy for each patient. The association between meniscal lesions and injury patterns was calculated through Fisher's exact test. Agreement between the presence of meniscal tear on MRI and in diagnostic arthroscopy was measured using the kappa test. The sensitivity and specificity of MRI were calculated. We inferred the presence of a meniscal tear by injury pattern using the Agresti-Coull confidence interval. For the statistical analysis, a significance of 5% and a confidence interval of 95% were considered. Results: Seventy patients with MLKIs were included, with a mean age of 30.69 years (SD 10.65). Forty-seven patients had meniscal lesions (67.1%). Of them, 6 had only medial meniscus tears, 31 had only lateral meniscus tears, and 10 had lesions of both menisci, comprising 57 meniscal lesions in total. An anterior cruciate ligament (ACL) + medial collateral ligament/posteromedial corner (MCL/PMC) was the most common injury pattern (52.86% of all patients). Of these 37 patients, 78.38% had meniscal injuries, and most of them (68.97%) were only lateral meniscus injuries. The odds ratio (OR) of having a meniscal tear when having an ACL + medial-side injury was 4.83 (95% CI; 0.89–26.17). Patients with ACL + lateral-side injury pattern had meniscal tears in 42.86%. The lateral meniscus was involved in 100% of these patients. 62.5% of medial meniscus injuries were treated by meniscal repair, and 37.5% by partial meniscectomy. 58.54% of lateral meniscus injuries were treated by meniscal repair, and 39.02% by partial meniscectomy. Agreement calculated using the kappa test between MRI and diagnostic arthroscopy for medial meniscal lesions was 78.57%, and for lateral meniscal lesions was 84.29%. Conclusion: The ligament injury pattern and the side of the injured collateral ligament influenced the incidence and laterality of meniscal damage. ACL + medial-side injuries were shown to have significantly greater meniscal damage compared to other injury patterns. It is crucial to have a high index of suspicion, obtain a high-quality MRI, and arthroscopically evaluate any possible meniscal lesions in MLKIs. [ABSTRACT FROM AUTHOR]

The posteromedial corner (PMC) of the knee is an anatomical region formed by ligamentous structures (medial collateral ligament, posterior oblique ligament, oblique popliteal ligament), the semimembranosus tendon and its expansions, the posteromedial joint capsule, and the posterior horn of the medial meniscus. Injuries to the structures of the PMC frequently occur in acute knee trauma in association with other ligamentous or meniscal tears. The correct assessment of PMC injuries is crucial because the deficiency of these supporting structures can lead to anteromedial rotation instability or the failure of cruciate ligaments grafts. This article reviews the anatomy and biomechanics of the PMC to aid radiologists in identifying injuries potentially involving PMC components. [ABSTRACT FROM AUTHOR]

Abstract Purpose Ruptures of the posterior cruciate ligament (PCL) are often accompanied by posterolateral corner (PLC) and posteromedial corner (PMC) injuries. This study investigates the incidence and impact of PMC and PLC injuries on posterior tibial translation (PTT). It was hypothesized that PMC injuries are more common and impactful than previously reported. Methods In this retrospective study, all patients with a PCL injury between January 2016 and December 2023 and received magnetic resonance imaging (MRI) within 30 days of trauma were included. Patients with atraumatic PCL instability, missing MRI or additional anterior cruciate ligament (ACL) rupture were excluded. Posttraumatic MRI was analyzed for peripheral injuries. Preoperative stress radiographs for PTT were measured, and the side‐to‐side difference was calculated. The statistical significance level was set at p 10 mm is equally caused by PLC and PMC‐associated injuries. Knowledge about the severity and localization of peripheral‐associated injuries is therefore essential for therapeutic decision‐making. Level of Evidence Level III retrospective cohort study.

