REVIEW ARTICLE
A Review of Surgical and Nonsurgical Outcomes of Medial Knee Injuries Mark P. Smyth, MD* and Jason L. Koh, MDw
Abstract: Medial-sided knee injuries can result in pain, instability, and loss of function. Many clinical studies have been written on the treatment of medial-sided knee injuries; however, the vast majority are isolated case series of surgical or nonoperative treatment regimens, and only a few randomized prospective clinical trials can be found in the literature that compare different treatment modalities. Comparison of these treatments is challenging due to the variety of medial-sided structures that can be involved, the multiple different approaches to treatment, and the variability of how objective and subjective clinical outcomes are reported. In this paper we report on the injuries by extent and type of anatomic structures damaged including partial medial-sided injuries, completed isolated medialsided knee injuries, and combined injuries. In general, most authors concur that isolated partial or complete medial collateral ligament (MCL) injuries can be treated nonoperatively with a brace and early motion with good clinical outcomes. Prospective, randomized trials support nonoperative treatment of the MCL in combined anterior cruciate ligament-MCL injuries. Knee dislocations and posterior medial corner injuries appear to have better results with surgical management including reconstruction. Multiple reconstructive techniques have been described for chronic injuries but it is difficult to compare their results. Key Words: medial collateral ligament, posteromedial corner, MCL repair, MCL reconstruction, knee dislocation
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edial-sided knee injuries can result in pain, persistent instability, and loss of function. However, the nature of these injuries is heterogenous in terms of age, anatomy, pathoanatomy, chronicity, and treatment. Multiple soft tissue structures help to stabilize the medial aspect of the knee. The largest and most identifiable structure is the superficial medial collateral ligament (MCL). It courses from just proximal and posterior to the medial epicondyle and has a broad-based insertion distally in the posterior medial tibia. It is the primary restraint to varus. The deep MCL is a thickening of the medial joint capsule with meniscofemoral and meniscotibial fibers that anchor the medial aspect of the meniscus to bone. The posterior oblique ligament (POL) has 3 bands, the most prominent of which is the central band. The central band of the POL attaches 7.7 mm distal and 6.4 mm posterior to the adductor tubercle on the femur. It attaches distally to the posteromedial aspect of the proximal tibia and it reinforces posteromedial joint capsule. It assists in providing external rotational stability. Finally, the pes tendons and hamstrings assist with stability. The semimembranosus, specifically, aids in stabilize the posteromedial corner of the knee.1 From the *University of Chicago, Chicago, IL; and wNorthShore University HealthSystem, Evanston, IL. Disclosure: The authors declare no conflict of interest. Reprints: Jason L. Koh, MD, NorthShore University HealthSystem, 2650 Ridge Avenue, Walgreen’s 2505, Evanston, IL. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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The complex anatomy of the medial aspect of the knee has led to some difficulty in designing a standardized treatment algorithm of injuries involving these structures. Therefore, outcomes of studies involving the treatment of medial knee injuries, likewise, are difficult to interpret. Many studies report results on the treatment of medial collateral ligament injuries only. Other studies stress the importance of the posteromedial knee structures in restoring valgus and rotatory stability to the knee. When reviewing the literature it is important to clarify exactly what injury pattern is being treated. Some studies report on acute medial collateral ligament injuries, whereas other comment on chronic tears. Further complicating the literature interpretation of medial-sided knee injuries is that they are commonly associated with damage to other ligaments around the knee. Fetto and Marshall2 found an associated ligament injury with a grade III MCL tear in 78.1% of cases, 95% of which were anterior cruciate ligament injuries. In another study, 88% of patients who underwent medial collateral ligament repair were found to have a concomitant ACL rupture.3 Whether in isolation or in combination with other ligament injuries, multiple treatments have been reported in the literature. A wide spectrum of nonoperative protocols as well as surgical repair and ligament reconstruction options have been described, many of which have shown favorable outcomes in terms of stability, return to activity and subjective outcome measures. Unfortunately, most studies are low level of evidence and reported as case series. We reviewed PubMed August 2014 using search terms MCL and medial collateral ligament. In our review of the literature, we only found 3 randomized prospective clinical studies in the literature.4–6 Other confounding variables to the interpretation of outcomes in the lack of standardization in exactly what outcomes are reported (Table 1). Although most studies have some sort of assessment of valgus stability, whether that is medial opening on physical examination, stress radiographs, or subjective stability. However, validated outcome scores such as the Lysholm scale, International Knee Documentation Committee (IKDC) criteria, and Knee Injury and Osteoarthritis Outcome Score (KOOS) are only reported in more recent studies making comparison of outcomes with older reports more difficult. In this review we have chosen to compare outcomes of different studies by categorizing them according to the injury pattern. First, partial medial-sided ligament injuries will be discussed, followed by isolated complete medial injuries, and finally the outcomes of combined medial collateral ligament injuries and combined cruciate injuries will be reviewed.
GRADE I/II MEDIAL COLLATERAL LIGAMENT INJURIES With regard to injuries of the medial side of the knee, the greatest agreement in the literature can be found in the www.sportsmedarthro.com |
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TABLE 1. Variables in Reporting Outcomes of Treatment of Medial Instability of the Knee
Anatomic
Treatment
Outcomes Reporting
Partial medial-sided injuries Nonoperative management Isolated medial-sided injuries Repair vs. reconstruction of Isolated complete medial collateral ligament medial knee injuries injuries Reconstruction techniques for Combined posteriormedial corner and medial medial knee injuries collateral ligament injuries Combined anterior cruciate and medial collateral ligament injuries Chronic medial collateral ligament injuries
treatment of isolated low-grade, partial medial collateral ligament injuries (grade I and II) (Table 2). Most authors have suggested nonoperative treatment for such injuries.2,7–10 In a case series of 38 patients with partial medial collateral ligament ruptures treated with functional bracing and rehabilitation, 74% had regained nearly normal knee function by 3 months and excellent Lysholm functional scores were reported in 33 of 38 patients at 4-year followup. Functional scores were slightly lower at 10 years but remained high with excellent scores in 71% of patients and good to excellent scores in 92%. Thirteen percent of patients had radiographic evidence of early arthritis at 10 years.9 Partial medial collateral ligament injuries are common in the athletic population. Derscheid et al7 found that 51 of 70 knee injuries in college football players were grade I or II medial collateral ligament sprains over a 4-year period. Although these injuries are common in this population, athletes that sustain these injuries are often able to return to the playing field quickly after only a short period of rest and active rehabilitation. In the same study, Derscheid and colleagues found that college football players with grade I partial medial collateral ligament injuries were able to return to full, unprotected participation after an average of 10.6 days of activity lost. Players with grade II injuries were able to return after a mean of 19.5 days lost. Their reinjury rate was 8%, which was equal to the injury rate in their population, so they concluded that there was no increased risk of reinjury with this treatment protocol.7 In summary, partial medial collateral ligament injuries are effectively treated with nonoperative means. Usually this involves a short period of rest and functional bracing. When pain subsides, range of motion is full, and strength returns, athletes are allowed to return to play provided they suffered a true partial medial collateral ligament injury and medial stability has been maintained.
