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Posteromedial Corner : Diagnosis, Management, and Outcomes A Critical Analysis Review

Mark E. Cinque, MS Abstract » The posteromedial corner of the knee comprises the superficial Jorge Chahla, MD, PhD medial collateral (MCL), deep MCL, posterior oblique Bradley M. Kruckeberg, BA ligament, oblique popliteal ligament, and posterior horn of the . The main medial knee structure is the superficial MCL. Nicholas N. DePhillipo, MS, ATC, OTC » Injuries to the medial knee are the most common knee ligament injuries. A comprehensive history and physical examination are key to Gilbert Moatshe, MD the diagnosis of a posteromedial corner . Patients often present Robert F. LaPrade, MD, PhD with swelling and over the medial line after an injury involving a valgus and external rotation force. The valgus stress and anteromedial drawer tests can aid the clinician in deciphering whether Investigation performed at the an isolated medial structure was injured or if a complete posterome- Steadman Philippon Research dial corner injury is likely. Institute, Vail, Colorado » Valgus stress radiographs can be utilized to quantify the amount of medial joint gapping. A side-to-side difference in gapping of 3.2 mm is consistent with an isolated superficial MCL tear, and a side-to-side difference of $9.8 mm is consistent with a complete posteromedial corner injury. Magnetic resonance imaging is also a useful tool in the detection of medial-sided injuries and has been reported to have an 87% accuracy.

» Although a large number of can be treated nonoperatively, complete posteromedial corner injuries may require surgical treatment to restore joint stability and . There is heterogeneity between techniques with regard to the type of graft, the tibial and femoral tunnel position, and the tensioning protocol. Anatomic techniques have been reported to better restore knee kinematics and function.

edial-sided knee injuries prompt identification and evaluation to are among the most improve long-term prognosis of the common knee ligament knee1,2. Grade-III medial-sided injuries, injuries encountered by as defined by LaPrade et al.3, have been orthopaedicM surgeons. These injuries often reported to have a concomitant cruciate occur when a valgus stress is applied to the ligament injury in as many as 78% of knee along with tibial external rotation. cases (47 of 60 patients)2. These ligament injuries can occur in isola- Recently, there has been increasing tion or with concomitant meniscal or interest in the posteromedial corner of the cruciate ligament injuries, which require knee that has led to better understanding of

Disclosure: There was no external funding for this work. On the Disclosure of Potential Conflicts of which are provided with the online version of the article COPYRIGHT © 2017 BY THE Interest forms, , one or more of the authors JOURNAL OF BONE AND JOINT checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena , INCORPORATED outside the submitted work (http://links.lww.com/JBJSREV/A250).

JBJS REVIEWS 2017;5(11):e4 · http://dx.doi.org/10.2106/JBJS.RVW.17.00004 1 | Posteromedial Corner Knee Injuries: Diagnosis, Management, and Outcomes