Purpose: The purpose of this study was to retrospectively analyse the pattern of injury to the medial knee structures in anterior cruciate ligament (ACL) injured patients. It was hypothesised that anteromedial injuries would be more common than posteromedial lesions. Methods: One hundred and twenty subjects aged 18–25 years with a primary ACL injury were included. Patients were excluded if the time between injury and magnetic resonance imaging (MRI) was more than 28 days or if a knee dislocation or fracture was present. The MRIs were analysed with particular emphasis on injuries to the medial knee structures, menisci and bone bruise patterns. Injuries to the ligaments and anteromedial retinaculum (AMR) were graded according to severity, ranging from periligamentous oedema (grade I), partial fibre disruption of less or more than 50% (grade IIa or IIb) to complete tears (grade III). Results: AMR injury was seen in 87 subjects (72.5%) on the coronal plane and in 88 (73.3%) on the axial plane, with grade III lesions observed in 27 (22.5%) and 29 knees (24.2%). Injuries to the superficial medial collateral ligament (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL) were detected in 60 patients (50%), 93 patients (77.5%) and 38 patients (31.6%). However, grade III injuries to the POL were observed in only seven knees (5.8%). Medial meniscus injuries were associated with lesions of the sMCL and AMR (p < 0.05), while lateral meniscus injuries were significantly more common in patients with dMCL rupture (p < 0.05). Conclusion: Data from this study suggest that injuries to the AMR are much more common than posteromedial lesions in subjects with ACL injuries. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Introduction: Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. Materials & methods: N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. Results: N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). Conclusions: One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. Level of evidence: Level II. [ABSTRACT FROM AUTHOR]

Abstract Objective This study aims to evaluate the possibility of characterizing an extra-articular thickening in the knee anteromedial quadrant in routine MRI scans. Materials and methods Firstly, in a pilot study, for a better understanding of this extra-articular thickening trajectory in MRI, polytetrafluoroethylene (PTFE) tubes were attached to the ligament structure topography in two dissected pieces. Afterward, 100 knee MRI studies were randomly selected from our database, and 97 met the inclusion criteria. Two musculoskeletal radiologists interpreted the exams separately. Both had previously studied the ligament in the cadaveric knee MRI with the PTFE tube. Results The intraobserver and interobserver agreement for the ligament identification was calculated using Cohen’s Kappa coefficient. The first radiologist identified the structure in 41 of the 97 scans (42.2%), and the second radiologist in 38 scans (39.2%). The interobserver agreement was substantial, with a Kappa of 0.68 and an agreement of 84.5%. The results suggest that this extra-articular thickening, recently called Anterior Oblique Ligament (AOL) in the literature, is a structure that can be frequently visualized on MRI scans with a high level of interobserver agreement in a relatively large number of exams. Conclusion Therefore, this study indicates that MRI is a promising method for evaluating this anteromedial thickening, and it may be used for future studies of the Anterior Oblique Ligament.

Objective: This study aims to evaluate the possibility of characterizing an extra-articular thickening in the knee anteromedial quadrant in routine MRI scans. Materials and methods: Firstly, in a pilot study, for a better understanding of this extra-articular thickening trajectory in MRI, polytetrafluoroethylene (PTFE) tubes were attached to the ligament structure topography in two dissected pieces. Afterward, 100 knee MRI studies were randomly selected from our database, and 97 met the inclusion criteria. Two musculoskeletal radiologists interpreted the exams separately. Both had previously studied the ligament in the cadaveric knee MRI with the PTFE tube. Results: The intraobserver and interobserver agreement for the ligament identification was calculated using Cohen's Kappa coefficient. The first radiologist identified the structure in 41 of the 97 scans (42.2%), and the second radiologist in 38 scans (39.2%). The interobserver agreement was substantial, with a Kappa of 0.68 and an agreement of 84.5%. The results suggest that this extra-articular thickening, recently called Anterior Oblique Ligament (AOL) in the literature, is a structure that can be frequently visualized on MRI scans with a high level of interobserver agreement in a relatively large number of exams. Conclusion: Therefore, this study indicates that MRI is a promising method for evaluating this anteromedial thickening, and it may be used for future studies of the Anterior Oblique Ligament. [ABSTRACT FROM AUTHOR]

The posteromedial corner (PMC) is a common location for knee joint pain, and accurate diagnosis is essential for appropriate treatment. The frequent causes of pain in the PMC include pathologies of the posterior part of the medial meniscus, damage to articular cartilage, popliteal cysts and the semimembranosus tendinopathy. Currently, magnetic resonance imaging is the gold standard for assessing knee joint disorders, but its availability and cost can limit its use in some cases. In this pictorial essay, we presented the use of ultrasonography as an alternative method for assessing PMC. We present a series of images to demonstrate the value of ultrasonography and describe the methods used for assessing PMC with a particular focus on semimembranosus tendinopathy. [ABSTRACT FROM AUTHOR]

