INDICATIONS

Medial ligament injuries are among the most frequently treated problems of the knee joint, with the majority not requiring operative intervention. Whereas isolated superficial medial collateral ligament (SMCL) ruptures are common, concomitant damage to the anterior cruciate ligament (ACL) also occurs in many cases, especially in young and active patients.^{6,11,14,28,33}

Overall, there are four types of SMCL injury patterns: (1) SMCL alone, (2) associated posteromedial capsular (PMC) tears (posterior oblique ligament [POL]), (3) associated ACL or posterior cruciate ligament (PCL) tears with patterns 1 or 2, and (4) multiple ligament injuries or knee dislocations.

The mechanism of injury to the medial ligaments involves a valgus stress with usually a combined external tibial rotation component from either a noncontact (pivoting or cutting) or a contact injury (direct blow to the lateral side of the thigh or knee). The decision process regarding the appropriate treatment of medial ligament injuries involves determining the severity of the injury to the entire knee, including the other knee ligaments, and the specific injury pattern of the medial structures and menisci.

The medial structures identified for purposes of surgical treatment consist of the SMCL, deep medial collateral ligament (DMCL, including meniscus attachments), and the PMC, which includes the structures referred to as the POL and semimembranosus attachments.^22,44 The key to the diagnosis and treatment of medial ligament injuries relies on a comprehensive understanding of the intricate anatomy on the medial side of the knee. This is presented in detail in Chapter 1, Medial and Anterior Knee Anatomy. In Figure 24-1, the osseous attachments of the medial structures are shown. Figure 24-2 shows the medial and posteromedial ligament structures, which are discussed in detail. Figure 24-3 shows the relationship of the semimembranosus muscle attachments to the posteromedial structures and POL. These include the bifurcation of the semimembranosus tendon into a direct and anterior area just distal to the joint line and a minor attachment of the direct arm to the medial coronary ligament along the posterior horn of the medial meniscus. The semimembranosus tendon sheath makes up a distal tibial expansion that includes a medial and lateral division. A major attachment of the semimembranosus forms the oblique popliteal ligament, which is a broad fascial band that courses laterally attaching to the fabella, posterolateral capsule, and plantaris (see Chapter 1, Medial and Anterior Knee Anatomy, Figs. 1–4 to 1–10).

FIGURE 24-1 The medial capsule, ligament, and muscle bone attachments are shown. A key to surgical repair and reconstruction of medial injuries is to restore normal anatomy and attachment locations.

FIGURE 24-2 A and B, The anatomy of the medial and posteromedial aspect of the knee. The posteromedial capsule is shown divided into three functional regions, commonly designated as the posterior oblique ligament (POL).

FIGURE 24-3 Semimembranosus muscle attachments to the posteromedial structures.

It is important to understand and classify the soft tissue injury of all the medial structures. The majority of acute medial ligament injuries that involve damage to the SMCL alone, or SMCL and PMC, are treated conservatively. The nonoperative treatment algorithm is shown in Figure 24-4 and discussed later in more detail. Gross major disruption of all of the medial structures alone or in addition to the ACL or PCL tears involve a group of select knees. The treatment of these gross ligament disruptions is discussed in a later section of this chapter.

FIGURE 24-4 Treatment algorithm for patients with acute medial ligament ruptures.

In cases of chronic injury to the medial ligaments, it is important to obtain a complete history and objective and functional rating. The authors’ use the Cincinnati Knee Rating System (CKRS) for this analysis (see Chapter 44, The Cincinnati Knee Rating System) to determine patient complaints of giving-way and the levels of activity at which this symptom occurs as an indication for surgical stabilization procedures. In this chapter, instability refers to an increase in abnormal motion limits as detected on the physical examination, and is not used to indicate giving-way events.

CONTRAINDICATIONS

Patients that have medial ligament tears classified as first, second, or third degree that demonstrate either no increase or a mild to moderate increase in medial joint opening at 0° and 30° of flexion do not require acute medial ligament reconstruction.

A valgus malalignment and valgus thrust on walking contraindicates a medial ligament reconstruction in chronic cases without first performing an osteotomy to correct the lower limb malalignment. Alternatively, a genu varus provides a theoretical benefit of decreased tensile loads on the medial ligament structures.

In chronic cases of disruption of the medial ligaments, particularly associated with ACL or PCL tears, joint arthritis and associated pain and swelling may exist that contraindicate a soft tissue reconstruction. The patient goals and anticipated symptoms from the preexisting arthrosis are carefully considered.

Sedentary, nonathletic patients who do not experience pain, swelling, or giving-way with daily activities do not require surgery. These patients are advised to maintain their ideal body weight and obtain yearly consultations to monitor the knee joint.

Patients with severe lower extremity muscle atrophy are not candidates for surgery until adequate muscle strength is regained. The high potential for postoperative complications exceeds the potential benefits in these patients, especially in regard to developmental patella infera, quadriceps shutdown, and arthrofibrosis. A formal program of physical therapy should be pursued, which may be required for many months to improve overall lower limb muscle strength and function, particularly in multiligament injuries.

Associated medical problems may exist that either require treatment or contraindicate surgery including complex regional pain syndrome, diabetics, vascular insufficiency, skin lesions, infectious conditions, obesity, or other diseases.

CLINICAL BIOMECHANICS

A considerable amount of discrepancy exists in the literature regarding the use of terminology to describe and classify the medial ligament injuries from an anatomic standpoint and the abnormal motion limits that exist (see Chapter 3, The Scientific Basis for Examination and Classification of Knee Ligament Injuries). The authors agree with Hughston and coworkers¹⁹ that the clinician must clearly separate and classify medial ligament tears into first degree (tear involving a few fibers), second degree (partial tear, no instability, ≤3 mm of medial joint opening), and third degree (complete rupture) (TABLE 24-1; see also Fig. 24-4).^{5,10,11,13,20,21,32,42} This is one of the earliest systems devised and is based on a classification proposed by the American Medical Association.¹ The problem has arisen, as amply demonstrated in TABLE 24-1, that this classification system has been modified extensively by different authors and it is often not possible to categorize the injury severity of the knees under treatment. For example, some authors in TABLE 24-1 refer to a second-degree or grade 2 instability as one that has a definite laxity or mild to moderate instability, even though the original definition of a second-degree or grade 2 injury represented only a partial ligament tear without any major increase in medial joint opening. Thus, it is necessary in the review of the literature to perform a subset analysis, which has been done in this chapter, to try to obtain the category or type of injury under treatment and the authors’ treatment recommendations.

TABLE 24-1 Published Classification Systems for Ruptures to the Medial Structures of the Knee

MCL, medial collateral ligament.

For purposes of this chapter, the injury classification based on the clinical examination is shown in Figure 24-4. Note that the medial ligament injuries are based on the first-, second-, and third-degree original classification system proposed; the increases in medial joint opening for the third-degree injury are based on the increase in medial joint opening and external tibial rotation. Some classification systems use a system in which each grade represents a further 5-mm increase in joint opening (grades 1, 2, and 3) over the contralateral normal knee, whereas other systems use the grade to represent the absolute amount of joint opening in the injured knee (grades 1+, 2+, and 3+). This chapter uses the increase in millimeters of medial joint opening between the injured and the contralateral normal knee to diagnose the medial ligament injury, because this is the system used in the published biomechanical and kinematic studies to be presented.