the and its role in knee kine- on the diagnosis and management of The posterior oblique ligament has matics. The posteromedial corner of the posteromedial corner knee injuries and 3 fascial attachments at the distal aspect knee includes 5 major components: the assesses current posteromedial corner of the semimembranosus tendon8. The superficial medial collateral ligament reconstruction techniques and out- main arm of the posterior oblique liga- (MCL), the deep MCL, the posterior comes. Current reconstruction tech- ment is the central arm, which arises oblique ligament, the oblique popliteal niques for the superficial MCL and from the main semimembranosus ten- ligament, and the posterior horn of the posterior oblique ligament have been don and reinforces the deep MCL and medial meniscus. Historically, the no- described in the literature and therefore then continues to attach to and blend menclature of the medial knee structures will be the focus in the anatomic and with the posteromedial joint capsule and has been inconsistent, leading to con- biomechanical sections. medial meniscal junction8. The femoral fusion and controversy4-6. In an attempt attachment of the central arm of the to standardize the nomenclature and to Quantitative Anatomy of the posterior oblique ligament is located accurately guide anatomic reconstruc- Posteromedial Corner 7.7 mm distal and 2.9 mm anterior to tions, LaPrade et al.3,7,8 reported on the The anatomy of the posteromedial cor- the gastrocnemius tubercle. quantitative anatomy of the medial ner of the knee is complex, which can The semimembranosus tendon has structures of the knee and identified render injuries to any combination of multiple tibial attachments that provide each of the structures in relation to reli- structures challenging to treat surgically. dynamic stabilization to the postero- able anatomic landmarks9,10. The posteromedial corner of the knee medial corner15,16. The anterior arm of Assessment of medial knee injuries comprises the superficial MCL, the deep the semimembranosus attaches to the can be challenging; therefore, in addi- MCL, the posterior oblique ligament, deep to the proximal attachment of tion to a detailed physical examination, the oblique popliteal ligament, and the the superficial MCL, and the direct arm imaging studies are recommended to posterior horn of the medial meniscus attaches posteromedial to the medial assist in the diagnosis. The grade of (Fig. 1). To properly treat an injury to tibial crest8 (Fig. 1). the medial knee injury is based on the any combination of the structures in the number of structures that are torn, and posteromedial corner, it is necessary to Diagnosis of Posteromedial treatment options depend on the loca- understand not only anatomic relation- Corner Injuries tion of the tear and presence of concur- ships, but also the biomechanical roles Biomechanics of the rent ligament injury. The majority of of each structure both individually and Posteromedial Corner medial injuries will usually heal without as a unit. There is an intricate interplay between operative intervention2,11. However, a The main medial structure is the the posteromedial structures, and an subset of patients with grade-III medial superficial MCL, which averages 10 to important load-sharing distribution be- knee injuries will develop persistent pain 12 cm in length. The femoral superficial tween the superficial MCL and the and continued functional rotatory or MCL attachment is 3.2 mm proximal posterior oblique ligament has been valgus instability after nonoperative and 4.8 mm posterior to the medial epi- reported that depends on the knee flex- treatment. Identifying patients at risk for condyle. The superficial MCL has 2 ion angle17. The proximal superficial poor outcomes following conservative tibial attachments: the proximal tibial MCL is the primary knee valgus management is important but chal- attachment, which is a soft-tissue at- stabilizer across all knee flexion lenging because of inconsistent reports. tachment 1 cm distal to the joint line on angles8,10,18,19. The proximal superfi- There is still controversy in the literature the anterior arm of the semimembra- cial MCL acts as a secondary stabilizer on the treatment of combined postero- nosus tendon, and the distal attachment to external and internal rotation medial corner injuries with concomitant on the tibia, which is located 6 cm distal depending on the knee flexion angle9,20. cruciate ligament injuries. Some authors to the joint line. The deep MCL is a The distal superficial MCL acts as a have advocated for nonoperative treat- thickening of the medial joint capsule, primary stabilizer for both external and ment of all medial-sided injuries2; which is firmly adherent to, but separa- internal rotation. The posterior oblique however, because of the increased risk of ble from, the superficial MCL. The deep ligament and the posteromedial capsule developing persistent anteromedial ro- MCL femoral attachment site is ap- provide primary valgus restraint in ex- tatory instability, leading to increased proximately 1 cm distal to that of the tension, and the superficial MCL plays force on the reconstructed cruciate lig- superficial MCL and courses distally to a more dominant role in flexion because aments, most authors advocate for con- attach to the medial part of the menis- of relaxation of the posterior oblique current operative treatment of medial cus, which includes the meniscofemoral ligament in flexion9. Moreover, biome- structures in a knee with injury to mul- and meniscotibial divisions. On the chanical studies have demonstrated the tiple ligaments1,12,13. tibia, the deep MCL attaches approxi- role of the posterior oblique ligament as This article provides a critical mately 3 to 4 mm distal to the joint a primary stabilizer for internal rotation analysis of the current, relevant literature line14. and a secondary stabilizer for valgus