Background: While most medial-sided knee injuries can be managed conservatively, high-grade injuries of the posteromedial corner have been reported to have less than optimal outcomes with conservative approaches, resulting in residual valgus and rotational instability. Consensus among experts postulates that treatment should be based on reconstructing both the superficial medial collateral ligament (sMCL) and the posterior oblique ligament (POL). We present a modified technique of a tibial-sling anatomic MCL reconstruction with a POL limb. Indications: High-grade injuries of the posteromedial corner, specifically injuries with medial joint gapping in extension or grade 3 medial-sided tears. Technique Description: The MCL is reconstructed with a semitendinosus autograft in a tibial sling, created by converging perpendicular bone tunnels at its anatomic tibial insertion, and fixed to a femoral tunnel in the isometric point just posterior and proximal to the medial epicondyle with the knee at 30° of flexion. That same single femoral tunnel will be shared by the two strands of the semitendinosus graft and a limb of gracilis autograft to reproduce the POL, passed through a tibial tunnel in the posteromedial margin of medial tibial condyle, and fixed in extension. Discussion/Conclusion: As recent evidence suggests that medial reconstruction should be preferred over repair, due to favorable complication and failure rates, we describe a technique that is both anatomic-based, reproducing the 2 main medial knee structures (sMCL, POL), and also cost-saving, with decreased need of fixation devices. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication. Graphical Abstract This is a visual representation of the abstract. [ABSTRACT FROM AUTHOR]

Objective To introduce posteromedial corner release with the knee in the figure‐of‐four position versus the conventional position for varus knee arthroplasty. Methods This is a retrospective study. From March 2015 to September 2019, a series of 123 patients (139 knees) with varus knee were randomly and blindly allocated to experimental group (60 patients; 68 knees) and control group (57 patients; 65 knees). Patients in experimental group underwent posteromedial corner release with the knee in the figure‐of‐four position; and patients in control group with the knee in the conventional position. If soft tissue balance was not completely achieved or the medial gap was still tight, an additional loosening technique were used to achieve symmetric medial and lateral space in both groups. Time for soft tissue balancing was defined as the time from the start of the spacer test to the end of the balance test. Length of release was defined as the distance from the osteotomy surface of the tibial plateau to the farthest structures released. The rating system of Hospital for Special Surgery (HSS) knee score was used to evaluate the clinical results. Quantitative variables were described as mean and standard deviation, and compared by one‐way analysis of variance. Results The mean age of experimental group and control group was 70.2 ± 8.7 years and 68.7 ± 6.2 years, respectively (P > 0.05). Preoperatively, the mean HSS score of the groups was 38.2 ± 11.3 and 39.1 ± 10.7, respectively (P > 0.05). The mean varus knee angle was 19.7° ± 9.3° and 19.3° ± 10.7°, respectively (P > 0.05). The mean time for soft tissue balancing was 8.4 ± 3.3 min and 11.3 ± 6.9 min in experimental and control group, respectively (P 0.05). No complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in the patients. Conclusion The posteromedial corner can be released more extensively and thoroughly when the knee is placed in the figure‐of‐four position during varus knee arthroplasty.

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. [ABSTRACT FROM AUTHOR]

Objective: To identify the posterior oblique ligament and assess incidence and patterns of injury to the ligament on MRI of acute knee trauma. Subjects and methods: One hundred twenty-three MRI studies met the study criteria. For each case, the posterior oblique ligament was identified and scored as injured or normal. Incidence of proximal and distal posterior oblique ligament tears was calculated. Fisher's tests were employed to determine significance of association between tears of the posterior oblique ligament and components of the posteromedial corner and other capsuloligamentous structures of the knee. Results: The posterior oblique ligament was reliably identified as a distinct structure in 123 MRI scans that met the criteria and was consistently labeled as intact or torn. Posterior oblique ligament tear was seen in 61.7% of knee trauma with proximal injury in 56.5% and distal injury in 97.3% of positive cases. Posterior oblique ligament disruption was a part of multiligamentous injury in 94.7% of positive cases. Posterior oblique ligament injuries (n = 76) had an extremely significant relationship with oblique popliteal ligament tears (n = 27) (p = 0.0001), semimembranosus tendon insertion tears (n = 15) (p = 0.0005), and medial collateral ligament tears (n = 15) (p = 0.0005) and a highly significant association with medial meniscus tears (n = 68) (p = 0.0049) and posterior cruciate ligament tears (n = 12) (p = 0.0033). The association with anterior cruciate ligament tears (n = 53) was not significant. Conclusions: The posterior oblique ligament is a distinct radiological entity consistently identified in acute trauma MRI. Disruptions of the distal posterior oblique ligament are frequent in complex knee injury, notably in association with oblique popliteal ligament, medial collateral ligament, and semimembranosus tendon tears. [ABSTRACT FROM AUTHOR]

