Surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries

  • Hideyuki KogaEmail author
  • Takeshi Muneta
  • Kazuyoshi Yagishita
  • Young-Jin Ju
  • Ichiro Sekiya



Although various surgical procedures have attempted to restore valgus stability in medial knee injuries, so far none has achieved satisfactory results. The purpose of this study was to assess clinical outcome for patients with grade 3 valgus instability who were treated according to our surgical management strategy.


Eighteen patients with both acute and chronic grade 3 medial knee injuries, all of which had combined cruciate ligament injuries, were treated with a proximal advancement of both the superficial medial collateral ligament (MCL) and posterior oblique ligament together with underlying deep MCL and joint capsule, in conjunction with cruciate ligament reconstructions in chronic phase. Augmentation with doubled semitendinosus tendon was added in 7 patients whose medial knee stability had been considered to be insufficient with only the proximal advancement procedure. They were evaluated preoperatively and at final follow-up.


Manual valgus laxities at 0° and 30°, as well as side-to-side difference in medial joint opening in stress radiograph, were significantly improved at final follow-up. The Lysholm knee scale was also significantly improved. Median values of the subjective evaluations of the patients’ satisfaction, stability and sports performance level measured with visual analogue scale at final follow-up were 82 (60–100), 94 (71–100) and 88 (60–100), respectively.


Clinical outcomes of our surgical management strategy were reasonable in terms of restoring medial knee stability. This treatment protocol can help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries.

Level of evidence

Retrospective case series, Level IV.