A review of the in vitro cadaveric biomechanical function of the medial ligaments and ACL in resisting medial joint opening, external tibial rotation, and internal tibial rotation is provided in Figure 24-5, summarized in TABLE 24-2, and discussed in more detail in Chapter 3, The Scientific Basis for Examination and Classification of Knee Ligament Injuries. A finding of increased medial joint space at 30° of flexion (third-degree sprain, parallel fibers of the SMCL), but not at 0° of flexion, indicates that the PMC (including the POL) is still functional. Any further increase in medial joint opening at 0° indicates concurrent damage to the PMC. With complete disruption of the SMCL and PMC, the ACL and PCL become a restraint to further medial joint opening. Knees with rupture to both the medial collateral ligament (MCL) and the POL will demonstrate increases in external tibial rotation (average of 9° at 30° of flexion), increases in internal tibial rotation (average of 12° at 30° of flexion), and increases in abduction testing at 0° and 30° of flexion (averages of 6° and 9°, respectively). The results show the importance of performing the dial tibial rotation test (see Chapter 22, Posterolateral Ligament Injuries: Diagnosis, Operative Techniques, and Clinical Outcomes) to determine the anterior subluxation of the medial tibial plateau with medial ligament injuries. With a combined MCL/POL injury, there will be a noticeable increase in internal and external tibial rotation. The PMC is an important structure for stabilizing the extended knee under valgus loading.^35–37 With knee flexion, the PMC slackens and the MCL becomes the dominant restraint. In the extended knee, with posterior drawer and internal rotation, the PMC tightens based on its attachments at the femur (just posterior to the adductor tubercle) and the posteromedial aspect of the tibia. The increase in abduction for a combined MCL/POL injury and MCL/ACL injury at 15° to 45° of flexion is nearly the same (see Fig. 24-5B). The major difference between these injuries is in increased abduction at full extension in the MCL/POL ruptured knee.

FIGURE 24-5 A, The external rotation limits in the intact knee (bottom curve) first increased with flexion to 30° and then decreased with further flexion (11 donors). Cutting just the superficial medial collateral ligament (MCL Cut) increased the external rotation limits (16 donors). Further cutting of the posteromedial capsule (PMC; MCL + PMC Cut) produced a further increase in the external limit at all flexion angles, but the increase was again greater in flexion than in extension. Cutting the superficial MCL, the PMC, and the anterior cruciate ligament (ACL) allowed for a large increase in the external limit, particularly from 15° to 45° flexion (top curve). B, The abduction rotation limits (valgus opening) of the intact knee (bottom curve, 11 donors). Cutting only the MCL (MCL Cut) produced a small increase (∼2°–4°) in the abduction limit from 15° to 75° of flexion. Cutting the ACL (MCL + ACL Cut) increased the abduction limit (6 donors). Cutting the PMC in addition to the MCL (MCL + PMC Cut) with the ACL intact allowed for a further small but consistent increase (2°–3°) over the superficial MCL alone (6 donors). When compared with the intact knee, this injury combination increased the abduction limit approximately 6° to 7° at both 15° and 30° of flexion. Subsequently cutting the ACL (top curve) caused a large increase in the abduction limits at all flexion angles (9 donors). Note that the MCL + ACL cut produced a similar increase in abduction at 15°, 30°, and 45° of flexion as the MCL + PMC cut, but not at full extension.

(A and B, From Haimes, J. L.; Wroble, R. R.; Grood, E. S.; Noyes, F. R.: Role of the medial structures in the intact and anterior cruciate ligament–deficient knee. Limits of motion in the human knee. Am J Sports Med 22:402–409, 1994.)

The increase in medial joint opening and external tibial rotation shown in Figure 24-5 provides an indication of an associated ACL tear when these motion limits are distinctly abnormal. In these knees, there is a large increase in anterior tibial translation and the pivot shift test is in the grade III category.

The function of the PMC/POL in resisting internal tibial rotation is shown in Figure 24-6. An increase in the internal rotation limit at low flexion angles is a further diagnostic test for PMC/POL rupture, detected by the dial test.

FIGURE 24-6 The internal rotation limits of the intact knee (bottom curve) increased progressively as the knee was passively flexed (11 donors). Cutting the superficial MCL (MCL Cut) produced only a small increase in the internal rotation limits (6 donors). Cutting the MCL and PMC (MCL + PMC Cut) caused large increases in the internal rotation limits from 0° to 45° of flexion (6 donors). Cutting the MCL, the PMC, and the ACL (top curve) caused similarly large increases in the internal limits from 0° to 45° of flexion relative to the intact knee (6 donors). However, these increases were not significantly different from those seen with the MCL and PMC cut.

(From Haimes, J. L.; Wroble, R. R.; Grood, E. S.; Noyes, F. R.: Role of the medial structures in the intact and anterior cruciate ligament–deficient knee. Limits of motion in the human knee. Am J Sports Med 22:402–409, 1994.)

Sims and Jacobson⁴⁴ reviewed 93 knees that underwent operative treatment for acute MCL injuries. These authors reported that 93% had associated injury to the POL following the description of Hughston and Eilers.²² The authors emphasized the importance of identification and repair of the POL and tears of the semimembranosus capsular attachment (present in 70% of knees) and associated peripheral detachment of the medial meniscus (present in 30% of knees; Fig. 24-7). The authors postulated that a dynamic function of the semimembranosus attachments exists for knee stability, but this is unproved experimentally. Although some authors describe rupture and surgical repair of the POL alone (anteromedial rotatory instability), the biomechanical data show that the POL is not a primary restraint for medial joint opening or external tibial rotation. Interestingly, an isolated POL injury does produce an increase in internal tibial rotation (see Fig. 24-6), although again, this injury pattern clinically involves a combined PCL/POL disruption.

FIGURE 24-7 Three major injury patterns (injury to the POL is common to all): (1) injury to the POL with semimembranosus disruption, (2) injury to the POL with complete peripheral meniscocapsular detachment, and (3) POL injury with semimembranosus injury and peripheral meniscocapsular detachment. Disruption at any level is capable of disabling the dynamic function of the semimembranosus.⁴⁴

CLINICAL EVALUATION

Diagnostic Clinical Tests

The clinical tests for the assessment of ligament injuries are shown in Figure 24-8. SMCL disruption is determined by manual valgus stress testing at 0° and 30° of knee flexion. The surgeon estimates the amount of joint opening (in millimeters) between the initial closed contact position and the open position of each tibiofemoral compartment (avoiding internal or external tibial rotation). The result is recorded according to the increase in the tibiofemoral compartment of the injured knee compared with that of the opposite normal knee.

FIGURE 24-8 Demonstration of manual knee stability tests. A and B, Posterior drawer test at 90° knee flexion. C, Lachman test. D, Pivot shift test. E, Valgus test, palpating for medial joint opening at 30° and 0° flexion. F, Varus manual test, palpating for lateral joint opening, at 30° and 0° flexion. G–I, External rotation–internal rotation “dial test.” G, Starting position (performed at 30° and 90° flexion). H, Maximum at 30° flexion. I, Maximum at 90° flexion. J and K, Hyperextension and varus recurvatum tests supine and standing positions.

Critical Points CLINICAL EVALUATION

• Detailed history.

• Cincinnati Knee Rating System to evaluate subjective, objective, functional categories.

• Treat acute injuries with neurovascular examination, immobilization 5–7 days.

• Comprehensive examination of the knee joint

Range of flexion and extension.

Knee joint effusion and swelling.

Knee motion limits and subluxations compared with the contralateral knee.

Alignment patellofemoral joint.

Patellofemoral and tibiofemoral crepitus.

Tenderness along medial joint line, entire course of the SMCL.

Overall lower limb alignment.

Neurovascular status.

Gait.

• Diagnostic clinical tests

Manual valgus stress testing 0°, 30° flexion.

Lachman and pivot shift testing

KT-2000 arthrometer test, 20° flexion, 134 N.

Medial posterior tibiofemoral step-off on posterior drawer test 90° flexion.

Tibiofemoral rotation dial test 30°, 90° with patient in supine position.