Abstract Background The purpose of this study was to evaluate the influence of posterior medial corner (PMC) injuries on clinical outcome and second-look arthroscopic findings after anterior cruciate ligament (ACL) reconstruction. Methods Seventy-eight consecutive patients underwent a second-look arthroscopic surgery after ACL reconstruction and magnetic resonance imaging (MRI) examination of the PMC. The patients were divided into a PMC intact group (n = 42) and a PMC injured group (n = 36). The stability and clinical outcomes were evaluated using the Lachman test, pivot-shift test, a KT-2000 arthrometer, and the Lysholm knee scoring scale. Graft tension and synovial coverage were evaluated in second-look arthroscopy. Results The clinical function showed no significant differences regarding PMC injury. Although the graft tendon tension revealed no significant differences (p = 0.141), the second-look arthroscopic findings indicated that the PMC intact group showed better synovial coverage compared to the PMC injured group (p = 0.012). Conclusion Patients who injured the PMC had poor synovial coverage as assessed by second-look arthroscopic findings after transtibial ACL reconstruction, even though clinical outcomes and stability showed no significant differences.

Purpose: Posterior stress radiography is recommended to identify isolated or combined posterior cruciate ligament (PCL) deficiencies. The posterior drawer in internal (IR) or external rotation (ER) helps to differentiate between these combined instabilities. The purpose of this study was to evaluate posterior stress radiography (PSR) in isolated and combined PCL deficiency with IR and ER compared to PSR in neutral rotation (NR) for diagnosing combined PCL instabilities., Methods: Six paired fresh-frozen human cadaveric legs (n = 12) were mounted in a Telos device for PSR. The tibia was rotated using an attached foot apparatus capable of rotating the foot 30° internally and externally. A posterior tibial load of 15 kp (147.1 N) was applied to the tibial tubercle at 90° knee flexion, and a lateral radiograph was obtained. This was repeated with the foot in 30° IR and ER. The PCL, posterolateral complex (PLC), and posteromedial complex (PMC) were sectioned in six knees, while the PMC was sectioned before the PLC in the other six knees. Posterior tibial displacement (PTD) was measured radiographically. Statistical analysis was performed using a two-way ANOVA and a mixed model with Bonferroni correction, and the significance was set at p < 0.05. Furthermore, intra- and interobserver reliability was determined., Results: Cutting the PCL significantly increased the radiographic PTD by 9.8 ± 1.8 mm (side-to-side difference compared to the intact state of the knee, n = 12; p < 0.001). This further increased to 12.2 ± 2.3 mm (n = 6; p < 0.01) with an additional PLC deficiency and to 15.4 ± 3.4 mm (n = 6; p < 0.05) with an additional PMC deficiency. A combined PLC and PMC deficiency resulted in an increase of the PTD to 15.9 ± 4.5 mm (n = 12; p < 0.01). In the PCL/PLC deficient state, ER did not demonstrate a higher PTD, compared to the NR and IR posterior drawer. In the PCL/PMC deficient state in IR, PTD was 1.6 ± 0.7 mm (p < 0.01) higher compared to NR and 3.2 ± 1.9 mm (p < 0.05) higher compared to ER. We showed excellent intra- and interobserver reliability (0.987-0.997)., Conclusion: Combined PCL instabilities resulted in a significant increase in posterior tibial displacement in posterior stress radiographs. However, PSR in IR or ER was unable to differentiate between these combined instabilities. Based on our data, additional stress radiographs in rotation are unlikely to provide any diagnostic benefit in the clinical setting., Level of Evidence: There is no level of evidence as this study was an experimental laboratory study., (© 2024 The Author(s). Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. Methods: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. Results: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. Conclusion: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. Level of evidence: Level V. [ABSTRACT FROM AUTHOR]