Objective outcomes: valgus stability assessment—Physical examination, stress radiographs Subjective outcomes: subjective stability Validated outcome scores Return to play Reinjury rate
COMPLETE MEDIAL COLLATERAL LIGAMENT DISRUPTIONS (ISOLATED GRADE 3 INJURIES) Complete disruptions of the medial collateral ligament have historically been managed both operatively and nonoperatively; even the nonoperative treatment options have varied greatly from cast immobilization to early motion and functional rehabilitation. In 1980, Hastings reported a treatment protocol for complete isolated medial collateral ligament injuries that involved 2 to 6 weeks of immobilization in plaster, followed by a hinged brace. The majority of their patients were able to return to athletic competition 3 to 4 weeks after the plaster was removed.11 Indelicato12 showed a protocol of 2 weeks of immobilization followed by cast bracing for 4 weeks lead to faster recovery of strength than surgical treatment. However, prolonged immobilization has fallen out of favor, with most modern nonoperative protocols stressing early motion. One such protocol involves range of motion exercises starting on day 1 or 2 after injury, use of a lateral hinged knee brace, and a progressive physical therapy protocol. All of the patients available for follow-up were able to return to full participation and 79% of patients’ felt they had returned to preinjury performance levels. At an average of 5.3 years follow-up, the mean HSS knee score was 45.9, with all patients scoring in the good to excellent range. The reinjury rate in their study was 3%.13 Further support for nonoperative treatment was found in a randomized clinical study published in 1987 of 200 patients with isolated medial collateral ligament tears, isolated anterior cruciate ligament tears, or both. Patients in this study were randomized to conservative versus surgical repair of the injured structures. They found that isolated medial collateral ligament injuries did not benefit from surgical treatment.4
TABLE 2. Summary of Outcome Studies of Partial Medial Collateral Ligament Injuries
References Study Design Derscheid et al7 Kannus et al8 Lundberg et al9
Study Groups
Prospective 51 partial MCL tears in case series college football players Retrospective 54 partial MCL tears 27 case series complete MCL tears Prospective 38 partial MCL tears case series
Treatment
Findings
Conservative early functional rehabilitation Conservative immobilization followed by rehabilitation Conservative early functional rehabilitation
Grade I returned to full participation after 10.6 d lost, Grade II injuries after 19.5 d Median Lysholm score of 94 (partial tears) and 66 (complete tears) at 9 y Median Lysholm score of 95 at 10 y, 100 at 4 y
MCL indicates medial collateral ligament.
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Surgical and Nonsurgical Outcomes of Medial Knee Injuries
TABLE 3. Summary of Outcome Studies of Isolated Complete Medial-sided Knee Injuries
References
Study Design
al2
Case series
Fetto et
Study Groups 265 MCL injuries with/ without associated ligament injuries, 150 treated with surgery, 115 nonoperative 30 isolated complete collateral ligament tears (26 isolated MCL tears) in 29 patients Isolated grade III MCL injuries. Group I: surgical repair, Group II: nonoperative treatment 154 knees with anteromedial rotatory instability. 89 available for follow-up
Treatment
Findings
Variety of nonoperative treatment Surgery did not improve outcomes in consisting of immobilization vs. isolated lesions, but it did improve compression wrapping. Multiple outcomes in mixed lesions different operative procedures utilized
Hastings11
Case series
Indelicato et al12
Prospective case series
Hughtston et al15
Case series
Sandberg et al4
Randomized 200 patients including those Conservative vs. surgical clinical with an isolated ACL, study isolate MCL, or both Case series 28 complete MCL tears in Conservative 2 wk casted in 30 degrees, Average time to full contact drills was college football players followed by 4 wk in hinged brace 9.2 wk after injury 30-90 Case series 41 patients who had repair Surgical repair of the posterior oblique 38/41 had good stability and normal of acute complete MCL ligament and the semimembranosus range of motion at an average of 22 y tears. 24/41 had ACL complex follow-up. Radiographic changes tears were slight or absent in all but 4 Prospective 35 athletes with isolated Conservative early functional Mean HSS score was 45.9 at a mean of case series grade III MCL tears rehabilitation 5.3 y follow-up. 3% reinjury rate
Indelicato et al16 Hughston17
Reider et al13
Conservative cast for 2-5 wk followed by bracing Group I: surgical repair. Group II: 2 wk in plaster cast followed by 4 wk in a cast brace Surgical repair
23/29 patients had no complaints referable to their knees, 4/29 had objective medial laxity on stress x-ray, but only 1 was symptomatic 15/16 in group I and 17/20 in group II had a good or excellent result. Group II regained strength in 11.3 wk compared with 14.9 wk in group I Knees with an unrepaired ACL did not progress to instability and deterioration. 71% of athletes returned to equal or higher level of sport. 23% did not return to sport for reasons other than injury MCL injuries did not benefit from surgical treatment
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament.
However, not all outcome studies have had positive results with respect to nonoperative treatment. Kannus found that compared with grade II sprains of the medial collateral ligament, grade III injuries treated nonoperatively tended to have more instability, lower functional scores, and a higher rate of osteoarthritis on radiographs. Thus, they suggested surgical treatment for these injuries.8 Operative treatment of the medial structures of the knee has been described in the literature as early as 1936,14 and some early authors describe surgical repair of complete injuries to the medial structures with good outcomes (Table 3).15,17–20 Hughston and Barrett15 reported that 94% of patients with open medial-sided repair who were injured during organized athletics were able to return to their preinjury level of athletic function. Critical to their decision for operative treatment was complete ligament disruption along with a component of anteromedial rotary instability (AMRI). Patients with AMRI will demonstrate increased anterior translation of the tibia when an anterior drawer test is performed with the foot held in 15 degrees of external rotation when compared with neutral or external rotation. They felt this indicated that the structures of the posteromedial corner including the posterior oblique ligament and the semimembranosus complex, in addition to the superficial medial collateral ligament, had been disrupted. Therefore, their results may be more consistent with combined injury treatment rather than isolated MCL sprains. A follow-up study by the same group with an average of 22 years of follow-up, demonstrated that 38 of 41 patients Copyright
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treated with a protocol involving medial collateral ligament repair and stressing reconstitution of the semimembranosus complex had good stability and normal range of motion. Applying this data to isolated medial-sided ligament injuries may not be appropriate; however, as 24 of the 41 knees had concomitant anterior cruciate ligament ruptures. It does, however, demonstrate that repairing the medial structures, including the posteromedial corner, does seem to improve stability in knees that demonstrate AMRI on examination, irrespective of the integrity of the anterior cruciate ligament as will be discussed in the next section.17
COMBINED INJURIES As previously stated, complete injuries to the medial collateral ligament are more often than not associated with other ligamentous structures around the knee and can result in complex multiplanar instability (Tables 4, 5). Central to achieving good outcomes of combined ligamentous injuries of the knee is restoring stability to the joint, whether that is with operative or nonoperative treatment protocols. Perhaps the most commonly studied combined pattern is a medial collateral ligament injury combined with an anterior cruciate ligament disruption, and there is considerable controversy when discussing treatment of this injury pattern. Historically, operative treatment was recommended for treatment of the medial collateral ligament. Fetto and Marshall2 demonstrated that 79% of mixed
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TABLE 4. Summary of Outcomes Studies of Combined ACL/MCL Lesions
References
Study Design
Jokl et al21
Retrospective 28 patients with combined ACL/ case series MCL tears
Study Groups
Conservative for both injuries
Treatment
Ballmer et al22
Prospective case series
All treated with ACL reconstruction alone
14 patients with compete ACL/ MCL injuries
MCL managed nonoperatively in Shelbourne Retrospective 84 ACL/MCL tears. The first 16 case series patients had ACL reconstruction last 68 patients et al23 and open MCL repair. The last 68 had reconstruction of the ACL only Case series 20 patients with ACL/MCL tears. All patients treated operatively Robins 13 proximal and 7 distal to the with ACL reconstruction and et al24 joint line MCL repair Noyes et al25
Frolke et al26 Petersen et al27
Shirakura et al28
Nakamura et al29
Halinen et al6
Halinen et al5
Findings 20/28 had good or excellent results. 11/15 who played contact sports and 6/9 who played noncontact sports returned to preinjury athletic activity All returned to preinjury athletics, 12/14 had excellent subjective outcome. 12/14 had 0-2 mm of opening to clinical valgus stress at 30 degrees. 2/14 had 3-5 mm All had a firm endpoint to valgus stress at 30 degrees of flexion. 96% had no subjective instability after surgery
Distal lesions had improved motion and faster recovery of motion. And required fewer reoperations Prospective 46 ACL/MCL ruptures. Group I ACL allograft reconstruction in all No patient had >2mm increase case series (34 pts): all medial structures patients. Group I: treated with valgus opening at 5 or 25 degrees ruptured. Group II (12 pts): repair; Group II: MCL treated of knee flexion. Group I had superficial MCL ruptured only conservatively 58% excellent or good outcomes, group II had 91% Case series 22 patients with combined ACL/ MCL repair, nonoperative 7 patients were later advised to MCL tears treatment of the ACL have their ACL reconstructed Retrospective Combined ACL/MCL injuries. All MCL injuries treated with a hinged Late ACL reconstruction had less case series MCL injuries treated brace (6wks) and early motion motion loss, lower rate of nonoperatively. group I: 27 rearthroscopy for extension loss, patients with ACL reconstruction and improved Lysholm scores within 3 wks; group II: 37 patients (89.9 vs. 85.3) with ACL reconstruction after 10 wk Case series 25 patients with combined ACL/ 14 had MCL repair, 11 had MCL No difference in clinical laxity, MCL tears. ACL treated managed conservatively. KT-1000 measurements, or nonoperatively in all patients Selection for surgery based on Tegner scores. There was a extent of the MCL tear. significantly higher Lysholm nonoperatively functional score in the operative group Prospective 17 patients with an ACL tear ACL reconstructed, MCL initially All 5 patients who had MRI cohort combined with MRI grade III managed nonoperatively. Six had evidence of damage over the MCL tear residual laxity and had late MCL whole length of the superficial reconstruction or advancement MCL had residual valgus laxity despite bracing Prospective, 47 patients with ACL/MCL tears. Identical rehabilitation protocols No difference between groups in randomized Early ACL reconstruction in both post op for both groups with subjective function, postop clinical groups. Group I: MCL repaired; early ROM in a hinged brace stability, ROM, muscle power, study Group II: Nonoperative MCL return to activities, Lysholm score and IKDC evaluation Randomized 47 patients with combined ACL and ACL treated with early Surgical repair group had greater prospective grade III MCL randomized into 2 reconstruction in both groups. flexion deficit at all follow-up clinical groups. Group I: Acute MCL MCL in group I was repaired intervals but not statistically study repair (23), Group II MCL with suture anchors, direct significant 52 or 104 wk. treated nonoperatively (24) suturing, or suturing through Quadriceps muscle power deficit bone tunnels was improved at 52 and 104 wk in the nonrepair group
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament; MRI, magnetic resonance imaging.