Manual varus stress testing 0°, 30° flexion.

Observe gait for lower limb valgus alignment, valgus thrust during ambulation.

• Radiographs

Standard anteroposterior.

Lateral 30° flexion.

Weight-bearing posteroanterior 45° flexion.

Patellofemoral axial.

Medial stress, both knees, 20° flexion, neutral tibial rotation, 67 N varus force.

Posterior stress in PCL ruptures.

Lateral stress in lateral ligament ruptures.

Full standing both lower extremities, from femoral heads to ankle joints, knees with varus or valgus lower extremity malalignment.

• Magnetic resonance imaging to reveal location of ligament anatomic disruptions, bone contusions, other ligament ruptures, meniscus tears.

The integrity of the ACL is determined by Lachman and pivot shift testing. The result of the pivot shift test is recorded on a scale of 0 to III, with a grade of 0 indicating no pivot shift; grade I, a slip or glide; grade II, a jerk or clunk with the subluxation-reduction; and grade III, gross subluxation with impingement of the posterior aspect of the lateral side of the tibial plateau against the femoral condyle. A KT-2000 arthrometer test may be done at 20° of flexion (134 N force) to quantify total anteroposterior (AP) displacement. The medial posterior tibiofemoral step-off on the posterior drawer test is done at 90° of flexion.

The tibiofemoral rotation dial test at 30° and 90° with the patient in the supine position is done to determine whether increases in external tibial rotation occur with anterior subluxation of the medial tibial plateau (and not posterior subluxation of the lateral tibial plateau, indicating a posterolateral ligament injury).³² An increase in internal rotation may occur with MCL/POL disruptions (maximum 15°–45° flexion). Associated lateral and posterolateral disruptions are determined by varus stress testing at 0° and 30° of knee flexion.

A careful observation of the patient’s gait is performed to determine whether there is a lower limb valgus alignment and valgus thrust during ambulation.

CONSERVATIVE VERSUS OPERATIVE TREATMENT RULES AND PLANNING

Acute Medial and Posteromedial Ligament Ruptures

The treatment rationale for patients with acute medial ligament ruptures is shown in Figure 24-4. The algorithm is divided into three major sections based on the extent of injury to the SMCL and PMC/POL. The first- and second-degree injuries are treated initially with a functional brace, weight-bearing as tolerated, and rehabilitation as detailed in Chapter 25, Rehabilitation of Medial Ligament Injuries. Some second-degree injuries may have considerable medial pain and swelling; in these cases, an extension brace is used for the initial 1 to 2 weeks after the injury.

The rule for conservative treatment of all third-degree medial ligament injuries involves the necessity for short-term immobilization to allow the medial ligament structures to heal with the least elongation or laxity by limiting medial joint opening and external tibial rotation. In addition, meniscotibial attachment tears requiring protection for healing may exist. The lower limb is placed in a cylinder cast to allow “stick-down” of the disrupted medial soft tissues. Plaster immobilization is required because a soft hinged or functional brace, even if maintained at 0° of extension, does not provide sufficient protection to maintain medial joint line closure to allow close approximation of the disrupted medial ligament and meniscus attachment soft tissues. Patients are allowed toe-touch weight-bearing and perform quadriceps isometrics every hour, palpating the muscle tension and increase in thigh volume with their hand. Electrical muscle stimulation is also used. These modalities are important because thigh atrophy can occur even with short-term immobilization.

Critical Points CONSERVATIVE VERSUS OPERATIVE TREATMENT RULES AND PLANNING

Acute Injuries

• First- and second-degree injuries treated with a functional brace, weight-bearing as tolerated, rehabilitation.

• Third-degree injuries treated with short-term (10 days) immobilization, cylinder cast, to allow the medial ligament structures to heal. Toe-touch weight-bearing, quadriceps isometrics hourly, electrical muscle stimulation.

• 10 days, cast split into anterior/posterior shell, patient performs range of motion 0°–90° in figure-of-four position. 3 wk later, brace replaces cast.

OPERATIVE TREATMENT

• Injury rehabilitated for 7 days. If motion to 90° and initial quadriceps muscle function are restored, and the joint and extremity soft tissue swelling is in the mild range.

• Indications

Displaced meniscus tear.

High-performance athletes with complete disruption of SMCL and POL.

PCL tears with gross disruption of the SMCL and POL, all-inside arthroscopic PCL reconstruction and open medial repair.

Knee Dislocations

• Treat injury with stick-down conservative program; manage associated injuries at a later time period.

• Add posterior calf pad to cylinder cast to maintain gentle posterior loading, prevent posterior tibial subluxation.

• Lateral radiograph to verify tibiofemoral reduction.

• Vascular consultation indicated.

• Operative repair considered in athletic patients.

Chronic Injuries

• Patients with severe muscle atrophy require preoperative rehabilitation, patient education before consideration of reconstruction.

• Appropriate grafts for cruciate procedures determined preoperatively.

At 7 days, the cylinder cast is split into an anterior and a posterior shell (Fig. 24-10) and the therapist assists the patient with ROM from 0° to 90° in a figure-of-four position (Fig. 24-11) with the hip joint externally rotated to protect the healing medial tissues, described in detail in Chapter 41, Prevention and Treatment of Knee Arthrosis. This protected ROM program is taught to the patient and performed three to four times a day. The split-cylinder cast protection in extension is maintained for 3 weeks, followed by a soft hinged brace. The rehabilitation and crutch-weaning program is detailed in Chapter 25, Rehabilitation of Medial Ligament Injuries. It must be stressed that the senior author has commonly encountered knees referred for treatment in which a complete SMCL injury (and partial-to-complete POL injury) was treated with a soft functional brace in which the golden period of the first few weeks after the injury was lost. A residual symptomatic increased medial joint opening and external tibial rotation required a chronic medial and posteromedial reconstruction.

FIGURE 24-10 A cylinder cast split into an anterior and a posterior shell to allow the patient to perform range of motion exercises.

FIGURE 24-11 Flexion overpressure exercise in a figure-of-four position.

It is possible to treat almost all medial ligament injuries (with or without concomitant ACL ruptures) using this conservative stick-down program. Operative treatment is recommended for select cases, as discussed next. A displaced meniscus tear on MRI would indicate the necessity to perform a meniscus repair. When there is an associated ACL tear, an ACL reconstruction is performed at an elective time, or under ideal conditions (minimal swelling, early motion), an ACL procedure is performed along with the meniscus repair. In high-performance athletes with gross disruption of the SMCL and POL (with or without ACL tear), the senior author prefers to perform an anatomic repair to restore anatomic continuity and function. In addition, in these gross medial disruptions, the repair of the medial meniscus attachments is always required. In select knees with acute SMCL, POL, and ACL injuries, the medial meniscus may be partially dislodged from the joint, and the distal SMCL so extensively displaced or coiled, that there is a reduced chance that protected immobilization would result in functional medial ligament structures (see Fig. 24-9). An example is the illustrative case described later in this chapter. In the authors’ experience, these knees do better with operative repair. A four-strand semitendinosus-gracilis (STG) autograft may be selected if there is an indication to decrease the morbidity of a bone-patellar tendon-bone (B-PT-B) autograft. The authors prefer an autograft over allografts for reasons discussed in detail in Chapter 7, Anterior Cruciate Ligament Primary and Revision Reconstruction: Diagnosis, Operative Techniques, and Clinical Outcomes.

FIGURE 24-9 Magnetic resonance imaging (MRI) demonstrates extensive damage to the medial ligamentous structures. The superficial medial collateral ligament (SMCL) is disrupted from its proximal attachment and there is disruption of meniscus attachments and the POL. MRI provides important information on the injury severity. The finding of a coiled lax SMCL, particularly close to an attachment site, is a relative indication for surgery, because immobilization would not be expected to allow for approximation of the SMCL/POL injury. An open operative repair was performed in this athlete, along with an ACL reconstruction.