Objective: To introduce posteromedial corner release with the knee in the figure‐of‐four position versus the conventional position for varus knee arthroplasty. Methods: This is a retrospective study. From March 2015 to September 2019, a series of 123 patients (139 knees) with varus knee were randomly and blindly allocated to experimental group (60 patients; 68 knees) and control group (57 patients; 65 knees). Patients in experimental group underwent posteromedial corner release with the knee in the figure‐of‐four position; and patients in control group with the knee in the conventional position. If soft tissue balance was not completely achieved or the medial gap was still tight, an additional loosening technique were used to achieve symmetric medial and lateral space in both groups. Time for soft tissue balancing was defined as the time from the start of the spacer test to the end of the balance test. Length of release was defined as the distance from the osteotomy surface of the tibial plateau to the farthest structures released. The rating system of Hospital for Special Surgery (HSS) knee score was used to evaluate the clinical results. Quantitative variables were described as mean and standard deviation, and compared by one‐way analysis of variance. Results: The mean age of experimental group and control group was 70.2 ± 8.7 years and 68.7 ± 6.2 years, respectively (P > 0.05). Preoperatively, the mean HSS score of the groups was 38.2 ± 11.3 and 39.1 ± 10.7, respectively (P > 0.05). The mean varus knee angle was 19.7° ± 9.3° and 19.3° ± 10.7°, respectively (P > 0.05). The mean time for soft tissue balancing was 8.4 ± 3.3 min and 11.3 ± 6.9 min in experimental and control group, respectively (P < 0.05). The mean length of releasing posteromedial corner structures was 35.5 ± 13.4 mm and 27.3 ± 9.7 mm in experimental and control group, respectively (P < 0.05). Additional special loosening techniques were performed in eight knees in experimental group and seven knees in control group. The HSS scores 5 years after surgery were 95.1 ± 16.9 and 94.8 ± 17.2 respectively (P > 0.05). No complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in the patients. Conclusion: The posteromedial corner can be released more extensively and thoroughly when the knee is placed in the figure‐of‐four position during varus knee arthroplasty. [ABSTRACT FROM AUTHOR]

Introduction: The medial collateral ligament (MCL) is one of the main stabilizers of the knee, but its injury occurs in conjunction with other ligaments. Objective: To determine the prevalence of MCL lesions by magnetic resonance imaging, their degrees and associated lesions in our institution. Material and Methods: Retrospective study from January to April 2018 where KNEE MRIs were evaluated where the MCL lesion was presented to evaluate the degree and type of associated injuries. Results: We included 368 studies, prevalence of isolated MCL lesion of 3.07%, grade I and grade II, prevalence of concomitant MCL lesions was 17.66% grade I (75%), grade II (15%) and grade III (3%). Associated injuries were medial meniscus injury (46.15%), anterior cruciate ligament injury (30.7%), isolated bone contusion (18.46%), chodral injuries (37.58%), medial vastus injury (14.51%), patellar medial retinacular injury (14.51%), vastus lateral injury (9.23%), posterior cruciate ligament injury (6.15%), lateral meniscus injury (4.61%), iliotibial band tenosynovitis (4.61%), medial facet avulsion fracture (3.07%), Pes Anserine tenosynovitis (3.07%). Conclusion: Prevalence of 17.66% of the MCL injuries in our hospital by magnetic resonance, the first 2 degrees predominate, with a wide spectrum of associated knee injuries. [ABSTRACT FROM AUTHOR]