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Fig. 1 Figs. 1-A and 1-B The posteromedial corner. AMT 5 adductor magnus tendon, VMO 5 obliquus muscle, SM 5 , MPFL 5 medial patellofemoral ligament, MGT 5 medial gastrocnemius tendon, POL 5 posterior oblique ligament, sMCL 5 superficial medial collateral ligament, ME 5 medial epicondyle, AT 5 adductor tubercle, and GT 5 gastrocnemius tendon. Fig. 1-A Illustration. (Reproduced from: LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007 Sep;89[9]:2000-10.) Fig. 1-B Cadaveric specimen showing soft-tissue attachments of the posteromedial side of the knee. and external rotation7,21. Valgus insta- The degree of valgus gapping is related to posterolateral tibial rotation with an in- bility, which is observed in the setting the severity of the injury. For isolated crease of tibial external rotation via an of medial-sided tears, increases the forces superficial MCL tears, the maximum increased excursion of the tibial tubercle. on both the anterior cruciate ligament amount of valgus gapping should be Additionally, the dial test should be (ACL) and the posterior cruciate liga- observed with the knee in 20° to 30° performed at both 30° and 90° of knee ment (PCL), increasing the risk of graft of flexion. If valgus gapping is observed flexion19,21. A positive dial test, defined failure if the posteromedial corner is with the lower limb in full extension, by increased anteromedial tibial trans- not concurrently repaired or a concurrent injury to the meniscofe- lation observed as increased excursion of reconstructed19,22. moral deep MCL attachment, the the tibial tubercle from the neutral po- Patients with a posteromedial posterior oblique ligament, or both sition when a rotational force is applied corner injury often have pain, valgus structures should be suspected. Fur- to the tibia while the is fixed, may instability, and anteromedial rotatory thermore, physical examination find- be indicative of a medial knee injury21. instability. A detailed history and phys- ings suggestive of valgus gapping in Patients with injuries to the posterolat- ical examination are important initial extension should raise the suspicion for eral corner structures also may present steps in the diagnosis and will help to a concomitant ACL injury21,23. with increased tibial external rotation; guide further workup of suspected The anteromedial drawer test is hence, pathologic external rotation is posteromedial injuries. performed with the knee in 80° to 90° of not pathognomonic for posteromedial flexion and the foot externally rotated corner injuries. In posteromedial Physical Examination 10° to 15°. The examiner then exerts an corner injuries, the anteromedial aspect A comprehensive examination should anterior and external rotatory force on of the tibia subluxates anteriorly on the be carried out at different knee flexion the foot and the tibia and assesses the femur, and in the posterolateral corner angles to evaluate the different postero- amount of anteromedial tibial rotation. injuries, the posterolateral aspect of the medial structures. Patients with postero- The examiner visually assesses the loca- tibia subluxates posteriorly on the fe- medial corner injuries have increased tion of tibial rotation to differentiate mur. Biomechanical studies have dem- laxity with application of a valgus stress. between anteromedial and onstrated the important role of the

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Fig. 2 Valgus stress radiographs of the right and left in a patient with a left- sided posteromedial corner injury. A comparison of medial compartment gapping reveals a side-to-side differ- ence of 3.8 mm, indicative of a complete superficial MCL injury.

posterior oblique ligament in control- Imaging Pellegrini-Stieda calcification20. Valgus ling internal rotation near full extension. The 2 primary imaging modalities used stress radiographs made with the knee On physical examination, an increased for diagnosing posteromedial corner in 20° of flexion are more helpful in valgus gapping in extension and an in- injuries are valgus stress radiographs makinganobjectivediagnosis.A3.2-mm creased internal rotation near full ex- and magnetic resonance imaging (MRI). side-to-side difference in medial tension can be observed in posterior Radiographs should be obtained for gapping is consistent with a complete oblique ligament injuries. Complete suspected medial knee injuries; how- superficial MCL injury24. Furthermore, posterolateral corner injuries will result ever, these images are often normal fol- biomechanical studies have demon- in increased varus gapping and increased lowing acute injuries. Chronic medial strated that a complete posteromedial external rotation of the tibia. A 10° to15° knee injuries may present with hetero- corner injury can result in a side-to-side side-to-side difference in rotation is topic ossification of the femoral inser- difference of $9.8 mm of medial gap- considered pathologic. tion of the MCL, referred to as the ping24 (Fig. 2). Long-leg, weight-

Fig. 3 Coronal cut of an MRI (T2 sequence) demonstrating a proximal tear of the superficial MCL (sMCL) (Fig. 3-A) and a tear of the meniscofemoral ligament portion of the deep MCL (Fig. 3-B). Of note, osseous edema can be seen on the lateral compartment. ME 5 medial epicondyle.