ACL/MCL lesions had a poor result with nonoperative treatment, thus recommending operative repair of all combined injuries. The previously mentioned study by Hughston17 identified that combined ACL/MCL lesions that had been treated with repair of only the MCL stressing reconstitution of the posteromedial corner had good longterm results with no difference in instability or joint
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deterioration, irrespective of the status of the anterior cruciate ligament. A later study also recommended conservative treatment of the ACL with MCL repair. However, in their series of 22 patients, 7 patients were advised to undergo later ACL reconstruction with 5 patients having the procedure performed at last follow-up. They advised that late reconstruction of the anterior cruciate ligament
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Surgical and Nonsurgical Outcomes of Medial Knee Injuries
TABLE 5. Outcomes of Clinical Studies of Combined MCL/PCL Injuries and Knee Dislocations
References Study Design Ohkoshi et al30
Case series
Study Groups 9 traumatic knee dislocations, 6 of which had MCL injuries
Lind et al31 Retrospective 61 chronic MCL injuries (13 case series isolated, 48 combined ligament injuries (34 ACL)). 50 patients available for follow-up
Treatment
Findings
Early PCL reconstruction, with second stage reconstruction of other ligaments as needed
Reconstruction of the MCL and posterior oblique ligament using a semitendinosus graft. ACL and PCL reconstructed as needed
Kim et al32 Case series
26 patients with complete MCL Reconstruction of MCL and tears. 12 had concomitant ACL posterior oblique ligament using tears, 6 had concomitant PCL semitendinosus. ACL and PCL tears. 24 were available for f/u at reconstructed as needed 2y
Yoshiya et al33
Case series
24 patients with symptomatic Anatomically reconstructed the medial instability of the knee. All anterior longitudinal component had surgery >3 mo after injury. if the superficial MCL with 22 had combined cruciate injuries autogenous semitendinosus and gracilis tendons
Stannard34
Prospective case series
Knee dislocations with 73 Group A had MCL repair, Group posteromedial corner tears. B had reconstruction of Group A had repair, group B had posteromedial corner and MCL autograft and group C had with autograft. Group C had allograft reconstruction reconstruction with allograft
Kitaumura Case series et al35
30 patients with chronic combined All ligaments were reconstructed. MCL/cruciate ligament injuries. MCL was reconstructed with a 16 MCL/ACL, 5 MCL/PCL, doubled autogenous 9 MCL/ACL/PCL semitendinosus graft
Case series
14 patients with chronic MCL MCL reconstructed with Achilles injury who failed nonoperative bone plug allograft. ACL and treatment with combined cruciate PCL reconstructed as needed ligament injury
Marx et al36
Only 1 patient required MCL reconstruction at second stage. Average side to side laxity with KT-1000 was 2.3 ± 1.9 mm. No knees had varus or valgus instability 98% normal or nearly normal medial stability IKDC score. 74% normal or nearly normal overall IKDC score. 91% of patients were satisfied or very satisfied Valgus laxity improved less than 2 mm of opening in 92% (normal according to IKDC criteria). ROM was normal or near normal in all patients. Mean postop Lysholm score was 91.9 21/24 patients symptoms were rated as normal or nearly normal according to the IKDC criteria. All had normal or near normal ROM. All had 2 mm or less medial joint opening post operatively (normal according to IKDC criteria) 5/25 patients in group A, 1/27 in group B, 1/21 in group C failed their repair or reconstruction. Lysholm scores improved from 89 to 94 in repair groups, 85 to 87 in reconstruction groups Lysholm scores averaged 94.8 points without significant difference among groups. In the IKDC evaluation, 9 patients were graded as A, 17 were graded as B and 3 were graded as C, 1 was graded as D. There was no significant difference in medial joint opening between reconstructed and intact knees All 14 cases had grade 0-1 medial joint laxity. In cases of MCL and primary ACL reconstruction, IKDC subjective score was 91, Lysholm score was 92 and KOOS sports score was 93
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament .
could be performed if conservative treatment of this ligament had failed.26 Others prefer to decide whether to treat the medial structures operatively depending on the extent of injury to the medial side of the knee. In a study by Shirakura and colleagues a group of 14 ACL/MCL injuries with grade III MCL tears that demonstrated anterior subluxation of the medial tibial plateau during laxity tests under anesthesia received suture repair with ligament stapling of the medialsided structures without ACL reconstruction. Compared with 11 patients treated nonoperatively for either ligament, they found that there was no difference in ligamentous laxity or Tegner activity scores. The operative group did have significantly higher Lysholm functional scores (98.5 Copyright
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vs. 93.8).28 They found no difference in proximal or distal lesions. Robins and colleagues examined how the proximaldistal location of medial collateral ligament injury affected postoperative motion after combined MCL repair and ACL reconstruction. They found that the distal lesions had faster return of motion and greater maximal flexion than the proximal lesions. They concluded that proximal injuries should to be treated more aggressively with physical therapy. Another treatment option discussed in their paper was to only repair distal lesions, as these injuries seem to be more tolerant of surgical treatment.24 Nakamura and colleagues also examined the importance of the location and extent of the lesion on the capacity for healing. In their prospective cohort study of 17 patients they found that all 5
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patients who had magnetic resonance imaging evidence of medial collateral ligament damage over the whole length of the ligament had residual valgus laxity despite nonoperative treatment with a brace.29 More recent literature supports a differing approach; initial conservative treatment of the MCL with reconstruction of the anterior cruciate ligament.23,25,37 Shelbourne and colleagues treated 68 patients with combined ACL/MCL injuries with reconstruction of the ACL only. 96% of their patients were without subjective instability and all patients had a firm endpoint to valgus at 30 degrees. Further, they found no statistically significant difference in stability or reoperation rates when compared with patients they had previously treated with ACL reconstruction combined with MCL repair.23 This approach was further validated with a prospective randomized trial of 47 patients of combined ACL/MCL disruption. All patients were treated with acute ACL reconstruction with 23 patients being treated with concomitant MCL repair and 24 patients without MCL repair. They found no difference in postoperative stability, range of motion, muscle power, return to activities, or outcome scores at a mean 20 months follow-up.6 A prospective randomized clinical study also supported improved outcomes with nonoperative treatment of the medial collateral ligament in combined knee injuries. Halinen and colleagues randomized 47 patients with combined ACL and grade III MCL injuries into early reconstruction of the ACL with repair of the MCL (group I) or early reconstruction of the ACL with nonoperative treatment of the MCL (group II). They found that the group of patients who had their MCL treated nonoperatively had faster restoration of flexion and quadriceps muscle strength.5 Combined ACL/MCL injuries are commonly secondary to low-velocity sporting activities, and in these injury patterns may be amenable to nonoperative treatment of the MCL with delayed reconstruction of the ACL. However, high velocity knee dislocation injuries should be recognized as a much more severe injury pattern necessitating earlier stabilization with poorer outcomes.19,38 In a study comparing acute (within 3 wk) and chronic (after 3 wk) repair/ reconstruction of knee dislocations, Harner and colleagues found that those in the acutely treated group had higher objective stability and higher subjective scores. They also found that patients with these injuries were able to return to strenuous labor or high-demand sports activities unpredictably, irrespective of the acuity of treatment.39 Although a trial of nonoperative treatment of the MCL is an acceptable treatment plan for some injury patterns, not all patients will progress to healing and normal medial stability.19,38,40 Further, chronic injuries to the medial structures of the knee may not have adequate tissue quality and quantity to be amenable to surgical repair. The commonly used anatomic technique by Kim and colleagues is only one of many that have been described in the literature, with most studies of reconstruction techniques reporting good outcomes in terms of stability or subjective patient outcomes.30–33,41–44 However, comparing outcomes among these multiple techniques can be difficult to interpret. Some techniques reconstruct only the medial collateral ligament, although others emphasize anatomic reconstruction of the posteromedial corner structures as well. No clinical outcome studies have been reported comparing different techniques. Multiple injury patterns are reported