Introduction: Multiligament knee injury with posteromedial laxity is serious and usually requires surgery. Reconstruction is preferable to repair. The main aim of the present study was to report clinical results and laximetry for an original posteromedial corner (PMC) allograft reconstruction technique known as The Versailles Technique. The secondary aim was to determine prognostic factors for surgery. The study hypothesis was that anatomic PMC reconstruction by tendon allograft provides satisfactory medium-term clinical and laximetric results., Methods: A retrospective study assessed postoperative clinical and laximetric results after PMC allograft reconstruction at a minimum 12 months' follow-up. Laxity was assessed on comparative bilateral stress X-rays, and functional results on the International Knee Documentation Committee (IKDC) score, the Lysholm score and the Knee injury and Osteoarthritis Outcome Score (KOOS)., Results: Twenty-six patients were included between 2013 and 2019. Mean follow-up was 27.4±9 months. Mean subjective IKDC score was 69.21±17.36, mean Lysholm score 77.78±14.98 and mean KOOS 66.44±18.52., Objective: IKDC results were 77% grade A, 22% grade B, and 0% grade C or D. Mean medial differential laxity in forced varus was 0.83±1.26mm. Mean subjective IKDC scores were poorer in Schenck KD-III than KD-I (p=0.03). Functional results were comparable with acute and with chronic laxity. Age correlated inversely with median KOOS (p=0.009). There was no correlation between postoperative radiologic laxity in forced varus and functional results., Discussion: Versailles anatomic PMC allograft reconstruction for acute or chronic posteromedial knee laxity showed medium-term efficacy in restoring good objective and subjective stability., Level of Evidence: IV; retrospective observational study., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background Simultaneous injury of two or more knee ligaments with concurrent tears involving the anterior cruciate and medial collateral ligaments is considered to be associated with femorotibial knee dislocations (KD). The purpose of this study is to characterize multiligamentous knee injury patterns associated with dislocations on MRI and to describe the incidence of their sequelae such as tibial plateau fractures, peroneal nerve injuries, and posterolateral corner (PLC) injuries. Participants and methods After obtaining institutional ethical committee approval, we retrospectively identified 108 multiligamentous knee injuries in 100 patients who met with trauma and were treated at our tertiary care center between April 2014 and December 2018. Descriptive statistics were reported using numbers and percentages for categorical variables in cases of multiligamentous injuries, ipsilateral tibial plateau fractures, ipsilateral femoral fractures, peroneal nerve injury, arterial injury, compartment syndrome, and PLC injuries. Results The most common (39.8%) injury pattern was a combined disruption of the anterior cruciate ligament, posterior cruciate ligament, and PLC. Schenck KD III-M was the most common injury type in KD, constituting 16.7%. Medial-sided injuries were the most common injury patterns seen with KD. There was a significant risk of peroneal nerve injury with lateral-sided injuries. Conclusion KD, though rare, may have devastating clinical sequelae such as compartment syndrome if not recognized and treated. Therefore, it is necessary to recognize imaging findings of femorotibial joint dislocations and associated injuries to the adjacent neurovascular bundles.

The purpose of our study was to assess effect of posteromedial corner(PMC) injury on clinical outcomes and second-look arthroscopic findings after posterior cruciate ligament(PCL) reconstruction using Achilles tendon allograft. A total of 51 patients who underwent arthroscopic PCL reconstruction for PCL rupture and second-look arthroscopy were retrospectively enrolled in our study from 2009 to 2019. The subjects were divided into two groups: PMC intact group included 31 patients; and PMC injured group included 18 patients. At least 1 years follow-up, clinical outcomes and arthroscopic findings including synovial coverage, tension were evaluated. Arthroscopic findings including the synovial coverages, tension showed significantly better at PMC intact group. (p < 0.005) but, no statistic difference was seen in clinical outcomes including KT-2000 value, last Lysholm score, posterior drawer test. For PCL ruptures with PMC injuries, treatment for PMC should be considered due to graft status. IV. [ABSTRACT FROM AUTHOR]

Meniscal ramp lesions occur much more frequently than was previously considered, and particularly so in ACL-injured knees. The historically high rate of missed diagnoses is a result of unfamiliarity with this injury pattern within the orthopedic community, and also the difficulty in diagnosis. A systematic exploration of the posteromedial compartment of the knee is mandatory to reliably identify ramp lesions. Failure to recognize and repair these injuries is associated with persistent anterior and posteromedial instability. Understanding their nature, biomechanics, and epidemiology is essential in allowing orthopedic surgeons to suspect their presence and adequately treat these lesions. [ABSTRACT FROM AUTHOR]