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bearing, anteroposterior radiographs are depends largely on the experience of interposed between the attachment important in chronic MCL injuries to the examiner. and the superficial MCL tissue. assess for valgus alignment. A second, more objective, radio- MRI can also be utilized to identify graphic classification is based on bilateral Operative Management injured posteromedial corner structures valgus stress radiographs, made at 20° of High-grade injuries of the posterome- and to identify concomitant injuries. knee flexion. As stated before, a 3.2-mm dial corner, specifically injuries with Coronal MRI sequences (Fig. 3) are increase in medial gapping compared valgus gapping in extension or grade-III particularly useful in imaging the with the contralateral lower limb is meniscotibial MCL tears, have a medial knee structures and have been consistent with a complete superficial higher risk of not healing, with a resul- reported to have an accuracy of 87%23. MCL injury, and a 9.8-mm increase in tant residual valgus and rotational Also, lateral compartment bone bruises medial gapping compared with the instability18,32. Persistent instability have been described as a secondary sign contralateral lower limb is consistent increases the load on the cruciate liga- of medial-sided knee injuries. Lateral with combined posteromedial corner ment grafts, increasing the risk of re- compartment bone bruises have been injury24. construction graft failure. Therefore, in reported to be present in 45% of isolated a setting of a multiligament knee injury medial knee injuries25. Treatment of Grade-III Medial involving the posteromedial corner, Ultrasound can also be used to Knee Injuries early concurrent augmentation (if the visualize the MCL26,27 and has been Nonoperative Management posterior oblique ligament can be reported to be effective in evaluating Grade-I and II superficial MCL injuries repaired) is recommended to facilitate MCL injuries in 1 small series28; how- are usually treated nonoperatively. early mobilization and rehabilitation33. ever, it has not been demonstrated to However, the treatment of grade-III Allograft tendons can be utilized for the be superior to stress radiographs or injuries is largely dependent on the reconstruction in chronic medial-sided MRI evaluation of isolated MCL and presence or absence of concomitant injuries involving the posterior oblique posteromedial corner injuries. ligament tears19. Isolated, acute grade- ligament in which the posterior oblique III posteromedial corner injuries are ligament cannot be repaired primarily. Classification typically managed with nonoperative Allograft tissue is also utilized in patients The clinical injury classification relies on treatment with bracing for 5 to 7 weeks who have deficient because the amount of medial compartment and physical rehabilitation programs of a previous surgical procedure. gapping present with an applied valgus that focus on restoring quadriceps Patients with chronic posterome- stress during the physical examination. function, enhancing knee range of mo- dial knee injuries who report rotatory The American Medical Association tion,and controlling edema30.Although and valgus instability would likely re- (AMA) grading scale is frequently uti- several different knee rehabilitation quire a full posteromedial reconstruc- lized to classify the severity of injuries29. protocols have been proposed to treat tion (superficial MCL and posterior A grade-I tear presents with localized isolated, acute medial knee injuries, oblique ligament). These patients with pain along the medial knee structures satisfactory outcomes have been reported chronic injury should be evaluated for and 0 to 5 mm of medial compartment regardless of protocol disparity10. frontal plane knee alignment, because gapping compared with the contralat- There is no consensus in the current those with a valgus alignment may re- eral, uninjured knee. An isolated grade- literature on whether a hinged knee quire a first-stage osteotomy or a super- II medial knee injury also presents with brace is necessary to treat grade-III me- ficial MCL or posteromedial corner localized pain along the medial knee dial knee injuries. Our protocol utilizes a reconstruction with a concurrent distal structures and demonstrates substantial brace during the early phases of reha- femoral osteotomy. If alignment is not gapping with a present end point. Fi- bilitation and then either continues to corrected prior to or concurrently with nally, a grade-III, or complete, medial use the brace through the ongoing a ligament surgical procedure, the pos- knee injury is present when there is no competitive season or discontinues use teromedial corner reconstruction graft defined end point. Of note, the gap 8 to 12 weeks after the injury. Injury has a higher risk of failure. sizes corresponding with grade-I injuries pattern has been shown to affect out- have been reported to be 0 to 5 mm, comes following nonoperative treat- Anatomic Superficial MCL those for grade-II injuries have been ment. Proximal MCL injuries have Augmentation Technique reported to be 6 to 10 mm, and those for superior outcomes when compared with An anteromedial hockey-stick incision is grade-III injuries have been reported to distal injuries31. The poor healing of performed and blunt dissection is car- be .10 mm compared with the unin- distal superficial MCL injuries may be ried out over the sartorius . The jured contralateral knee. However, be- due to the poor vascularity in the distal semitendinosus and gracilis tendons are cause of the subjective nature of this test, superficial MCL tibial attachment and isolated and an open-ended the accuracy is less than optimal and the tendency of the pes tendons to be tendon stripper is used to detach the

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tendons proximally. Care is taken to the adductor magnus tendon as a refer- length is removed. A passing suture is preserve their distal insertion. The pos- ence. The superficial MCL proximal thenpulledthroughthetunnel topullthe teromedial aspect of the tibia is identi- attachment is 12 mm distal and 8 mm graft into the reconstruction tunnel. The fied at this point and 2 double-loaded anterior to the adductor tubercle8.A knee is positioned at 20° of flexion in suture anchors are placed at the distal sharp dissection is performed on the neutral rotation, a gentle varus force for tibial insertion of the superficial MCL, superficial MCL proximal attachment reduction is applied, and the grafts are 6 cm distal to the joint line. The first to define it, and an eyelet pin is placed fixed with a 7 3 23-mm bioabsorbable anchor is placed at the posterior inser- through its center with an aiming guide. screw.Aspinalneedleisusedtodefinethe tion and then is used as a reference for A 35-mm-deep tunnel is reamed using joint line, the last double-loaded suture the second anchor, which is placed a 7-mm acorn reamer. Both tendon anchor is inserted 12 mm distal to the slightly anterior and proximal. The grafts are then passed through deep to joint line, and the sutures are tied to the semitendinosus and gracilis tendons the sartorial fascia along the native grafts with the knee positioned at 20° of are now sutured to the tibia, along with course of the superficial MCL. A guide- knee flexion and in neutral rotation to the remnant superficial MCL, to re- pin is then placed in the femoral recon- reconstitute the superficial MCL proxi- constitute the distal superficial MCL struction tunnel and the graft is mal tibial attachment (Fig. 4-A). tibial attachment. Once the hamstring measured from this point such that In patients with multiligament in- grafts are secured distally, proximally, 30 mm of graft is whipstitched for later juries, the sequence of graft fixation is the adductor tubercle is identified using passage into the tunnel. The excess graft dependent on the involved .