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regarding the number of different knee ligaments involved both between and within individual studies. Both allograft and autograft tissues have been utilized. For these reasons, future clinical studies comparing repair techniques may improve the ability of the treating surgeon to choose one reconstruction technique over another to achieve maximal outcomes for their patients. However, there has been one more recent study that compared outcomes of repair versus reconstruction of posteromedial corner injuries in knee dislocation patterns. A repair was performed of the posteromedial corner if there was a medial avulsion injury of the posteromedial corner including the medial collateral ligament and the posterior oblique ligament or if there was high quality tissue amenable for repair within 4 weeks of injury. All other patients had an anatomic posteromedial reconstruction with either allograft or autograft. They found that 5/25 of patients who had their MCL repaired had a failure of repair, whereas only 2/48 reconstructions failed and demonstrated that reconstruction of the medial structures lead to better stability in this injury pattern. However, 37% of their patients were lost to follow-up. There was no difference in return to full-time employment, and the incidence of arthrofibrosis was similar in both groups (20% of repairs, 17% of reconstructions).34
AUTHORS’ APPROACH TO MEDIAL-SIDED KNEE INJURIES Medial-sided knee injuries can be difficult to treat. Our approach to partial (grade I/II) injuries is similar to that of many authors; we treat these injuries with a short period of bracing and early motion. This is followed by a return to sport when strength and stability return. We also tend treat the medial side of the knee nonoperatively when the MCL alone is injures as well as when combined with an anterior cruciate ligament injury. When combined, the ACL is treated with reconstruction in a delayed manner after the MCL has healed and knee motion has returned. We reconstruct the medial ligamentous structures in cases in which valgus laxity or anteromedial rotatory instability persists despite nonoperative treatment, and when the MCL injury is combined with at least 2 other ligament injuries. We have found the reconstruction method of Kim and colleagues to provide excellent stability and reproducible outcomes. In this method, the distal end of the semitendinosus tendon is left attached to the tibia while the proximal end is stripped from its muscle belly with a tendon stripper. After the proximal muscle is removed, the proximal end is whip stitched with a no. 2 nonabsorbable suture. A K-wire is placed in the middle of the MCL femoral insertion. Isometry is confirmed by looping the graft over the wire and placing the knee through a range of motion. Once confirmed, a 6.5 mm cancellous screw with a spiked washer is placed in this location. The graft is pulled taught and the knee place in 30 degrees of flexion and varus while the screw is tightened down to bone. The free end of the graft is then pulled distally and sutured under tension into the insertion of the semimembranosus with no. 2 nonabsorbable suture. With this technique, the anterior arm replicates the MCL, whereas the posterior arm provides additional rotational stability by reproducing the course of the posterior oblique ligament.32 Postoperatively, the knee is placed in a brace and early motion is allowed.
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CONCLUSIONS In conclusion, outcome studies of treatment strategies of medial-sided knee injuries can be difficult to interpret. However, some conclusions can be made. Isolated partial or complete MCL injuries can be treated nonoperatively with a brace and early motion with good outcomes in terms of stability and return to play. However, many complete injuries are associated with other ligaments within the knee, and there is even variation in reporting which medial structure was injured. Nonoperative management of acute MCL injuries in ACL-MCL injured patients is supported by 2 randomized prospective trials. In knee dislocation patterns in which the medial tissues are not amenable to repair, reconstruction may produce better outcomes, but the optimal reconstruction technique has not been proven. REFERENCES 1. LaPrade RF, Engebretsen AH, Ly TV, et al. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89:2000–2010. 2. Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res. 1978;132:206–218. 3. Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004;32:337–345. 4. Sandberg R, Balkfors B, Nilsson B, et al. Operative versus nonoperative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am. 1987;69:1120–1126. 5. Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am. 2009;91:1305–1312. 6. Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2006;34: 1134–1140. 7. Derscheid GL, Garrick JG. Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9:365–368. 8. Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1988;226:103–112. 9. Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med. 1996;24:160–163. 10. Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc. 2006;14:84–90. 11. Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1980;147:22–28. 12. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65:323–329. 13. Reider B, Sathy MR, Talkington J, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med. 1994;22:470–477. 14. Mauck H. A new operative procedure for instability of the knee. J Bone Joint Surg. 1936;18:894–990. 15. Hughston JC, Barrett GR. Acute anteromedial rotatory instability. Long-term results of surgical repair. J Bone Joint Surg Am. 1983;65:145–153.
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Surgical and Nonsurgical Outcomes of Medial Knee Injuries
16. Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Relat Res. 1990;256:174–177. 17. Hughston JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Joint Surg Am. 1994;76:1328–1344. 18. Nicholas JA. The five-one reconstruction for anteromedial instability of the knee. Indications, technique, and the results in fifty-two patients. J Bone Joint Surg Am. 1973;55:899–922. 19. Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc. 2006;14:78–83. 20. O’Donoghue DH. Reconstruction for medial instability of the knee. J Bone Joint Surg Am. 1973;55:941–954. 21. Jokl P, Kaplan N, Stovell P, et al. Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. J Bone Joint Surg Am. 1984;66:741–744. 22. Ballmer PM, Ballmer FT, Jakob RP. Reconstruction of the anterior cruciate ligament alone in the treatment of a combined instability with complete rupture of the medial collateral ligament. A prospective study. Arch Orthop Trauma Surg. 1991;110:139–141. 23. Shelbourne KD, Porter DA. Anterior cruciate ligament-medial collateral ligament injury: nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction. A preliminary report. Am J Sports Med. 1992;20:283–286. 24. Robins AJ, Newman AP, Burks RT. Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries. The effect of medial collateral ligament rupture location. Am J Sports Med. 1993;21:20–25. 25. Noyes FR, Barber-Westin SD. The treatment of acute combined ruptures of the anterior cruciate and medial ligaments of the knee. Am J Sports Med. 1995;23:380–389. 26. Frolke JP, Oskam J, Vierhout PA. Primary reconstruction of the medial collateral ligament in combined injury of the medial collateral and anterior cruciate ligaments. Short-term results. Knee Surg Sports Traumatol Arthrosc. 1998;6:103–106. 27. Petersen W, Laprell H. Combined injuries of the medial collateral ligament and the anterior cruciate ligament. Early ACL reconstruction versus late ACL reconstruction. Arch Orthop Trauma Surg. 1999;119:258–262. 28. Shirakura K, Terauchi M, Katayama M, et al. The management of medial ligament tears in patients with combined anterior cruciate and medial ligament lesions. Int Orthop. 2000;24:108–111. 29. Nakamura N, Horibe S, Toritsuka Y, et al. Acute grade III medial collateral ligament injury of the knee associated with anterior cruciate ligament tear. The usefulness of magnetic resonance imaging in determining a treatment regimen. Am J Sports Med. 2003;31:261–267. 30. Ohkoshi Y, Nagasaki S, Shibata N, et al. Two-stage reconstruction with autografts for knee dislocations. Clin Orthop Relat Res. 2002;398:169–175. 31. Lind M, Jakobsen BW, Lund B, et al. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med. 2009;37:1116–1122. 32. Kim SJ, Lee DH, Kim TE, et al. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br. 2008;90:1323–1327. 33. Yoshiya S, Kuroda R, Mizuno K, et al. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. 2005;33:1380–1385. 34. Stannard JP, Black BS, Azbell C, et al. Posteromedial corner injury in knee dislocations. J Knee Surg. 2012;25:429–434.