Objective: To identify the posterior oblique ligament and assess incidence and patterns of injury to the ligament on MRI of acute knee trauma. Subjects and methods: One hundred twenty-three MRI studies met the study criteria. For each case, the posterior oblique ligament was identified and scored as injured or normal. Incidence of proximal and distal posterior oblique ligament tears was calculated. Fisher's tests were employed to determine significance of association between tears of the posterior oblique ligament and components of the posteromedial corner and other capsuloligamentous structures of the knee. Results: The posterior oblique ligament was reliably identified as a distinct structure in 123 MRI scans that met the criteria and was consistently labeled as intact or torn. Posterior oblique ligament tear was seen in 61.7% of knee trauma with proximal injury in 56.5% and distal injury in 97.3% of positive cases. Posterior oblique ligament disruption was a part of multiligamentous injury in 94.7% of positive cases. Posterior oblique ligament injuries (n = 76) had an extremely significant relationship with oblique popliteal ligament tears (n = 27) (p = 0.0001), semimembranosus tendon insertion tears (n = 15) (p = 0.0005), and medial collateral ligament tears (n = 15) (p = 0.0005) and a highly significant association with medial meniscus tears (n = 68) (p = 0.0049) and posterior cruciate ligament tears (n = 12) (p = 0.0033). The association with anterior cruciate ligament tears (n = 53) was not significant. Conclusions: The posterior oblique ligament is a distinct radiological entity consistently identified in acute trauma MRI. Disruptions of the distal posterior oblique ligament are frequent in complex knee injury, notably in association with oblique popliteal ligament, medial collateral ligament, and semimembranosus tendon tears. [ABSTRACT FROM AUTHOR]

Background: In cases of acute combined posteromedial and anterior cruciate ligament (ACL) injuries, primary repair of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with suture tape augmentation may be a reasonable alternative to standard tendon reconstruction techniques. Purpose/Hypothesis: The purpose was to examine the rotational and valgus laxity with ACL strain following sMCL and POL repair with suture tape augmentation at various degrees of knee flexion. It was hypothesized that this technique would restore knee laxity and kinematics comparable with those of the intact state. Study Design: Controlled laboratory study. Methods: Ten cadaveric knee specimens (mean ± SD, 57.9 ± 5.9 years) were obtained. Specimens were tested with the tibia fixed and the femur mobile on an X-Y table. Each specimen was tested in 4 conditions according to the state of the sMCL and POL: native, deficient, repaired with suture tape augmentation, and reconstructed with tendon allografts. Valgus laxity was tested with 40-N force applied in the lateral direction of the femur, and rotational motion was tested with 5-N torque applied to the tibia. ACL strain during valgus stress was also measured. Each condition was tested in 0°, 15°, 30°, 45°, and 60° of knee flexion. Results: Dissection of the sMCL and POL led to significantly increased valgus laxity in all flexion angles, with a significant increase in ACL strain at 30° (P <.001) and 45° (P <.001). Ligament repair with suture tape augmentation demonstrated similar valgus and rotational laxity as compared with intact specimens, with the exception of increased internal rotation at 30° (P =.005). Ligament reconstruction resulted in significantly increased valgus opening at 45° (P =.048) and significantly increased internal rotation at 30° (P <.001) as compared with the native state. Direct comparison between surgical techniques showed no significant differences. Conclusion: At time zero, ligament repair of the posteromedial knee with suture tape augmentation restored close-to-native valgus and rotatory laxity, as well as native ACL strain for cases of complete sMCL and POL avulsion. Clinical Relevance: Ligament repair of the sMCL and POL with suture tape augmentation may be a reasonable alternative to tendon reconstruction techniques in cases of acute combined posteromedial and ACL injuries with valgus and rotatory instability. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to introduce a novel arthroscopic treatment for medial and posteromedial instability of the knee and present the primary and follow-up results., Methods: All patients who underwent the arthroscopic approach to treat medial and posteromedial corner instability from 2007 to 2017 were included in this report. Overall, 45 patients were included, among which 75.6% were male. The mean age of patients was 32.2 ± 8.4 years. Overall, 44.4% and 15.6% of patients had associated meniscal injuries and chondral lesions, respectively. The mean follow-up duration of patients was 84.2 ± 25.3 months., Results: Overall, 37 patients developed a full range of motion (82.2%), and most patients (95.6%) showed excellent quadriceps strength (grades 4 and 5). All patients had a normal or 1+ posterior drawer test, Pivot shift test, and Lachman test on physical examination. Moreover, 60% had an associated isolated anterior cruciate ligament injury, 17.8% had an isolated posterior collateral ligament injury, and 17.6% had a combination of more than one ligament injury. One patient developed septic arthritis. Two patients experienced pain, and one pain patient developed pain with a bony spur formation in the medial epicondyle. Three patients showed a 2+ medial collateral ligament (MCL) test (moderate instability) at the final follow-up, all of whom had multi-ligament injuries. All patients, except the three patients who had a failed MCL reconstruction, returned to their previous activities., Conclusion: This study described a novel arthroscopic treatment of MCL injury, and the results showed acceptable postoperative and clinical outcomes. As the use of minimally invasive surgery may minimize multiple complications associated with open surgery, it is suggested that further studies be conducted regarding this approach when faced with patients who have MCL injuries requiring surgery., Competing Interests: None, (2024 © BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