Fig. 4 Figs. 4-A and 4-B Schematic representations of a left knee. Fig. 4-A Superficial MCL augmentation technique. ME 5 medial epicondyle. (Reproduced, with permission, from: Wijdicks CA, Michalski MP, Rasmussen MT, Goldsmith MT, Kennedy NI, Lind M, Engebretsen L, LaPrade RF. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med. 2013 Dec;41[12]:2858-66. Epub 2013 Sep 13.) Fig. 4-B Full posteromedial corner reconstruction. sMCL 5 superficial MCL and POL 5 posterior oblique ligament. (Reproduced, with permission, from: Wijdicks CA, Ewart DT, Nuckley DJ, Johansen S, Engebretsen L, LaPrade RF. Structural properties of the primary medial knee ligaments. Am J Sports Med. 2010 Aug;38[8]:1638-46.)

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The senior author performs multiliga- reconstruction of the proximal and distal adductor tubercle and constitutes the ment reconstructions in the following divisions of the superficial MCL and “lighthouse” (a critical structure within order: PCL, posterolateral corner, ACL, the posterior oblique ligament using 2 an anatomical area that gives a surgeon and, lastly, MCL or posteromedial cor- separate semitendinosus grafts3. For this perspective during initial soft-tissue ner. Concomitant, early anatomic re- technique, a 7 3 25-mm closed socket dissection) to the medial side of the construction of all torn ligaments has tunnel is reamed at the distal superficial knee44. The medial epicondyle is located been reported to better restore knee joint MCL attachment, 6 cm distal to the 12.6 mm distal and 8.3 mm anterior to kinematics while allowing for early joint line. When there is a concurrent the adductor tubercle. An eyelet passing rehabilitation3,14,33-38. Furthermore, PCL reconstruction, tunnel conver- pin is drilled through the superficial isolated cruciate ligament reconstruc- gence can be avoided by aiming the su- MCL femoral attachment aiming ante- tion in knees with collateral ligament perficial MCL tunnel 30° distally42,43.A riorly and proximally. Prior to reaming deficiency has been shown to change 7 3 25-mm closed-socket tibial poste- the superficial MCL tunnel, an eyelet joint kinematics39 and increase graft rior oblique ligament reconstruction pin is drilled at the femoral posterior forces on the ACL and PCL40,41. Thus, tunnel is reamed, aiming toward the oblique ligament attachment (7.7 mm single-stage reconstruction is advocated Gerdy tubercle10. However, when there distal and 2.9 mm anterior to the gas- in the setting of multiligament injuries. is a concurrent PCL tunnel, the poste- trocnemius tubercle) and parallel to rior oblique ligament tunnel should be the superficial MCL femoral eyelet pin, Anatomic Posteromedial aimed 15 mm medial to the Gerdy tu- ensuring enough bone bridge between Corner Reconstruction bercle to avoid tunnel convergence42. the tunnels. A 7-mm reamer used to LaPrade et al. outlined an anatomi- The distal attachment of the ad- ream both the superficial MCL and cally based posteromedial corner ductor magnus tendon is a reliable posterior oblique ligament reconstruc- reconstruction technique that includes landmark for identification of the tion tunnels to a depth of 25 mm. When

Fig. 5 Figs. 5-A through 5-D Intraoperative photographs of an anatomic posteromedial corner reconstruction. Fig. 5-A Two suture anchorsare usedto securethedistal superficialMCL (sMCL)to itsanatomictibialattachment. Fig. 5-BAguideis thenusedto drillthe femoral sMCL insertion tunnel. A surgical tool is placed deep in the adductor tendon to allow the surgeon to identify the sMCL femoral footprint. Fig. 5-C The whipstitched hamstring graft is brought into the surgical field and is measured to ensure that there is sufficientlength.Fig.5-D ThesMCL graftis fixedwith thetibia inneutralrotationat 20°of flexionanda slightvarus reductionforce to ensure that no medial compartment gapping occurs.