Medial collateral ligament (MCL) Medial knee injury Operative procedure Posterior oblique ligament Multiple ligament injury 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Anderson DR, Weiss JA, Takai S et al (1992) Healing of the medial collateral ligament following a triad injury: a biomechanical and histological study of the knee in rabbits. J Orthop Res 10:485–495PubMedCrossRefGoogle Scholar
  2. 2.
    Andersson C, Gillquist J (1992) Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. A long-term follow-up study. Am J Sports Med 20:7–12PubMedCrossRefGoogle Scholar
  3. 3.
    Ballmer PM, Jakob RP (1988) The non operative treatment of isolated complete tears of the medial collateral ligament of the knee. A prospective study. Arch Orthop Trauma Surg 107:273–276PubMedCrossRefGoogle Scholar
  4. 4.
    Bin SI, Nam TS (2007) Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy 23:1066–1072PubMedCrossRefGoogle Scholar
  5. 5.
    Coobs BR, Wijdicks CA, Armitage BM et al (2010) An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 38:339–347PubMedCrossRefGoogle Scholar
  6. 6.
    Derscheid GL, Garrick JG (1981) Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains. Am J Sports Med 9:365–368PubMedCrossRefGoogle Scholar
  7. 7.
    Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy 18:703–714PubMedCrossRefGoogle Scholar
  8. 8.
    Fetto JF, Marshall JL (1978) Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res 132:206–218PubMedGoogle Scholar
  9. 9.
    Griffith CJ, Wijdicks CA, LaPrade RF et al (2009) Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. Am J Sports Med 37:140–148PubMedCrossRefGoogle Scholar
  10. 10.
    Halinen J, Lindahl J, Hirvensalo E et al (2006) Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med 34:1134–1140PubMedCrossRefGoogle Scholar
  11. 11.
    Halinen J, Lindahl J, Hirvensalo E (2009) 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 91:1305–1312PubMedCrossRefGoogle Scholar
  12. 12.
    Hara K, Niga S, Ikeda H et al (2008) Isolated anterior cruciate ligament reconstruction in patients with chronic anterior cruciate ligament insufficiency combined with grade II valgus laxity. Am J Sports Med 36:333–339PubMedCrossRefGoogle Scholar
  13. 13.
    Hefti F, Muller W, Jakob RP et al (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234PubMedCrossRefGoogle Scholar
  14. 14.
    Holden DL, Eggert AW, Butler JE (1983) The nonoperative treatment of grade I and II medial collateral ligament injuries to the knee. Am J Sports Med 11:340–344PubMedCrossRefGoogle Scholar
  15. 15.
    Hughston JC (1994) 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 76:1328–1344PubMedGoogle Scholar
  16. 16.
    Ibrahim SA (1999) Primary repair of the cruciate and collateral ligaments after traumatic dislocation of the knee. J Bone Joint Surg Br 81:987–990PubMedCrossRefGoogle Scholar
  17. 17.
    Ibrahim SA, Ahmad FH, Salah M et al (2008) Surgical management of traumatic knee dislocation. Arthroscopy 24:178–187PubMedCrossRefGoogle Scholar
  18. 18.
    Indelicato PA (1983) Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am 65:323–329PubMedGoogle Scholar
  19. 19.
    Inoue M, McGurk-Burleson E, Hollis JM et al (1987) Treatment of the medial collateral ligament injury. I: The importance of anterior cruciate ligament on the varus-valgus knee laxity. Am J Sports Med 15:15–21PubMedCrossRefGoogle Scholar
  20. 20.
    Kovachevich R, Shah JP, Arens AM et al (2009) Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc 17:823–829PubMedCrossRefGoogle Scholar
  21. 21.
    Krackow KA, Thomas SC, Jones LC (1986) A new stitch for ligament-tendon fixation. Brief note. J Bone Joint Surg Am 68:764–766PubMedGoogle Scholar
  22. 22.
    LaPrade RF, Engebretsen AH, Ly TV et al (2007) The anatomy of the medial part of the knee. J Bone Joint Surg Am 89:2000–2010PubMedCrossRefGoogle Scholar
  23. 23.
    Laprade RF, Bernhardson AS, Griffith CJ et al (2010) Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med 38:330–338PubMedCrossRefGoogle Scholar
  24. 24.
    Mauck HP (1936) A new operative procedure for instability of the knee. J Bone Joint Surg 18:984–990Google Scholar
  25. 25.
    Nagineni CN, Amiel D, Green MH et al (1992) Characterization of the intrinsic properties of the anterior cruciate and medial collateral ligament cells: an in vitro cell culture study. J Orthop Res 10:465–475PubMedCrossRefGoogle Scholar
  26. 26.
    Osti L, Papalia R, Del Buono A et al (2010) Simultaneous surgical management of chronic grade-2 valgus instability of the knee and anterior cruciate ligament deficiency in athletes. Knee Surg Sports Traumatol Arthrosc 18:312–316PubMedCrossRefGoogle Scholar
  27. 27.
    Owens BD, Neault M, Benson E et al (2007) Primary repair of knee dislocations: results in 25 patients (28 knees) at a mean follow-up of four years. J Orthop Trauma 21:92–96PubMedCrossRefGoogle Scholar
  28. 28.
    Reider B, Sathy MR, Talkington J et al (1994) Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study. Am J Sports Med 22:470–477PubMedCrossRefGoogle Scholar
  29. 29.
    Shelbourne KD, Porter DA (1992) 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 20:283–286PubMedCrossRefGoogle Scholar
  30. 30.
    Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49PubMedGoogle Scholar
  31. 31.
    Woo SL, Inoue M, McGurk-Burleson E et al (1987) Treatment of the medial collateral ligament injury. II: Structure and function of canine knees in response to differing treatment regimens. Am J Sports Med 15:22–29PubMedCrossRefGoogle Scholar
  32. 32.
    Yeh WL, Tu YK, Su JY et al (1999) Knee dislocation: treatment of high-velocity knee dislocation. J Trauma 46:693–701PubMedCrossRefGoogle Scholar
  33. 33.
    Yoshiya S, Kuroda R, Mizuno K et al (2005) Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med 33:1380–1385PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Hideyuki Koga
    • 1
    Email author
  • Takeshi Muneta
    • 1
  • Kazuyoshi Yagishita
    • 1
  • Young-Jin Ju
    • 1
  • Ichiro Sekiya
    • 1
  1. 1.Department of Orthopaedic SurgeryTokyo Medical and Dental University Hospital of MedicineBunkyo-kuJapan

Personalised recommendations