In select acute PCL tears with gross disruption of the SMCL and POL that do not have excessive soft tissue swelling and edema, the senior author prefers an all-inside arthroscopic PCL reconstruction and open medial repair. These knees have a gross amount of medial joint opening and posterior subluxation; surgical stabilization is preferred in younger active patients. Sedentary patients are treated with the stick-down cast program, with a posterior calf pad added to prevent posterior subluxation (confirmed with a lateral radiograph). An SMCL femoral or tibial avulsion may exist in which operative reattachment is indicated through a limited medial approach.

In knees considered for operative intervention, the knee is rehabilitated for 7 days, motion to 90° is obtained, and early quadriceps muscle function is restored. The joint and extremity soft tissue swelling must not be excessive. A routine venous ultrasound is conducted before surgery. In acute medial injuries, it is usually not necessary to perform an augmentation of the repair (described later for chronic reconstructions), because the suture fixation methods restore ligament continuity and healing after surgery is prompt. These knees are treated with an immediate ROM program as detailed in Chapter 25, Rehabilitation of Medial Ligament Injuries. Proximal medial ligament disruptions with extensive edema and soft tissue swelling are at risk for ectopic calcification and limitation of joint motion in the first 2 to 3 weeks after surgery. Indomethacin (Indocin) treatment is not routinely administered; however, observation is warranted because indomethacin is only effective if given within the early postoperative course.

Chronic Medial and Posteromedial Ruptures

Patients with chronic knee injuries that present with severe muscle atrophy require preoperative rehabilitation and patient education before consideration of surgical reconstruction. Frequently, patients who undergo MCL reconstruction (Fig. 24-12) require a concomitant ACL or PCL reconstruction. The appropriate grafts for the cruciate procedures should be determined, as detailed in separate chapters, and autogenous tissues are preferred. However, the surgeon should ensure that B-PT-B and Achilles tendon–bone allografts are available in multiligament reconstructions if needed and advise the patient of this possible choice.

FIGURE 24-12 Surgical algorithm.

INTRAOPERATIVE EVALUATION

All knee ligament subluxation tests are performed after the induction of anesthesia in both the injured and the contralateral limbs. The amount of increased anterior tibial translation, posterior tibial translation, lateral joint opening, medial joint opening, and external-internal tibial rotation is documented. With ACL and/or SMCL/POL disruptions, the lower portion of the bed is flexed and flexion of the knee is performed as required for the arthroscopic and open approaches (Fig. 24-13A). A leg holder is used for the initial arthroscopic and meniscus procedures and then removed. An alternative approach used in multiligament and PCL disruptions is to position the lower extremity with the foot in an Alvardo holder or thigh post and foot rest to allow the desired amount of knee flexion during surgery (see Fig. 24-13B). The arthroscopic pressure is maintained at a low setting with adequate outflow at all times to prevent fluid extravasation and popliteal and calf swelling, which is documented throughout the case. A thorough arthroscopic examination is conducted, documenting articular cartilage surface abnormalities and the condition of the menisci. It is rare to have the complication of fluid extravascation if these precautions are taken; however, if extravascation occurs, an open approach is used throughout the remainder of the procedure.

FIGURE 24-13 A, Initial operating room setup and patient positioning. Use of a thigh holder to achieve tibiofemoral joint opening, particularly for meniscus repairs. The thigh holder is removed after the arthroscopic procedure. The foot of the bed is placed at 30° flexion and a soft support is placed under the proximal thigh for the operative approach. B, In multiligament injuries, the preferred position is shown, allowing knee flexion to be controlled during the procedure as required for ACL or PCL arthroscopic reconstruction. The medial ligament repair/reconstruction is performed with the knee at 15° to 30° of flexion and a soft tissue pad beneath the thigh.

Medial and lateral tibiofemoral gap tests are done during the arthroscopic examination. The knee is flexed to 30° and a varus and valgus load of approximately 89 N applied. A calibrated nerve hook is used to measure the amount of lateral and medial tibiofemoral compartment opening. Knees that have 12 mm or more of absolute joint opening at the periphery of the medial or lateral tibiofemoral compartment indicate gross disruption of all the ligament structures. An absolute opening of 10 mm (∼7 mm increase over the contralateral limb) also indicates significant injury to the SMCL and PMC and, along with increased external tibial rotation, may represent a problem for athletic patients in twisting and cutting activities.

Appropriate arthroscopic procedures are performed as indicated including meniscus repairs or partial excision, débridement, and articular cartilage procedures.

Operative Treatment

Acute Medial and Posteromedial Ligament Repairs

The key to the operative procedure is a thorough understanding of the medial anatomy (see Figs. 24-1 to 24-224-3), because the integrity and injury to the SMCL, POL, semimembranosus attachments, and meniscus attachments (DMCL) need to be identified. The goal is to restore normal anatomy and function of all of these structures. The surgical dissection uses a layered approach⁴⁵ following the description provided in Chapter 1, Medial and Anterior Knee Anatomy (Fig. 24-14).

FIGURE 24-14 Medial layers of the knee. The gracilis and semitendinosus lie between layers 1 and 2.

Critical Points OPERATIVE TREATMENT

Acute Medial and Posteromedial Ligament Repairs

• Integrity, injury to SMCL, POL, semimembranosus attachments, meniscus attachments (DMCL) identified.

• Operative steps outlined in TABLE 24-3.

• Tourniquet used for initial exploration, then deflated during repair procedure.

• Limited cosmetic incision along the anteromedial aspect of the tibia preferred.

• First goal: restore normal anatomy, attachment sites.

• Second goal: perform meticulous anatomic repair of sufficient strength to allow immediate knee motion.

TABLE 24-3 Operative Steps for Acute Medial Ligamentous Ruptures

1 Use a limited medial approach, dissect skin flaps beneath fascia and not in subcutaneous tissue to preserve blood supply to overlying skin. 2 Approach carefully avoids superficial nerve structures, protects infrapatellar nerve branches to limit postoperative neuroma or loss of cutaneous sensation. 3 Incision anterior sartorial fascia extending from adductor tubercle to anterior border of SMCL, identify pes bursae, posterior retraction of pes tendons. 4 Limited medial dissection at site of injury, but not beyond, with preservation of vascular and nerve supply. 5 Identification of site of SMCL tear preoperatively on MRI and confirmation at surgery including medial patellofemoral ligament, which may require repair. 6 Identification of site of PMC tear on MRI and operatively using anatomic attachments shown in Figures 24-2 and 24-3. There may be interstitial tear or disruption at femoral or tibial attachments. 7 Identification of semimembranosus attachments and particularly tears at POL, meniscus attachments. 8 Identification of deep MCL and meniscal attachments requiring repair. 9 Appropriate repair of all disrupted structures using nonabsorbable and absorbable sutures to decrease overall suture load. Initial repair proceeds deep to superficial with meniscus attachments meticulously first repaired, usually by suture anchors. 10 SMCL repairs performed next to provide stable medial column. Repair frequently requires baseball-type sutures fixed to suture post at attachment site, which provides high-tensile strength for immediate postoperative motion. Avulsion at femur or tibia fixed by screw and soft tissue washer. Suture anchors may be used to supplement repair. 11 Avoid shortening SMCL at tibial attachment site by fixation too proximal, goal is to restore normal anatomic attachment locations. 12 Avoid placement of tibial staples or other large metallic fixation devices, which frequently are painful and require subsequent repeat surgery. 13 POL repair performed next, frequently requires suture anchor fixation at respective tear site. Anterior portion of POL sutured to posterior SMCL after femoral or tibial attachment repaired. Avoid constraint to full knee extension, which is tested after POL repair. 14 Perform final full knee extension and flexion at operative table to make sure that suture fixation of all soft tissue structures has not constrained normal joint motion. 15 Medial patellofemoral ligament and retinaculum closed with knee at 20°, avoiding overtensioning with normal lateral patellar glide of approximately one quadrant (25% patellar width) to avoid “capture” of patellofemoral joint and limited knee flexion. 16 Close partial fascia over SMCL, medial repair. 17 Meticulous hemostasis and closure of dead spaces beneath skin flaps to avoid hematoma. 18 Routine closure, double compression bandage with cotton, ice bladder, soft-hinged postoperative brace.