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the PCL is reconstructed concurrently, oblique ligament. Detailed information isolated posteromedial injury, assuming the superficial MCL should be aimed regarding graft type, fixation technique, appropriate progression with respect to 40° proximally and 40° anteriorly and and tensioning characteristics can be strength and completion of functional the posterior oblique ligament should be found in Table I. sport testing19,51,54. aimed 20° proximally and 20° anteriorly to avoid convergence with PCL Postoperative Management Clinical Outcomes tunnels43. Early protected range of motion and LaPrade and Wijdicks10 reported on 28 The posterior oblique ligament aggressive rehabilitation to decrease patients who underwent anatomic pos- graft is tightened first in full extension, postoperative stiffness should be teromedial corner reconstruction of the followed by the superficial MCL graft, performed10,49. The specific rehabilita- MCL and posterior oblique ligament which is fixed with the tibia in neutral tion protocol is dependent on concom- with concurrent cruciate or bicruciate rotation, at 20° of flexion and with a itant ligament injuries and resulting ligament reconstruction. Patients had slight varus reduction force to ensure reconstructions performed along with clinical improvement in mean subjective that no medial compartment gapping the posteromedial corner reconstruc- International Knee Documentation occurs. A suture anchor is placed at tion. Most commonly, patients who Committee (IKDC) scores from 44 to the proximal tibial attachment of the undergo complete posteromedial corner 76 points postoperatively and all 28 superficial MCL, 12.2 mm distal to reconstruction will remain partially or patients had resolution of side-to-side the medial joint line, and the graft non-weight-bearing with crutches and instability at 2-year follow-up. Radio- is secured14,38 (Figs. 4-B and 5-A passive range of motion up to 90° of graphically, improvements were reported through 5-D). knee motion beginning on postopera- in valgus stress radiographs from tive day 119,48,50,51, until 6 weeks after 6.3-mm to 1.3-mm side-to-side differ- Nonanatomic Posteromedial the surgical procedure. Most authors ence. All patients had ,3-mm joint Corner Reconstruction recommend a hinged knee brace for the space widening on the valgus stress Several nonanatomic reconstructions first 6 weeks after the surgical procedure, radiographs10. for posteromedial corner injuries have regardless of weight-bearing status or Outcomes following nonanatomic been described in recent years45-48. All range-of-motion protocols10,48,52,53. reconstruction of the posteromedial cor- of these involved reconstruction of Patients typically return to sports and ner have also been described. Kim et al.55 both the superficial MCL and posterior full activity in 6 to 9 months for an described a concomitant reconstruction

TABLE I Current Literature on Surgical Techniques for the Treatment of Posteromedial Corner Injuries

Graft Type Fixation Technique Reason for Reference Autograft Allograft Femur Tibia Nonanatomic Tensioning Technique

Anatomic LaPrade10 2 semitendinosus* 2 semitendinosus* Interference Interference NA† Superficial MCL: 20° flexion, (2012) screw screw, suture neutral rotation, varus stress anchor manual tension; posterior oblique ligament: full extension, manual tension Nonanatomic Dong45 (2014) Hamstring tendon Interference Suture Single femoral tunnel, Superficial MCL and posterior and tibialis anterior screw nonanatomic tibial oblique ligament: 30° flexion, tunnels neutral rotation, varus stress; manual tension Weimann46 2 semitendinosus Cortical button Interference Single femoral tunnel, Superficial MCL: full extension; (2012) screw medial epicondyle posterior oblique ligament: 45° femoral flexion; manual tension attachment Preiss47 2 semitendinosus Interference Interference Single femoral tunnel Superficial MCL: 30° flexion; (2012) screw screw posterior oblique ligament: full extension; manual tension Lind54 (2009) Semitendinosus Interference Interference Pes attachment, single Superficial MCL: 10° flexion, screw screw femoral tunnel neutral rotation; posterior oblique ligament: 60° flexion, neutral rotation; manual tension

*2 semitendinosus autografts or allografts. †NA 5 not applicable.