The posteromedial quadrant of the radial head is known to be different from the other quadrants. However, the explanation of this unique anatomical feature remains elusive. Hence, this study was designed to address this unique anatomical variance using three-dimensional μ CT (micro-computed tomography) analysis. Nine fresh cadaveric radial heads were scanned using μ CT. Three-dimensional subchondral bone and cartilage models were rendered. Both models were separated into the four quadrants at both the periphery (rim) and the articulating dish (fovea): anteromedial ( AM), posteromedial ( PM), posterolateral ( PL), and anterolateral ( AL). Each quadrant was analyzed in terms of (1) subchondral bone porosity ( SBP), (2) mean subchondral bone thickness ( MSBT), and (3) mean cartilage thickness ( MCT). There was a significant difference between the fovea and the rim in terms of its microarchitectural features. Although within the fovea, the PM quadrant did not differ significantly from the other quadrants, a significant difference was found within the rim. In terms of SBP, PM, AM, PL and AL were calculated as 33, 37, 36 and 35%, respectively. In terms of MSBT, PM, AM, PL and AL were calculated as 0.11, 0.10, 0.09, and 0.09 mm, respectively. In terms of MCT, PM, AM, PL and AL were calculated 1.09, 0.81, 0.84 and 0.83 mm, respectively. The PM corner of the radial head between the 8 and 9 o'clock positions, was beveled. This might explain why the PM quadrant of the rim differed significantly from the other quadrants in terms of its microarchitectural features. [ABSTRACT FROM AUTHOR]

Intra-articular entrapment of the medial collateral ligament (MCL) is a rare but recognised complication of traumatic injury to the posteromedial corner (PMC) of the knee. Considering the MCL is the most commonly injured ligament of the knee this complication is extremely rare with only a handful of cases describing MCL entrapment following distal avulsion of the MCL. We present the first known case of MCL entrapment following proximal avulsion of the MCL and posterior oblique ligament (POL) with the mid-substance of the MCL becoming entrapped in the joint, lying on the superior surface of the medial meniscus and extending up into the intercondylar notch. In addition, the medial patellar retinaculum was also entrapped in the medial aspect of the medial patellofemoral joint. MCL entrapment is best treated with expeditious surgical intervention and it is therefore crucial that the MRI findings are not overlooked. Details of the clinical assessment, MRI and operative findings are presented with a literature review of MCL entrapment. [ABSTRACT FROM AUTHOR]

Anterior cruciate and posterior cruciate injuries rarely occur in isolation and are often associated with injuries to the secondary or supporting structures that provide stability against rotational forces. These structures include the posterolateral and posteromedial corner ligaments and tendons, as well as the anterolateral ligament. If injuries to these secondary structures are not appreciated at the time of cruciate ligament reconstruction, an isolated cruciate ligament reconstruction may be predisposed to early failure. Thus it is crucial for radiologists interpreting knee magnetic resonance imaging to understand and report on injury to these ligaments and tendons at the time of initial injury to help the orthopaedic surgeon plan a comprehensive approach to ligament reconstruction. This strategy will ultimately result in improved patient outcomes. [ABSTRACT FROM AUTHOR]