MCL, medial collateral ligament; MRI, magnetic resonance imaging; PMC, posteromedial capsule; POL, posterior oblique ligament; SMCL, superficial medial collateral ligament.

Chronic Medial and Posteromedial Ligament Repairs

• Operative steps outlined in Table 24-4.

• Use remaining SMCL as a part of the reconstruction by femoral or tibial advancement based on the site of the prior tears.

• Augment the SMCL reconstruction with semitendinosus-gracilis tendons.

• Bone-patellar tendon-bone allograft used when no remaining medial ligamentous tissues are present.

• In most knees, the POL can be reattached to a prior disrupted femoral or tibial site and plicated as necessary to the posterior edge of the SMCL graft.

TABLE 24-4 Operative Steps for Chronic Medial Ligamentous Ruptures

1 Follow initial exposure steps provided in TABLE 24-3. 2 Identify integrity and tissue quality of remaining SMCL with goal of advancing SMCL tissue at femoral or tibial attachment site to restore its length and use remaining SMCL in reconstruction (possible in most cases unless replaced with poorly organized scar tissue, in which complete graft replacement SMCL and POL arm indicated). 3 Place incision along anterior POL border, just posterior to SMCL fibers. Confirm femoral, tibial attachments intact or require reattachment. 4 Identify semimembranosus, attachments, need for reattachment or repair. 5 Place incision along anterior border of SMCL, identify meniscus tibial and femoral attachments. 6 Perform SMCL advancement based on prior disruption. In rare cases in which complete graft replacement is required, proceed with identification of anatomic and confirm isometric femoral and tibial attachments and graft reconstruction. 7 For proximal disruptions, incise VMO border and attachment site and lift VMO in proximal direction. Preserve muscle attachment for later closure. Identify femoral SMCL attachment, osteotomize, and advance femoral SMCL insertion in line of fibers at 30° flexion. 8 For distal advancement, place fixation distal to normal attachment site in order not to shorten SMCL length. It will be first necessary to reattach meniscotibial attachments with suture anchors. Arthroscopy prior to procedure indicates need for meniscus peripheral repair based on proximal-distal meniscus displacement. 9 PMC advancement procedures performed with nonabsorbable sutures, suture anchors to femoral or tibial attachment site to resuspend structures. Only rarely is augmentation graft necessary to restore central POL arm 10 PMC plication procedures performed when capsular attachments to femur and tibia are intact and goal is to remove redundancy. Plication to posterior portion of SMCL accomplishes goal of restoring normal PMC tension as knee approaches extension. 11 Combined MCL advancement with STG autograft reconstruction is senior author’s choice. Allograft reconstruction used when STG not available. Harvest STG with closed-end tendon stripper, leave tibial attachment intact. At femoral site, locate STG at posterior and anterior border of SMCL using four-pronged staple (plus proximal SMCL advancement) or with femoral tunnel (distal SMCL advancement) when femoral attachment not disturbed. STG tendon is sutured to anterior and posterior aspect of SMCL. 12 Severe loss of all medial tissues requiring complete SMCL replacement treated with long B-PT-B allograft for secure bone fixation at tibial and femoral attachments. Alternative option is Achilles tendon–bone allograft reconstruction with bone placed at femoral attachment and collagenous portion of graft at tibial attachment. 13 Careful adjustment of medial patellofemoral ligament and medial retinaculum at 30° knee flexion to restore normal tension and allow normal lateral patellar glide. 14 Closure as detailed in TABLE 24-3.

B-PT-B, bone–patellar tendon–bone; MCL, medial collateral ligament; PMC, posteromedial capsule; POL, posterior oblique ligament; SMCL, superficial medial collateral ligament; STG, semitendinosus-gracilis; VMO, vastus medialis obliquus.

Before surgery, the operative extremity is signed by the patient and surgeon with nursing personnel present. A time-out is performed with the patient’s name, procedure, allergies, preoperative antibiotics, special precautions given and agreed upon by the surgeon, anesthetist, and nursing personnel.

The operative steps are outlined in TABLE 24-3. It is important to perform a careful limited dissection to avoid further disruption of the neurovascular supply of tissues (Fig. 24-15). Based on preoperative MRI and limited medial dissection, it is possible to identify the tear site of most of the soft tissue structures for the operative repair. A tourniquet is used for the initial exploration and then deflated during the repair portion of the procedure. A limited cosmetic incision along the anteromedial aspect of the tibia provides good exposure for both ACL and medial repairs and is favored over a two-incision approach (Fig. 24-16).

FIGURE 24-15 Surgical plication procedure for POL. A, Identification of laxity and redundant POL that involves all three components. In the majority of knees, there will exist concurrent laxity of the SMCL, which also requires surgical reconstruction as described (not shown). B, Incision into the POL just behind the SMCL, avoiding the medial meniscus tibial attachments. C, Suture plication vest-over-pants technique to restore tension in the POL, performed at 20° flexion in order to avoid overtensioning that would limit full knee extension.

FIGURE 24-16 A and B, Cosmetic skin incision of the knee joint in an expert skier, 6 months after bone–patellar tendon–bone (B-PT-B) ACL autograft and SMCL, POL, and displaced medial meniscus repair followed by an immediate motion program. In this knee with a gross medial disruption and a medial meniscus that was displaced into the joint, the decision was made to proceed with a combined arthroscopic and open repair of all structures. An ACL autograft (semitendinosus-gracilis [STG], B-PT-B) reconstruction is preferred over an allograft.

During the initial dissection, an incision is made into the sartorius fascia just anterior to the SMCL and the fascia and pes tendons are reflected posteriorly to allow identification of the medial structures. The tear site of the SMCL is usually easily identified. However, it may be more difficult to recognize the tear site for the PMC capsular arms referred to as the POL divisions (see Fig. 24-2). There may be interstitial tearing of capsular tissues without a definite tear, or the POL may be torn off its femoral or tibial attachment, requiring reattachment. The first goal is to restore normal anatomy. The SMCL, POL, and meniscus sutures are placed to restore anatomic attachment sites. The POL is closed at 10° to 15° of flexion, and the knee is taken to full extension to ensure the sutures are not overtensioned to constrain knee extension and produce a flexion contracture.

The second goal is to perform a meticulous anatomic repair of sufficient strength to allow immediate knee motion following the protocol provided in Chapter 25, Rehabilitation of Medial Ligament Injuries. Numerous ligament fixation devices are available, and a low-profile screw and soft tissue washer or four-prong staple and screw are favored, along with suture anchors. Standard baseball locking sutures of two to three throws are sufficient to tension soft tissues using a combination of nonabsorbable and absorbable sutures. On occasion, the medial ligament disruption is so extensive that it is necessary to perform an augmentation graft for the SMCL and PMC (POL division B; see Fig. 24-2) following the techniques outlined in a chronic medial reconstruction with either an STG autograft or allograft approach, as discussed next.