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TABLE II Current Literature on Clinical Outcomes After Surgical Treatment of Posteromedial Corner Injuries*

Reference LaPrade9 Stannard52 (2012) Koga51 (2012) Kim55 (2008) Lind54 (2009) (2012) Tardy50 (2017)

Level of Evidence IV IV IV IV IV IV No. of patients 28 18 24 50 48 19 Age† (yr) 32.4 24 36.3 34 36 36.3 Duration of 18 26 52.6 40 43 75 follow-up† (mo) Type of injury NR Acute 8 10 0 27 19 Chronic 20 8 50 21 0 IKDC score† NR NR NR (points) Preop. 43.5‡ NR NR Postop. 76.2‡ 37.4 to 42.6 81 Lysholm score† Not reported NR (points) Preop. 81 NR NR NR Postop. 91 91.9 87 89 Valgus stress† NR NR NR (mm) Preop. 6.2‡ 6.0‡ 7.8‡ Postop. 1.3‡ 1.0‡ 1.1‡

*NR 5 not reported. †The values are given as the mean. ‡There was a significant difference between scores (p , 0.05).

of the MCL and posterior oblique liga- radiographs and subsequently ,2-mm who underwent reconstruction of the ment utilizing semitendinosus autograft medial joint space opening in 22 (92%) MCL and posteromedial corner using with a preserved tibial attachment in 24 of 24 patients at the time of follow-up. ipsilateral semitendinosus autograft. patients. Preoperatively, the meanmedial Lind et al.54 reported 91% satisfaction in Medial stability according to the IKDC jointopeningwas7.8mmonvalgusstress retrospective evaluation of 50 patients score was normal or nearly normal (grade

TABLE III Recommendations for Care

Treatment Option Recommendation Grade*

Superficial MCL acute repair In cases of osseous avulsions, immediate repair has been reported to yield good B results. Superficial MCL augmentation Although both augmentation and reconstruction procedures have been reported to A produce excellent outcomes with low failure rates, no definitive conclusion has been made on whether to use an augmentation or reconstruction technique. Posteromedial corner reconstruction High-grade injuries of the posteromedial corner, specifically injuries with valgus A gapping in extension or grade-III meniscotibial MCL tears, have a higher risk of not healing, with a resultant residual valgus and rotational instability, and thus should be considered for posteromedial corner reconstruction. Furthermore, patients with chronic posteromedial knee injuries who report rotatory and valgus instability would likely require a full posteromedial reconstruction.

*Grade A indicates good evidence (Level-I studies with consistent findings) for or against recommending intervention. Grade B indicates fair evidence (Level-II or III studies with consistent findings) for or against recommending intervention. Grade C indicates conflicting or poor-quality evidence (Level-IV or V studies) not allowing a recommendation for or against intervention. Grade I indicates that there is insufficient evidence to make a recommendation.