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35. Kitamura N, Ogawa M, Kondo E, et al. A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries: clinical outcomes. Am J Sports Med. 2013;41:1274–1281. 36. Marx RG, Hetsroni I. Surgical technique: medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470: 798–805. 37. Azar FM, Aaron DG Jr. Surgical treatment of anterior cruciate ligament-posterior cruciate ligament-medial side knee injuries. J Knee Surg. 2005;18:220–227. 38. Klimkiewicz JJ, Petrie RS, Harner CD. Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures. Clin Sports Med. 2000;19:479–492, vii.
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39. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86A:262–273. 40. Jacobson KE, Chi FS. Treatment of chronic injuries to the medial side of the knee. Tech Knee Surg. 2007;6:106–111. 41. Wijdicks CA, Griffith CJ, Johansen S, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92:1266–1280. 42. Borden PS, Kantaras AT, Caborn DN. Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy. 2002;18:E19. 43. Grana WA, Gimple K. Reconstruction of traumatic complete loss of the medial collateral ligament: a case report. Clin Orthop Relat Res. 1981;160:153–157. 44. Stannard JP. Medial and posteromedial instability of the knee: evaluation, treatment, and results. Sports Med Arthrosc. 2010;18:263–268.
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A Review of Surgical and Nonsurgical Outcomes of Medial Knee Injuries Mark P. Smyth, MD* and Jason L. Koh, MDw
Abstract: Medial-sided knee injuries can result in pain, instability, and loss of function. Many clinical studies have been written on the treatment of medial-sided knee injuries; however, the vast majority are isolated case series of surgical or nonoperative treatment regimens, and only a few randomized prospective clinical trials can be found in the literature that compare different treatment modalities. Comparison of these treatments is challenging due to the variety of medial-sided structures that can be involved, the multiple different approaches to treatment, and the variability of how objective and subjective clinical outcomes are reported. In this paper we report on the injuries by extent and type of anatomic structures damaged including partial medial-sided injuries, completed isolated medialsided knee injuries, and combined injuries. In general, most authors concur that isolated partial or complete medial collateral ligament (MCL) injuries can be treated nonoperatively with a brace and early motion with good clinical outcomes. Prospective, randomized trials support nonoperative treatment of the MCL in combined anterior cruciate ligament-MCL injuries. Knee dislocations and posterior medial corner injuries appear to have better results with surgical management including reconstruction. Multiple reconstructive techniques have been described for chronic injuries but it is difficult to compare their results. Key Words: medial collateral ligament, posteromedial corner, MCL repair, MCL reconstruction, knee dislocation
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edial-sided knee injuries can result in pain, persistent instability, and loss of function. However, the nature of these injuries is heterogenous in terms of age, anatomy, pathoanatomy, chronicity, and treatment. Multiple soft tissue structures help to stabilize the medial aspect of the knee. The largest and most identifiable structure is the superficial medial collateral ligament (MCL). It courses from just proximal and posterior to the medial epicondyle and has a broad-based insertion distally in the posterior medial tibia. It is the primary restraint to varus. The deep MCL is a thickening of the medial joint capsule with meniscofemoral and meniscotibial fibers that anchor the medial aspect of the meniscus to bone. The posterior oblique ligament (POL) has 3 bands, the most prominent of which is the central band. The central band of the POL attaches 7.7 mm distal and 6.4 mm posterior to the adductor tubercle on the femur. It attaches distally to the posteromedial aspect of the proximal tibia and it reinforces posteromedial joint capsule. It assists in providing external rotational stability. Finally, the pes tendons and hamstrings assist with stability. The semimembranosus, specifically, aids in stabilize the posteromedial corner of the knee.1 From the *University of Chicago, Chicago, IL; and wNorthShore University HealthSystem, Evanston, IL. Disclosure: The authors declare no conflict of interest. Reprints: Jason L. Koh, MD, NorthShore University HealthSystem, 2650 Ridge Avenue, Walgreen’s 2505, Evanston, IL. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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The complex anatomy of the medial aspect of the knee has led to some difficulty in designing a standardized treatment algorithm of injuries involving these structures. Therefore, outcomes of studies involving the treatment of medial knee injuries, likewise, are difficult to interpret. Many studies report results on the treatment of medial collateral ligament injuries only. Other studies stress the importance of the posteromedial knee structures in restoring valgus and rotatory stability to the knee. When reviewing the literature it is important to clarify exactly what injury pattern is being treated. Some studies report on acute medial collateral ligament injuries, whereas other comment on chronic tears. Further complicating the literature interpretation of medial-sided knee injuries is that they are commonly associated with damage to other ligaments around the knee. Fetto and Marshall2 found an associated ligament injury with a grade III MCL tear in 78.1% of cases, 95% of which were anterior cruciate ligament injuries. In another study, 88% of patients who underwent medial collateral ligament repair were found to have a concomitant ACL rupture.3 Whether in isolation or in combination with other ligament injuries, multiple treatments have been reported in the literature. A wide spectrum of nonoperative protocols as well as surgical repair and ligament reconstruction options have been described, many of which have shown favorable outcomes in terms of stability, return to activity and subjective outcome measures. Unfortunately, most studies are low level of evidence and reported as case series. We reviewed PubMed August 2014 using search terms MCL and medial collateral ligament. In our review of the literature, we only found 3 randomized prospective clinical studies in the literature.4–6 Other confounding variables to the interpretation of outcomes in the lack of standardization in exactly what outcomes are reported (Table 1). Although most studies have some sort of assessment of valgus stability, whether that is medial opening on physical examination, stress radiographs, or subjective stability. However, validated outcome scores such as the Lysholm scale, International Knee Documentation Committee (IKDC) criteria, and Knee Injury and Osteoarthritis Outcome Score (KOOS) are only reported in more recent studies making comparison of outcomes with older reports more difficult. In this review we have chosen to compare outcomes of different studies by categorizing them according to the injury pattern. First, partial medial-sided ligament injuries will be discussed, followed by isolated complete medial injuries, and finally the outcomes of combined medial collateral ligament injuries and combined cruciate injuries will be reviewed.
GRADE I/II MEDIAL COLLATERAL LIGAMENT INJURIES With regard to injuries of the medial side of the knee, the greatest agreement in the literature can be found in the www.sportsmedarthro.com |
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TABLE 1. Variables in Reporting Outcomes of Treatment of Medial Instability of the Knee
Anatomic
Treatment
Outcomes Reporting
Partial medial-sided injuries Nonoperative management Isolated medial-sided injuries Repair vs. reconstruction of Isolated complete medial collateral ligament medial knee injuries injuries Reconstruction techniques for Combined posteriormedial corner and medial medial knee injuries collateral ligament injuries Combined anterior cruciate and medial collateral ligament injuries Chronic medial collateral ligament injuries
treatment of isolated low-grade, partial medial collateral ligament injuries (grade I and II) (Table 2). Most authors have suggested nonoperative treatment for such injuries.2,7–10 In a case series of 38 patients with partial medial collateral ligament ruptures treated with functional bracing and rehabilitation, 74% had regained nearly normal knee function by 3 months and excellent Lysholm functional scores were reported in 33 of 38 patients at 4-year followup. Functional scores were slightly lower at 10 years but remained high with excellent scores in 71% of patients and good to excellent scores in 92%. Thirteen percent of patients had radiographic evidence of early arthritis at 10 years.9 Partial medial collateral ligament injuries are common in the athletic population. Derscheid et al7 found that 51 of 70 knee injuries in college football players were grade I or II medial collateral ligament sprains over a 4-year period. Although these injuries are common in this population, athletes that sustain these injuries are often able to return to the playing field quickly after only a short period of rest and active rehabilitation. In the same study, Derscheid and colleagues found that college football players with grade I partial medial collateral ligament injuries were able to return to full, unprotected participation after an average of 10.6 days of activity lost. Players with grade II injuries were able to return after a mean of 19.5 days lost. Their reinjury rate was 8%, which was equal to the injury rate in their population, so they concluded that there was no increased risk of reinjury with this treatment protocol.7 In summary, partial medial collateral ligament injuries are effectively treated with nonoperative means. Usually this involves a short period of rest and functional bracing. When pain subsides, range of motion is full, and strength returns, athletes are allowed to return to play provided they suffered a true partial medial collateral ligament injury and medial stability has been maintained.