Chronic Medial and Posteromedial Ligament Repairs

The operative steps are the same as outlined for acute medial repairs in terms of the initial surgical approach and dissection. The specific additional steps are provided in Table 24-4.

In Figure 24-16, the cosmetic medial skin incision is shown for a patient who had a combined ACL and MCL reconstruction. The standard ACL skin incision is extended proximally to provide adequate exposure for the medial ligament procedure. One of the principles followed is to use the remaining SMCL as a part of the reconstruction by femoral or tibial advancement based on the site of the prior tears. The meniscus attachments medially may require appropriate suture fixation to restore the meniscotibial attachment, with distal SMCL advancement. The second principle is to augment the SMCL reconstruction with STG tendons, which is usually required. The STG tendons are tensioned based on isometric length-tension behavior with knee flexion-extension at surgery.

Following the operative principles outlined in Table 24-4, an example of a distal SMCL advancement supplemented with an STG reconstruction for chronic MCL deficiency is shown in Figure 24-17. In Figure 24-18, a more complex medial reconstructive procedure is shown that involved extensive repair of the meniscus attachments and STG tendon reconstruction of both the SMCL and the PMC (POL). The operative procedure provides sufficient strength to allow immediate knee motion postoperatively to lessen the risk of a joint contracture. These procedures involve extensive postoperative rehabilitation, which is described in Chapter 25, Rehabilitation of Medial Ligament Injuries. In Figure 24-19, a proximal advancement of the SMCL and PMC capsular plication are shown; this knee did not require augmentation with an STG graft. In Figure 24-20, the use of a B-PT-B allograft is shown for severe cases of chronic medial ligament disruption. This operative technique is reserved for cases in which no remaining medial ligamentous tissues are present. In most chronic medial ligament injuries, it is possible to use the remaining SMCL and PMC in the reconstructive procedure, and this graft is not required. The Achilles tendon is an alternative allograft, with the bone portion placed at the native SMCL femoral attachment and the full-thickness tendon fixed by a screw and soft tissue washer with additional baseball sutures at the native tibial attachment. The correct attachment points for the SMCL graft are at the native femoral and tibial attachments. If there is any question, the graft attachment is verified by placing a K-wire at the femoral site, attaching suture to the tibial site, and taking the knee through a full ROM. The POL is reattached to its native femoral or tibial site when disruption has occurred. For capsular redundancy, a plication procedure is performed to the posterior edge of the SMCL graft, which provides the stable medial column for the capsular reconstruction.

FIGURE 24-17 Demonstration of distal advancement of SMCL with STG reconstruction for chronic MCL insufficiency. A, The SMCL is dissected at its distal attachment and proximally to the joint. Arthroscopic examination showed that the medial meniscus attachments would be restored by reattachment of the meniscus tibial attachments, which was performed (not shown). B, Distal SMCL advancement supplemented with nonabsorbable baseball sutures through the distal SMCL to provide secure fixation. A plication of the PMC to the posterior edge of the SMCL has been performed. The STG tendons are passed through a small-diameter tunnel just posterior and anterior to the SMCL and sutured to the SMCL. The utilization of the prior SMCL provides for additional joint stabilization, allowing immediate protected knee motion.

FIGURE 24-18 A 22-year-old female elite soccer player referred for treatment for giving-way episodes on cutting movements after a prior partial ACL and complete disruption of the SMCL treated conservatively. There was a negative pivot shift and Lachman test; however, there was 12 mm of medial joint opening at 30°, 5 mm of medial joint opening at 0°, and 10° of increased external tibial rotation on the dial test. A and B, Demonstration of the valgus test at surgery with medial joint opening confirmed on arthroscopic examination. C, On surgical exploration, the medial meniscus attachment to the tibia required repair. The proximal SMCL was intact; however, the distal SMCL attachment was the site of the prior disruption. D, STG tendons left attached distally and advanced to reconstruct the posterior portion of the POL, placed through a femoral tunnel from posterior-to-anterior and brought along the anatomic course of the SMCL.

FIGURE 24-19 Demonstration of chronic medial ligament disruption treated with a proximal advancement of SMCL and PMC capsular plication. A, On initial exploration, the overlying sartorius retinaculum is split to expose the SMCL. An incision at the anterior border shows SMCL fibers, somewhat thickened, but without scar tissue replacement and suitable for an advancement procedure. If there is any question as to the integrity or future function of the SMCL, an STG graft is added, which is usually required, but not necessary in this case. B, The vastus medialis obliquus (VMO) attachment is incised and reflected proximally with dissection carried beneath the muscle without entering the knee joint. Osteotomy of the proximal SMCL attachment is performed. C, The SMCL with a 20- x 20-mm proximal bone attachment. Further inspection of the SMCL confirms that it is of a normal appearance with healthy collagen fibers and a tendon augmentation is not needed. The meniscus tibial attachments are intact and do not require fixation. D, Proximal fixation of the SMCL with screw and washer. The POL is shown and has been dissected to prove its proximal and distal attachments are intact.

FIGURE 24-20 Demonstration of the use of a long B-PT-B allograft for a severe medial ligament disruption in which no remaining SMCL was present. The bone portions of the graft are placed as an inlay on the femur and as an onlay on the tibia and fixated with cancellous and small fragment screws, respectively. A POL plication was performed (see Table 24-4 for operative steps).

COMPLICATIONS

The most frequent complication of medial and posteromedial ligament surgery relates to the approximately 25% of operated knees that will have initial limitations in regaining normal flexion and extension. It is necessary at surgery not to overtighten the POL plication or repair. The repair is performed at 10° to 15° of flexion, and the knee is taken to full extension at the end of the procedure. The SMCL augmentation or replacement is fixated at native femoral and tibial attachments and not overtensioned in order not to constrain the knee joint. The treatment of knee motion limitations, principles of patellofemoral mobilization, and muscle rehabilitation exercises are covered in detail in Chapter 25, Rehabilitation of Medial Ligament Injuries.

The authors use a 5-day course of maximum-dose nonsteroidal anti-inflammatory medication, which is begun the night before surgery. A firm double compression wrap and cotton dressing, ice delivery system, and elevation are used for the 1st week after surgery. Patients are carefully examined preoperatively and postoperatively for deep venous thrombosis, with ultrasound used on all acutely injured knees before surgery and postoperatively if warranted. After surgery, patients use calf compression venous return devices, and ankle pumps are performed hourly.

The complication of infection is rare with the use of preoperative intravenous antibiotics at appropriate doses, careful handling of tissues, and other precautions as detailed in Chapter 7, Anterior Cruciate Ligament Primary and Revision Reconstruction: Diagnosis, Operative Techniques, and Clinical Outcomes.

AUTHORS’ CLINICAL STUDY

A prospective study was conducted to determine the outcome of 46 knees with acute ACL-MCL ruptures in which all patients received an ACL reconstruction and either conservative or operative management of the medial ligament injury, based on the extent of the injury.³⁰ The inclusionary criteria were a complete rupture of the ACL, rupture to a portion or all of the medial ligamentous structures, no rupture to the other knee ligaments, and reconstruction performed within 10 weeks of the original knee injury.

Group I comprised 34 patients who sustained a complete rupture to all of the medial ligament structures (SMCL and PMC), which were repaired at the time of ACL reconstruction. There were 14 male and 20 female patients, mean age of 26 years (range, 13–51 yr), all but 3 of whom were injured during athletic activities. Surgery was delayed for at least 7 days in all patients to allow initiation of quadriceps muscle and ROM exercises and resolution of knee pain and effusion. All patients were treated with an irradiated ACL allograft, because this graft source was under prospective investigation at the authors’ center at the time of this study. All patients completed questionnaires from the CKRS a mean of 69 months (range, 24–107 mo) postoperatively, and all but 1 returned for a comprehensive clinical evaluation.