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A or B) in 98%. Improved outcomes are Bradley M. Kruckeberg, BA1, the knee. Sports Med Arthrosc. 2015 Jun;23(2): 71-6. Epub 2015 May 2. also reported after surgical treatment of Nicholas N. DePhillipo, MS, ATC, OTC2, 2,3,4 12. Bollier M, Smith PA. Anterior cruciate the posteromedial corner in the setting Gilbert Moatshe, MD , Robert F. LaPrade, MD, PhD1,2 ligament and medial collateral ligament of multiligament injuries50,52.However, injuries. J Knee Surg. 2014 Oct;27(5):359-68. Epub 2014 Jun 20. an early single-stage surgical procedure 1 Steadman Philippon Research Institute, 13. Wijdicks CA, Ewart DT, Nuckley DJ, rather than a delayed surgical procedure Vail, Colorado Johansen S, Engebretsen L, Laprade RF. yields better clinical outcomes50.Inad- Structural properties of the primary medial 2The Steadman Clinic, Vail, Colorado knee ligaments. Am J Sports Med. 2010 Aug; dition, reconstruction of the posterome- 38(8):1638-46. dial corner using either autograft or 3Oslo University Hospital, Oslo, Norway 14. Robinson JR, Bull AM, Thomas RR, Amis AA. The role of the medial collateral ligament and allograft in patients with a knee disloca- posteromedial capsule in controlling knee tion yields superior stability to that of 4Oslo Sports Trauma Research Center, laxity. Am J Sports Med. 2006 Nov;34(11): repair52. Details of each study included Norwegian School of Sports Sciences, 1815-23. Epub 2006 Jun 30. Oslo, Norway 15. Sims WF, Jacobson KE. The posteromedial are reported in Table II. corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004 Mar;32(2):337-45. Posteromedial corner reconstruc- E-mail address for R.F. LaPrade: tions are not without complications. [email protected] 16. Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L. The most commonly reported compli- Force measurements on the posterior oblique cations include deep implant removal, ORCID iD for R.F. LaPrade: 0000-0002- ligament and superficial medial collateral 9823-2306 ligament proximal and distal divisions to pain, wound , joint stiffness, applied loads. Am J Sports Med. 2009 Jan;37(1): and arthrofibrosis50,52,55. Stannard 140-8. Epub 2008 Aug 25. References and Bauer reported the prevalence of 17. Wijdicks CA, Griffith CJ, Johansen S, 1. Fanelli GC. Evaluation and treatment of Engebretsen L, LaPrade RF. Injuries to the to be 20% in the repair medial instability of the knee. Sports Med medial collateral ligament and associated group and 17% in the reconstruction Arthrosc. 2015 Jun;23(2):61-2. Epub 2015 May 2. medial structures of the knee. J Bone Joint Surg Am. 2010;92(5):1266-80. group. Furthermore, posteromedial 2. Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and nonoperative treatments of 18. Hughston JC. The importance of the corner repair was associated with higher medial collateral ligament rupture with early posterior oblique ligament in repairs of acute failure rates (20%)52. Reintervention anterior cruciate ligament reconstruction: a tears of the medial ligaments in knees with and prospective randomized study. Am J Sports without an associated rupture of the anterior rates after a posteromedial corner surgi- Med. 2006 Jul;34(7):1134-40. Epub 2006 Feb 1. cruciate ligament. Results of long-term follow- cal procedure are reported to be as high up. J Bone Joint Surg Am. 1994 Sep;76(9): 3. LaPrade RF, Engebretsen AH, Ly TV, Johansen 1328-44. as 26%50. Recommendations for care S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg 19. Fanelli GC, Harris JD. Surgical treatment are displayed in Table III. Am. 2007 Sep;89(9):2000-10. of acute medial collateral ligament and posteromedial corner injuries of the knee. 4. Last RJ. Some anatomical details of the knee Sports Med Arthrosc. 2006 Jun;14(2):78-83. joint. J Bone Joint Surg Br. 1948 Nov;30B(4): Conclusions 683-8. 20. Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Isolated grade-I or II MCL injuries and 5. Warren LF, Marshall JL. The supporting Engebretsen L. Radiographic identification of isolated grade-III superficial MCL tears structures and layers on the medial side of the primary medial knee structures. J Bone Joint the knee: an anatomical analysis. J Bone Joint Surg Am. 2009 Mar 1;91(3):521-9. may be treated nonoperatively. However, Surg Am. 1979 Jan;61(1):56-62. 21. Griffith CJ, LaPrade RF, Johansen S, ingrade-IIIsuperficialMCLinjurieswith 6. LaPrade MD, Kennedy MI, Wijdicks CA, Armitage B, Wijdicks C, Engebretsen L. Medial concomitant ligament lesions or in the LaPrade RF. Anatomy and biomechanics of knee injury: part 1, static function of the the medial side of the knee and their surgical individual components of the main medial presence of rotational instability (com- implications. Sports Med Arthrosc. 2015 Jun;23 knee structures. Am J Sports Med. 2009 Sep;37 plete posteromedial corner injury), (2):63-70. Epub 2015 May 2. (9):1762-70. Epub 2009 Jul 16. 7. Rasmussen MT, LaPrade CM, LaPrade RF. surgical reconstruction is often recom- 22. LaPrade RF, Moulton SG, Nitri M, Mueller W, Reconstruction of the posteromedial corner of Engebretsen L. Clinically relevant anatomy and mended. Stress radiographs and MRI theknee. In: Doral MN, Karlsson J, editors. Sports what anatomic reconstruction means. Knee injuries: prevention, diagnosis, treatment and are valuable in determining the extent Surg Sports Traumatol Arthrosc. 2015 Oct;23 rehabilitation. Berlin: Springer; 2015. p 1429-37. (10):2950-9. Epub 2015 May 10. of the injury and aiding in the treatment 8. Wijdicks CA, Michalski MP, Rasmussen MT, 23. Yao L, Dungan D, Seeger LL. MR imaging of choice. Early protected range of motion Goldsmith MT, Kennedy NI, Lind M, tibial collateral ligament injury: comparison Engebretsen L, LaPrade RF. Superficial medial and an aggressive postoperative rehabili- with clinical examination. Skeletal Radiol. 1994 collateral ligament anatomic augmented repair Oct;23(7):521-4. tation to decrease the prevalence of versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med. 2013 24. Laprade RF, Bernhardson AS, Griffith CJ, arthrofibrosis should be performed when Dec;41(12):2858-66. Epub 2013 Sep 13. Macalena JA, Wijdicks CA. Correlation of valgus possible. Future clinical randomized stress radiographs with medial knee ligament 9. Laprade RF, Wijdicks CA. Surgical technique: injuries: an in vitro biomechanical study. Am J studies investigating the effects of the development of an anatomic medial knee Sports Med. 2010 Feb;38(2):330-8. 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