Objective outcomes: valgus stability assessment—Physical examination, stress radiographs Subjective outcomes: subjective stability Validated outcome scores Return to play Reinjury rate
COMPLETE MEDIAL COLLATERAL LIGAMENT DISRUPTIONS (ISOLATED GRADE 3 INJURIES) Complete disruptions of the medial collateral ligament have historically been managed both operatively and nonoperatively; even the nonoperative treatment options have varied greatly from cast immobilization to early motion and functional rehabilitation. In 1980, Hastings reported a treatment protocol for complete isolated medial collateral ligament injuries that involved 2 to 6 weeks of immobilization in plaster, followed by a hinged brace. The majority of their patients were able to return to athletic competition 3 to 4 weeks after the plaster was removed.11 Indelicato12 showed a protocol of 2 weeks of immobilization followed by cast bracing for 4 weeks lead to faster recovery of strength than surgical treatment. However, prolonged immobilization has fallen out of favor, with most modern nonoperative protocols stressing early motion. One such protocol involves range of motion exercises starting on day 1 or 2 after injury, use of a lateral hinged knee brace, and a progressive physical therapy protocol. All of the patients available for follow-up were able to return to full participation and 79% of patients’ felt they had returned to preinjury performance levels. At an average of 5.3 years follow-up, the mean HSS knee score was 45.9, with all patients scoring in the good to excellent range. The reinjury rate in their study was 3%.13 Further support for nonoperative treatment was found in a randomized clinical study published in 1987 of 200 patients with isolated medial collateral ligament tears, isolated anterior cruciate ligament tears, or both. Patients in this study were randomized to conservative versus surgical repair of the injured structures. They found that isolated medial collateral ligament injuries did not benefit from surgical treatment.4
TABLE 2. Summary of Outcome Studies of Partial Medial Collateral Ligament Injuries
References Study Design Derscheid et al7 Kannus et al8 Lundberg et al9
Study Groups
Prospective 51 partial MCL tears in case series college football players Retrospective 54 partial MCL tears 27 case series complete MCL tears Prospective 38 partial MCL tears case series
Treatment
Findings
Conservative early functional rehabilitation Conservative immobilization followed by rehabilitation Conservative early functional rehabilitation
Grade I returned to full participation after 10.6 d lost, Grade II injuries after 19.5 d Median Lysholm score of 94 (partial tears) and 66 (complete tears) at 9 y Median Lysholm score of 95 at 10 y, 100 at 4 y
MCL indicates medial collateral ligament.
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Surgical and Nonsurgical Outcomes of Medial Knee Injuries
TABLE 3. Summary of Outcome Studies of Isolated Complete Medial-sided Knee Injuries
References
Study Design
al2
Case series
Fetto et
Study Groups 265 MCL injuries with/ without associated ligament injuries, 150 treated with surgery, 115 nonoperative 30 isolated complete collateral ligament tears (26 isolated MCL tears) in 29 patients Isolated grade III MCL injuries. Group I: surgical repair, Group II: nonoperative treatment 154 knees with anteromedial rotatory instability. 89 available for follow-up
Treatment
Findings
Variety of nonoperative treatment Surgery did not improve outcomes in consisting of immobilization vs. isolated lesions, but it did improve compression wrapping. Multiple outcomes in mixed lesions different operative procedures utilized
Hastings11
Case series
Indelicato et al12
Prospective case series
Hughtston et al15
Case series
Sandberg et al4
Randomized 200 patients including those Conservative vs. surgical clinical with an isolated ACL, study isolate MCL, or both Case series 28 complete MCL tears in Conservative 2 wk casted in 30 degrees, Average time to full contact drills was college football players followed by 4 wk in hinged brace 9.2 wk after injury 30-90 Case series 41 patients who had repair Surgical repair of the posterior oblique 38/41 had good stability and normal of acute complete MCL ligament and the semimembranosus range of motion at an average of 22 y tears. 24/41 had ACL complex follow-up. Radiographic changes tears were slight or absent in all but 4 Prospective 35 athletes with isolated Conservative early functional Mean HSS score was 45.9 at a mean of case series grade III MCL tears rehabilitation 5.3 y follow-up. 3% reinjury rate
Indelicato et al16 Hughston17
Reider et al13
Conservative cast for 2-5 wk followed by bracing Group I: surgical repair. Group II: 2 wk in plaster cast followed by 4 wk in a cast brace Surgical repair
23/29 patients had no complaints referable to their knees, 4/29 had objective medial laxity on stress x-ray, but only 1 was symptomatic 15/16 in group I and 17/20 in group II had a good or excellent result. Group II regained strength in 11.3 wk compared with 14.9 wk in group I Knees with an unrepaired ACL did not progress to instability and deterioration. 71% of athletes returned to equal or higher level of sport. 23% did not return to sport for reasons other than injury MCL injuries did not benefit from surgical treatment
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament.
However, not all outcome studies have had positive results with respect to nonoperative treatment. Kannus found that compared with grade II sprains of the medial collateral ligament, grade III injuries treated nonoperatively tended to have more instability, lower functional scores, and a higher rate of osteoarthritis on radiographs. Thus, they suggested surgical treatment for these injuries.8 Operative treatment of the medial structures of the knee has been described in the literature as early as 1936,14 and some early authors describe surgical repair of complete injuries to the medial structures with good outcomes (Table 3).15,17–20 Hughston and Barrett15 reported that 94% of patients with open medial-sided repair who were injured during organized athletics were able to return to their preinjury level of athletic function. Critical to their decision for operative treatment was complete ligament disruption along with a component of anteromedial rotary instability (AMRI). Patients with AMRI will demonstrate increased anterior translation of the tibia when an anterior drawer test is performed with the foot held in 15 degrees of external rotation when compared with neutral or external rotation. They felt this indicated that the structures of the posteromedial corner including the posterior oblique ligament and the semimembranosus complex, in addition to the superficial medial collateral ligament, had been disrupted. Therefore, their results may be more consistent with combined injury treatment rather than isolated MCL sprains. A follow-up study by the same group with an average of 22 years of follow-up, demonstrated that 38 of 41 patients Copyright
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treated with a protocol involving medial collateral ligament repair and stressing reconstitution of the semimembranosus complex had good stability and normal range of motion. Applying this data to isolated medial-sided ligament injuries may not be appropriate; however, as 24 of the 41 knees had concomitant anterior cruciate ligament ruptures. It does, however, demonstrate that repairing the medial structures, including the posteromedial corner, does seem to improve stability in knees that demonstrate AMRI on examination, irrespective of the integrity of the anterior cruciate ligament as will be discussed in the next section.17
COMBINED INJURIES As previously stated, complete injuries to the medial collateral ligament are more often than not associated with other ligamentous structures around the knee and can result in complex multiplanar instability (Tables 4, 5). Central to achieving good outcomes of combined ligamentous injuries of the knee is restoring stability to the joint, whether that is with operative or nonoperative treatment protocols. Perhaps the most commonly studied combined pattern is a medial collateral ligament injury combined with an anterior cruciate ligament disruption, and there is considerable controversy when discussing treatment of this injury pattern. Historically, operative treatment was recommended for treatment of the medial collateral ligament. Fetto and Marshall2 demonstrated that 79% of mixed