Group II comprised 12 patients who sustained a complete rupture to the SMCL only. The PMC structures were considered functional, because little to no increase was demonstrated in medial joint space opening on clinical valgus stress testing at 0°. There were 7 male and 5 female patients, with a mean age of 21 years (range, 16–33 yr), and all but 1 sustained the injury during sports activities. These patients underwent an initial nonoperative treatment program of at least 4 weeks of protection from valgus joint loads in a hinged knee brace locked at 0° of extension. The brace was removed three to four times a day for knee motion and exercises. After a period of rehabilitation of the medial ligament injury, an ACL reconstruction was performed. All of these patients completed questionnaires from the CKRS a mean of 50 months (range, 28–68 mo) postoperatively, and all but 1 returned for a comprehensive clinical evaluation.

In group I, a direct repair of the ruptured MCL was performed with two to four baseball-type sutures either to internally fixate the disrupted ligament back to the insertion site or to approximate the ligament ends. The sutures were tied over a soft tissue washer or staple. The capsular tissues were also repaired using multiple sutures. In 2 patients, the midsubstance rupture of the MCL was so severe that a semitendinosus autograft was incorporated into the repair.

Meniscus tears were common in both groups of patients, occurring in 23 patients (68%) in group I and in 11 patients (92%) in group II. The lateral meniscus was torn in 61% of the knees and the medial meniscus was torn in 33%. In group I, the medial meniscus was repaired in 12 knees and the lateral meniscus was repaired in 7 knees using techniques described in Chapter 28, Meniscus Tears, Diagnosis, Operative Techniques, and Clinical Outcomes.^38,39 Thirteen other lateral meniscus tears required partial resection. In group II, the medial meniscus was repaired in 3 knees and the lateral meniscus was repaired in 6 knees. Four other lateral meniscus tears required partial resection.

At follow-up, no patient in either group had more than 2 to 3 mm of increase in medial joint space opening (TABLE 24-5). Moderate patellofemoral crepitus was detected in 7 patients in group I and severe crepitus was found in 1 patient. One patient in group II had moderate patellofemoral crepitus. The crepitus was symptomatic with sports activities in 2 of these 9 patients. The ACL reconstructions were rated (based on knee arthrometer and pivot shift testing) as normal in 61% in group I and in 82% in group II; nearly normal in 21% in group I and in 18% in group II; and failed in 18% of group I.

Before the injury, all patients except 1 were participating in sports activities (TABLE 24-6). At follow-up, all except 3 patients in group I had returned to athletics, although over half had returned to a lower level of participation. No patient in either group had problems with walking or stair climbing. However, 7 patients in group I had significant difficulty squatting or kneeling. More patients in group I had swelling and pain with sports activities than those in group II (Fig. 24-21).

FIGURE 24-21 The postoperative distributions of swelling and pain scores are shown. Scale: 0, severe symptoms with activities of daily living; 2, moderate symptoms with activities of daily living; 4, no symptoms with activities of daily living but symptoms with sports; 6, no symptoms with swimming or cycling but symptoms with other sports activities; 8, no symptoms with running, twisting, or turning, but symptoms with jumping, hard pivoting, or cutting; 10, no symptoms with jumping, hard pivoting, or cutting.

(From Noyes, F. R.; Barber-Westin, S. D.: The treatment of acute combined ruptures of the anterior cruciate and medial ligaments of the knee. Am J Sports Med 23:380–391, 1995.)

The overall rating scores for group I, based on the CKRS, were excellent in 2 patients, good in 17, fair in 7, and poor in 7. Therefore, 58% in this group were rated as excellent or good, and 42% were rated as fair or poor. For group II, the overall ratings were excellent in 1 patient, good in 9, and fair in 1. Therefore, 91% in this group were rated as excellent or good, whereas 9% were rated as fair.

In this investigation, 74% of the patients sustained meniscus tears and 20% had noteworthy articular cartilage deterioration, and therefore, the results should not be compared with those of isolated ACL reconstruction studies. At an average of 5 years postoperatively, no patient demonstrated more than 2 to 3 mm of increase in medial joint opening at either 0° or 25° of knee flexion. Healing was therefore demonstrated in both the surgically repaired complete medial ligament disruptions and the conservatively treated knees with SMCL disruption.

The rehabilitation program and early treatment of knee motion limitations successfully restored at least 0° to 135° of knee motion in 96% of the patients. The treatment program of knee motion limitations, described in Chapter 41, Prevention and Treatment of Knee Arthrofibrosis, was instituted in 24% of the knees (26% of group I and 17% of group II). This program is most successful if begun early postoperatively, as early as 3 to 4 weeks if the initial motion goals have not been obtained. Patients with ruptures at or proximal to the medial joint line had a higher incidence of motion complications (7 of 15 patients, 47%) than those with ruptures located distal to the joint line (2 of 18 patients, 11%). Similar findings were reported by Robins and associates.³⁴

The strict overall rating system used in this investigation resulted in 14 patients receiving a fair or poor score. Seven of these 14 patients received this rating, in part, owing to failure of the ACL allograft and the authors advocate autogenous B-PT-B grafts for ACL reconstruction. At the time of the study, the authors used irradiated allografts, and as discussed in Chapter 7, Anterior Cruciate Ligament Primary and Revision Reconstruction: Diagnosis, Operative Techniques, and Clinical Outcomes, the irradiation process appeared to increase the rate of failure compared with other studies in which fresh-frozen allografts were selected. Patellofemoral joint symptoms accounted for the low ratings in 4 knees, and postoperative motion complications accounted for the ratings in 3 knees. This study was also conducted at a time in which complete disruptions of ACL and medial ligaments were more often treated by operative intervention.

The results of this study, along with other investigations,^{4,27,29,32,43} promoted a worthwhile reevaluation of the operative recommendation for combined ACL and medial ligament injuries, resulting in the conservative recommendations in this chapter, which have now been used for many years.

RESULTS FROM OTHER CLINICAL STUDIES

Since the early 1990s, several studies have been published that presented various treatment options and outcomes for isolated MCL injuries and combined ACL-MCL ruptures. As shown in Tables 24-7 and 24-8, the severity of the medial ligamentous injuries varies and, in many instances, is difficult to interpret owing to both the ambiguous terminology used to describe the degree or grade of the injury and the lack of data on the estimated (or measured) millimeters of medial joint opening at both 30° and 0° of knee flexion before and after treatment. Even fewer investigators use stress radiography to objectively measure medial joint opening before and after treatment. Therefore, the exact structures that are ruptured (and those that remain intact) in most studies are unknown. Future investigations should provide these data to enable clinicians to understand the exact anatomic structures involved and form rationale treatment decisions regarding which structures require operative restoration and the appropriate timing of those procedures.

In knees with combined ACL-MCL ruptures, additional problems in the published literature arise from the wide variety of treatment methods proposed and compared, including

The majority of clinical studies that have described the outcome of operative management of SMCL ruptures used primary suture repair procedures, some of which were combined with advancement of the PMC, for acute knee injuries.^{2,3,12,14,17,19,34,40} Only two series to date described the use of a graft to reconstruct chronic SMCL ruptures; both involved knees with multiligament injuries. Yoshiya and colleagues⁴⁶ followed 24 patients who underwent an STG SMCL reconstruction. The SMCL ruptures were classified as having gross medial instability with no firm endpoint. It is noted in this study that preoperative valgus stress radiographs measured only a mean of 4.1 mm (range, 3–6 mm) of increased medial joint opening and, therefore, it would appear that these knees would be in the category in which conservative treatment is usually recommended. Twelve patients had a concomitant ACL reconstruction, 7 had a concomitant PCL reconstruction, and 3 had a concomitant bicruciate reconstruction. At an average of 27 months postoperatively, stress radiographs revealed a mean of 0.2 mm (range, –1–+2 mm) increase in medial joint opening. The authors cautioned that, although the procedure was effective, it restored only the anterior longitudinal portion of the SMCL.