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TABLE 4. Summary of Outcomes Studies of Combined ACL/MCL Lesions
References
Study Design
Jokl et al21
Retrospective 28 patients with combined ACL/ case series MCL tears
Study Groups
Conservative for both injuries
Treatment
Ballmer et al22
Prospective case series
All treated with ACL reconstruction alone
14 patients with compete ACL/ MCL injuries
MCL managed nonoperatively in Shelbourne Retrospective 84 ACL/MCL tears. The first 16 case series patients had ACL reconstruction last 68 patients et al23 and open MCL repair. The last 68 had reconstruction of the ACL only Case series 20 patients with ACL/MCL tears. All patients treated operatively Robins 13 proximal and 7 distal to the with ACL reconstruction and et al24 joint line MCL repair Noyes et al25
Frolke et al26 Petersen et al27
Shirakura et al28
Nakamura et al29
Halinen et al6
Halinen et al5
Findings 20/28 had good or excellent results. 11/15 who played contact sports and 6/9 who played noncontact sports returned to preinjury athletic activity All returned to preinjury athletics, 12/14 had excellent subjective outcome. 12/14 had 0-2 mm of opening to clinical valgus stress at 30 degrees. 2/14 had 3-5 mm All had a firm endpoint to valgus stress at 30 degrees of flexion. 96% had no subjective instability after surgery
Distal lesions had improved motion and faster recovery of motion. And required fewer reoperations Prospective 46 ACL/MCL ruptures. Group I ACL allograft reconstruction in all No patient had >2mm increase case series (34 pts): all medial structures patients. Group I: treated with valgus opening at 5 or 25 degrees ruptured. Group II (12 pts): repair; Group II: MCL treated of knee flexion. Group I had superficial MCL ruptured only conservatively 58% excellent or good outcomes, group II had 91% Case series 22 patients with combined ACL/ MCL repair, nonoperative 7 patients were later advised to MCL tears treatment of the ACL have their ACL reconstructed Retrospective Combined ACL/MCL injuries. All MCL injuries treated with a hinged Late ACL reconstruction had less case series MCL injuries treated brace (6wks) and early motion motion loss, lower rate of nonoperatively. group I: 27 rearthroscopy for extension loss, patients with ACL reconstruction and improved Lysholm scores within 3 wks; group II: 37 patients (89.9 vs. 85.3) with ACL reconstruction after 10 wk Case series 25 patients with combined ACL/ 14 had MCL repair, 11 had MCL No difference in clinical laxity, MCL tears. ACL treated managed conservatively. KT-1000 measurements, or nonoperatively in all patients Selection for surgery based on Tegner scores. There was a extent of the MCL tear. significantly higher Lysholm nonoperatively functional score in the operative group Prospective 17 patients with an ACL tear ACL reconstructed, MCL initially All 5 patients who had MRI cohort combined with MRI grade III managed nonoperatively. Six had evidence of damage over the MCL tear residual laxity and had late MCL whole length of the superficial reconstruction or advancement MCL had residual valgus laxity despite bracing Prospective, 47 patients with ACL/MCL tears. Identical rehabilitation protocols No difference between groups in randomized Early ACL reconstruction in both post op for both groups with subjective function, postop clinical groups. Group I: MCL repaired; early ROM in a hinged brace stability, ROM, muscle power, study Group II: Nonoperative MCL return to activities, Lysholm score and IKDC evaluation Randomized 47 patients with combined ACL and ACL treated with early Surgical repair group had greater prospective grade III MCL randomized into 2 reconstruction in both groups. flexion deficit at all follow-up clinical groups. Group I: Acute MCL MCL in group I was repaired intervals but not statistically study repair (23), Group II MCL with suture anchors, direct significant 52 or 104 wk. treated nonoperatively (24) suturing, or suturing through Quadriceps muscle power deficit bone tunnels was improved at 52 and 104 wk in the nonrepair group
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament; MRI, magnetic resonance imaging.
ACL/MCL lesions had a poor result with nonoperative treatment, thus recommending operative repair of all combined injuries. The previously mentioned study by Hughston17 identified that combined ACL/MCL lesions that had been treated with repair of only the MCL stressing reconstitution of the posteromedial corner had good longterm results with no difference in instability or joint
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deterioration, irrespective of the status of the anterior cruciate ligament. A later study also recommended conservative treatment of the ACL with MCL repair. However, in their series of 22 patients, 7 patients were advised to undergo later ACL reconstruction with 5 patients having the procedure performed at last follow-up. They advised that late reconstruction of the anterior cruciate ligament
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Surgical and Nonsurgical Outcomes of Medial Knee Injuries
TABLE 5. Outcomes of Clinical Studies of Combined MCL/PCL Injuries and Knee Dislocations
References Study Design Ohkoshi et al30
Case series
Study Groups 9 traumatic knee dislocations, 6 of which had MCL injuries
Lind et al31 Retrospective 61 chronic MCL injuries (13 case series isolated, 48 combined ligament injuries (34 ACL)). 50 patients available for follow-up
Treatment
Findings
Early PCL reconstruction, with second stage reconstruction of other ligaments as needed
Reconstruction of the MCL and posterior oblique ligament using a semitendinosus graft. ACL and PCL reconstructed as needed
Kim et al32 Case series
26 patients with complete MCL Reconstruction of MCL and tears. 12 had concomitant ACL posterior oblique ligament using tears, 6 had concomitant PCL semitendinosus. ACL and PCL tears. 24 were available for f/u at reconstructed as needed 2y
Yoshiya et al33
Case series
24 patients with symptomatic Anatomically reconstructed the medial instability of the knee. All anterior longitudinal component had surgery >3 mo after injury. if the superficial MCL with 22 had combined cruciate injuries autogenous semitendinosus and gracilis tendons
Stannard34
Prospective case series
Knee dislocations with 73 Group A had MCL repair, Group posteromedial corner tears. B had reconstruction of Group A had repair, group B had posteromedial corner and MCL autograft and group C had with autograft. Group C had allograft reconstruction reconstruction with allograft
Kitaumura Case series et al35
30 patients with chronic combined All ligaments were reconstructed. MCL/cruciate ligament injuries. MCL was reconstructed with a 16 MCL/ACL, 5 MCL/PCL, doubled autogenous 9 MCL/ACL/PCL semitendinosus graft
Case series
14 patients with chronic MCL MCL reconstructed with Achilles injury who failed nonoperative bone plug allograft. ACL and treatment with combined cruciate PCL reconstructed as needed ligament injury
Marx et al36
Only 1 patient required MCL reconstruction at second stage. Average side to side laxity with KT-1000 was 2.3 ± 1.9 mm. No knees had varus or valgus instability 98% normal or nearly normal medial stability IKDC score. 74% normal or nearly normal overall IKDC score. 91% of patients were satisfied or very satisfied Valgus laxity improved less than 2 mm of opening in 92% (normal according to IKDC criteria). ROM was normal or near normal in all patients. Mean postop Lysholm score was 91.9 21/24 patients symptoms were rated as normal or nearly normal according to the IKDC criteria. All had normal or near normal ROM. All had 2 mm or less medial joint opening post operatively (normal according to IKDC criteria) 5/25 patients in group A, 1/27 in group B, 1/21 in group C failed their repair or reconstruction. Lysholm scores improved from 89 to 94 in repair groups, 85 to 87 in reconstruction groups Lysholm scores averaged 94.8 points without significant difference among groups. In the IKDC evaluation, 9 patients were graded as A, 17 were graded as B and 3 were graded as C, 1 was graded as D. There was no significant difference in medial joint opening between reconstructed and intact knees All 14 cases had grade 0-1 medial joint laxity. In cases of MCL and primary ACL reconstruction, IKDC subjective score was 91, Lysholm score was 92 and KOOS sports score was 93
ACL indicates anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament .
could be performed if conservative treatment of this ligament had failed.26 Others prefer to decide whether to treat the medial structures operatively depending on the extent of injury to the medial side of the knee. In a study by Shirakura and colleagues a group of 14 ACL/MCL injuries with grade III MCL tears that demonstrated anterior subluxation of the medial tibial plateau during laxity tests under anesthesia received suture repair with ligament stapling of the medialsided structures without ACL reconstruction. Compared with 11 patients treated nonoperatively for either ligament, they found that there was no difference in ligamentous laxity or Tegner activity scores. The operative group did have significantly higher Lysholm functional scores (98.5 Copyright
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vs. 93.8).28 They found no difference in proximal or distal lesions. Robins and colleagues examined how the proximaldistal location of medial collateral ligament injury affected postoperative motion after combined MCL repair and ACL reconstruction. They found that the distal lesions had faster return of motion and greater maximal flexion than the proximal lesions. They concluded that proximal injuries should to be treated more aggressively with physical therapy. Another treatment option discussed in their paper was to only repair distal lesions, as these injuries seem to be more tolerant of surgical treatment.24 Nakamura and colleagues also examined the importance of the location and extent of the lesion on the capacity for healing. In their prospective cohort study of 17 patients they found that all 5
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patients who had magnetic resonance imaging evidence of medial collateral ligament damage over the whole length of the ligament had residual valgus laxity despite nonoperative treatment with a brace.29 More recent literature supports a differing approach; initial conservative treatment of the MCL with reconstruction of the anterior cruciate ligament.23,25,37 Shelbourne and colleagues treated 68 patients with combined ACL/MCL injuries with reconstruction of the ACL only. 96% of their patients were without subjective instability and all patients had a firm endpoint to valgus at 30 degrees. Further, they found no statistically significant difference in stability or reoperation rates when compared with patients they had previously treated with ACL reconstruction combined with MCL repair.23 This approach was further validated with a prospective randomized trial of 47 patients of combined ACL/MCL disruption. All patients were treated with acute ACL reconstruction with 23 patients being treated with concomitant MCL repair and 24 patients without MCL repair. They found no difference in postoperative stability, range of motion, muscle power, return to activities, or outcome scores at a mean 20 months follow-up.6 A prospective randomized clinical study also supported improved outcomes with nonoperative treatment of the medial collateral ligament in combined knee injuries. Halinen and colleagues randomized 47 patients with combined ACL and grade III MCL injuries into early reconstruction of the ACL with repair of the MCL (group I) or early reconstruction of the ACL with nonoperative treatment of the MCL (group II). They found that the group of patients who had their MCL treated nonoperatively had faster restoration of flexion and quadriceps muscle strength.5 Combined ACL/MCL injuries are commonly secondary to low-velocity sporting activities, and in these injury patterns may be amenable to nonoperative treatment of the MCL with delayed reconstruction of the ACL. However, high velocity knee dislocation injuries should be recognized as a much more severe injury pattern necessitating earlier stabilization with poorer outcomes.19,38 In a study comparing acute (within 3 wk) and chronic (after 3 wk) repair/ reconstruction of knee dislocations, Harner and colleagues found that those in the acutely treated group had higher objective stability and higher subjective scores. They also found that patients with these injuries were able to return to strenuous labor or high-demand sports activities unpredictably, irrespective of the acuity of treatment.39 Although a trial of nonoperative treatment of the MCL is an acceptable treatment plan for some injury patterns, not all patients will progress to healing and normal medial stability.19,38,40 Further, chronic injuries to the medial structures of the knee may not have adequate tissue quality and quantity to be amenable to surgical repair. The commonly used anatomic technique by Kim and colleagues is only one of many that have been described in the literature, with most studies of reconstruction techniques reporting good outcomes in terms of stability or subjective patient outcomes.30–33,41–44 However, comparing outcomes among these multiple techniques can be difficult to interpret. Some techniques reconstruct only the medial collateral ligament, although others emphasize anatomic reconstruction of the posteromedial corner structures as well. No clinical outcome studies have been reported comparing different techniques. Multiple injury patterns are reported
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regarding the number of different knee ligaments involved both between and within individual studies. Both allograft and autograft tissues have been utilized. For these reasons, future clinical studies comparing repair techniques may improve the ability of the treating surgeon to choose one reconstruction technique over another to achieve maximal outcomes for their patients. However, there has been one more recent study that compared outcomes of repair versus reconstruction of posteromedial corner injuries in knee dislocation patterns. A repair was performed of the posteromedial corner if there was a medial avulsion injury of the posteromedial corner including the medial collateral ligament and the posterior oblique ligament or if there was high quality tissue amenable for repair within 4 weeks of injury. All other patients had an anatomic posteromedial reconstruction with either allograft or autograft. They found that 5/25 of patients who had their MCL repaired had a failure of repair, whereas only 2/48 reconstructions failed and demonstrated that reconstruction of the medial structures lead to better stability in this injury pattern. However, 37% of their patients were lost to follow-up. There was no difference in return to full-time employment, and the incidence of arthrofibrosis was similar in both groups (20% of repairs, 17% of reconstructions).34
AUTHORS’ APPROACH TO MEDIAL-SIDED KNEE INJURIES Medial-sided knee injuries can be difficult to treat. Our approach to partial (grade I/II) injuries is similar to that of many authors; we treat these injuries with a short period of bracing and early motion. This is followed by a return to sport when strength and stability return. We also tend treat the medial side of the knee nonoperatively when the MCL alone is injures as well as when combined with an anterior cruciate ligament injury. When combined, the ACL is treated with reconstruction in a delayed manner after the MCL has healed and knee motion has returned. We reconstruct the medial ligamentous structures in cases in which valgus laxity or anteromedial rotatory instability persists despite nonoperative treatment, and when the MCL injury is combined with at least 2 other ligament injuries. We have found the reconstruction method of Kim and colleagues to provide excellent stability and reproducible outcomes. In this method, the distal end of the semitendinosus tendon is left attached to the tibia while the proximal end is stripped from its muscle belly with a tendon stripper. After the proximal muscle is removed, the proximal end is whip stitched with a no. 2 nonabsorbable suture. A K-wire is placed in the middle of the MCL femoral insertion. Isometry is confirmed by looping the graft over the wire and placing the knee through a range of motion. Once confirmed, a 6.5 mm cancellous screw with a spiked washer is placed in this location. The graft is pulled taught and the knee place in 30 degrees of flexion and varus while the screw is tightened down to bone. The free end of the graft is then pulled distally and sutured under tension into the insertion of the semimembranosus with no. 2 nonabsorbable suture. With this technique, the anterior arm replicates the MCL, whereas the posterior arm provides additional rotational stability by reproducing the course of the posterior oblique ligament.32 Postoperatively, the knee is placed in a brace and early motion is allowed.
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CONCLUSIONS In conclusion, outcome studies of treatment strategies of medial-sided knee injuries can be difficult to interpret. However, some conclusions can be made. Isolated partial or complete MCL injuries can be treated nonoperatively with a brace and early motion with good outcomes in terms of stability and return to play. However, many complete injuries are associated with other ligaments within the knee, and there is even variation in reporting which medial structure was injured. Nonoperative management of acute MCL injuries in ACL-MCL injured patients is supported by 2 randomized prospective trials. In knee dislocation patterns in which the medial tissues are not amenable to repair, reconstruction may produce better outcomes, but the optimal reconstruction technique has not been proven. REFERENCES 1. LaPrade RF, Engebretsen AH, Ly TV, et al. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89:2000–2010. 2. Fetto JF, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res. 1978;132:206–218. 3. Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004;32:337–345. 4. Sandberg R, Balkfors B, Nilsson B, et al. Operative versus nonoperative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am. 1987;69:1120–1126. 5. Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am. 2009;91:1305–1312. 6. Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2006;34: 1134–1140. 7. Derscheid GL, Garrick JG. Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9:365–368. 8. Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1988;226:103–112. 9. Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med. 1996;24:160–163. 10. Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc. 2006;14:84–90. 11. Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1980;147:22–28. 12. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65:323–329. 13. Reider B, Sathy MR, Talkington J, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med. 1994;22:470–477. 14. Mauck H. A new operative procedure for instability of the knee. J Bone Joint Surg. 1936;18:894–990. 15. Hughston JC, Barrett GR. Acute anteromedial rotatory instability. Long-term results of surgical repair. J Bone Joint Surg Am. 1983;65:145–153.
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35. Kitamura N, Ogawa M, Kondo E, et al. A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries: clinical outcomes. Am J Sports Med. 2013;41:1274–1281. 36. Marx RG, Hetsroni I. Surgical technique: medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470: 798–805. 37. Azar FM, Aaron DG Jr. Surgical treatment of anterior cruciate ligament-posterior cruciate ligament-medial side knee injuries. J Knee Surg. 2005;18:220–227. 38. Klimkiewicz JJ, Petrie RS, Harner CD. Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures. Clin Sports Med. 2000;19:479–492, vii.
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39. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86A:262–273. 40. Jacobson KE, Chi FS. Treatment of chronic injuries to the medial side of the knee. Tech Knee Surg. 2007;6:106–111. 41. Wijdicks CA, Griffith CJ, Johansen S, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92:1266–1280. 42. Borden PS, Kantaras AT, Caborn DN. Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy. 2002;18:E19. 43. Grana WA, Gimple K. Reconstruction of traumatic complete loss of the medial collateral ligament: a case report. Clin Orthop Relat Res. 1981;160:153–157. 44. Stannard JP. Medial and posteromedial instability of the knee: evaluation, treatment, and results. Sports Med Arthrosc. 2010;18:263–268.
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