Fanelli and Edson⁹ described a procedure to reconstruct the SMCL in patients with “high-grade” SMCL ruptures using either an Achilles tendon allograft or a semitendinosus tendon autograft. The millimeters of increased medial joint opening at 0° and 30° of flexion that were present before surgery were not provided. The PMC was advanced and sutured into the graft. In a small series of 7 patients followed 2 to 10 years postoperatively, no increase was noted on manual valgus testing at 30° of knee flexion.

Halinen and coworkers¹⁴ published to date the only study of acute grade III medial ruptures (defined by the authors as > 10 mm increase in medial joint opening at 25° of flexion and a “subtle” increase at 5° of flexion) that were randomized to either a primary repair or a conservative management group. All 47 patients in the study also had complete ACL ruptures, which were reconstructed with a B-PT-B autograft. The reconstructions were performed between 4 and 23 days after the injury. At follow-up, a mean of 27 months postoperatively, stress radiographs (25° flexion) revealed a mean increase in medial joint opening of 0.9 mm (range, –0.8–+3.6 mm) in the SMCL operatively treated group, and 1.7 mm (range, –0.5–+6.4 mm) in the SMCL conservatively treated group. The authors concluded the SMCL ruptures do not require operative treatment when a concomitant ACL rupture is reconstructed early after injury.

Conservative management of SMCL ruptures has been recommended by many authors following the early investigations of Ellsasser and associates⁸ and Fetto and Marshall.¹¹ Ellsasser and associates⁸ reported successful management of isolated MCL injuries in athletes with nonoperative treatment as long as there were no other ligament or meniscus injuries and the knees were stable to valgus stress testing in full extension after the injury. Fetto and Marshall’s series¹¹ included patients with medial joint opening in full extension (termed grade III), and the authors noted that 80% of grade III medial ruptures had concomitant cruciate ligament damage. An excellent or good result in these knees was related to the recovery of ACL stability and not to residual medial joint opening. Many subsequently published studies verified the importance of an intact or reconstructed ACL in the successful nonoperative management of SMCL ruptures.^{4,15,18,23,24,26,27,32,43}

The question of the appropriate timing of ACL reconstruction in knees with concomitant SMCL tears has been addressed by a few investigations. Millett and colleagues²⁷ followed 18 patients who had an ACL reconstruction (B-PT-B or STG autograft) performed a mean of 7.5 days (range, 0–20 days) after an acute ACL-MCL injury. Seven patients had a grade II SMCL injury (5–10 mm medial joint opening at 30° flexion) and 12 had a grade III injury (>10 mm at 30° flexion). Postoperatively, the patients were kept in a brace to protect from excessive valgus loads. At follow-up, a mean of 45 months postoperatively, no valgus instability (at 30° flexion) or positive pivot shift test was detected in any patient. One patient required an arthroscopic procedure for arthrofibrosis. The authors did not provide data regarding the number of patients who returned to preinjury levels of activity or symptoms and functional limitations. They concluded that early ACL reconstruction did not increase the risk of complications, but acknowledged that it is unknown whether this treatment strategy provides superior results over those from a delayed ACL reconstruction approach.

Peterson and Laprell³² found a higher incidence of knee motion complications and poorer subjective scores in knees that underwent early ACL reconstruction (1–21 days after injury) compared with those in whom the ACL reconstruction was delayed (10–12 wk after injury). All patients in their series received a B-PT-B autograft and all had a grade III medial ligament rupture (defined as a positive valgus stress test without an endpoint). Postoperative rehabilitation included no brace in the ACL delayed group, a brace in the early ACL group with limits set from 0° to 100°, full weight-bearing within 1 week for all patients, and intensive therapy training for 2 to 3 months. The authors did not provide preoperative data on muscle strength or range of knee motion for either group. Speculation was made that the motion limitations were due to the postoperative brace worn in the early ACL group, although the amount of time the brace was worn was not provided.

Shelbourne and Patel⁴² reported that patients with acute combined ACL-SMCL ruptures treated with only ACL reconstruction had more rapid return of knee motion and muscle strength than those treated with ACL reconstruction and SMCL repair. However, 6 of the 13 knees in the combined ACL-SMCL repair group underwent 6 weeks of casting postoperatively whereas the remainder of the knees in the series initiated continuous passive motion on the 3rd postoperative day. The authors did not assess the effect of casting on the study’s outcome. In addition, the severity of the SMCL ruptures was unknown, as no data were provided on the millimeters of medial joint opening at either 30° or 0° of knee flexion before or after surgery. The authors later recommended that all MCL injuries be treated conservatively, regardless of the severity of the injury.⁴²

ILLUSTRATIVE CASE

Case 1

Acute Combined ACL, SMCL, POL Ligament Disruption with Dislodged Bucket-Handle Lateral Meniscus Tear in the Femoral Notch

A 16-year-old male sustained a twisting injury to his left knee while water skiing. He was evaluated 5 days after the injury. MRI showed a coiled, disrupted distal MCL rupture, meniscotibial attachment tears, a displaced lateral meniscus within the femoral notch, and an ACL midsubstance rupture (Fig. 24-22A). The physical examination showed 10 mm of increased medial joint opening at 30° of flexion and 5 mm increase at 0°, a positive Lachman test, and a grade III pivot shift test. Surgery was indicated to reduce and repair the lateral meniscus bucket-handle tear. Because the patient had minimal swelling, restoration of motion, and early return of quadriceps function, the decision was made to proceed with a combined ACL-MCL reconstruction.

FIGURE 24-22 Illustrative case, acute combined ACL-SMCL, POL ligament disruption with dislodged bucket-handle lateral meniscus tear in the femoral notch, see text.

Under anesthesia, the increases in medial joint opening and external tibial rotation were noted (see Fig. 24-22B), along with a positive Lachman test (see Fig. 24-22C). The operative setup allowed for full flexion and extension, with a leg holder used initially for the lateral meniscus repair (see Fig. 24-22D). At arthroscopy, the tearing of the meniscotibial attachments and a 12-mm increase in the medial gap test were noted. The meniscus had a normal relationship with the femoral condyle, indicating a distal attachment tear (see Fig. 24-22E). The lateral meniscus was displaced into the notch, which was reduced and repaired with multiple vertical divergent sutures placed with an inside-out technique through an accessory posterolateral incision (see Fig. 24-22F). An ACL four-strand STG reconstruction was performed using a two-incision technique to achieve anatomic central tibial and femoral attachment locations (see Chapter 7, Anterior Cruciate Ligament Primary and Revision Reconstruction: Diagnosis, Operative Techniques, and Clinical Outcomes). The distal ACL attachment was fixed after the MCL repair (see Fig. 24-22G).

The medial exploration through the medial incision showed a meniscotibial attachment tear, increased medial joint opening, and disrupted distal SMCL and POL at the tibial attachment (see Fig. 24-22H). The procedure was begun deep with the medial meniscotibial attachment repair using multiple sutures (see Fig. 24-22I). In this case, suture anchors were not required. The entire SMCL and POL tibial attachment sleeve was reattached with three No. 2 baseball sutures placed in the posterior, middle, and anterior portions. A four-prong low-profile staple was used for distal SMCL fixation and as a suture post (see Fig. 24-22J). The combined suture and staple fixation provided secure fixation to allow immediate knee motion (see Fig. 24-22K). The final appearance of the incision is shown in Figure 24-22L, which extended from the midpoint of the patella 10 cm to the point adjacent to the tibial tubercle.