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© 2021, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). Purpose: Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. Methods: This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. Results: Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18–52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24–72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). Conclusion: Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. Level of Evidence: IV

To evaluate the mid-term outcomes of anatomic medial complex reconstruction in cases of serious medial knee instability. Between 2010 and 2013, 23 patients who underwent anatomic medial complex reconstruction with a minimum 5-year follow-up were included. The Lysholm score, International Knee Documentation Committee subjective knee form (IKDC SKF), and Tegner activity scale scores were evaluated. Clinical and functional tests included valgus and sagittal stress tests, isokinetic muscle strength test, single leg hop for distance test (SLDT), and single leg vertical jump test (SLVT). The mean follow-up duration was 77.2 ± 10.8 months. At final follow-up, the Lysholm score improved from 49.7 ± 10.2 to 93.4 ± 12.4; the IKDC SKF score, from 46.2 ± 8.7 to 90.5 ± 13.9; and median Tegner activity, from 5 (4–7) to 7 (4–10) (P

To analyze the influence of meniscal tear pattern on clinical outcomes following arthroscopic partial meniscectomy in middle-aged patients with medial meniscal tears. A total of 123 patients (130 knees) aged ≥ 50 years who underwent arthroscopic partial meniscectomy for medial meniscal tears were evaluated. Inclusion criteria were none to moderate medial knee osteoarthritis [Kellgren–Lawrence (KL) grade ≤ 3] and a minimum of 2-year follow-up (median 4.6 years; range 2.1–8.0 years). Meniscal tears observed during arthroscopic examination were classified into six types: radial tear of the middle segment, posterior root tear, horizontal tear of the posterior segment, flap tear, minor tear, and complex tear. Postoperative outcomes were classified into effective (group 1) and non-effective (group 2) according to the pain relief administered 1 month postoperatively and at the final follow-up. Demographic variables, KL grade, type of meniscal tear, and postoperative follow-up period were evaluated. Forty knees (38%) were classified into group 1. Of the six types of tears, radial tear of the middle segment [odds ratio (OR) 4.1, 95% confidence interval (CI) 1.1–20.9] and flap tear (OR 12.9, 95% CI 1.8–140.7) were significant predictors of good outcome on multivariate logistic regression analysis. In middle-aged patients with medial meniscal tears, radial tear of the middle segment was independently associated with less pain following arthroscopic meniscectomy. Arthroscopic partial meniscectomy may be indicated in patients with radial tear if conservative treatment fails. Case–control study, Level III.

The influence of patient-specific instrumentations on the accuracy of unicompartmental medial knee replacement remains unclear. The goal of this study was to examine the ability of patient-specific instrumentation to accurately reproduce postoperatively what the surgeon had planned preoperatively. Twenty consecutive patients (20 knees) who suffered from isolated unicompartmental medial osteoarthritis of the knee and underwent medial knee replacement using newly introduced magnetic resonance imaging-based patient-specific instrumentation were assessed. This assessment recorded the following parameters: (1) the planned and the postoperative mechanical axis acquired through long-leg AP view radiographies; (2) the planned and the postoperative tibial slope acquired by means of standard AP and lateral view radiographies; and (3) the postoperative fit of the implanted components to the bone in coronal and sagittal planes. The hypothesis of the study was that there was no statistically significant difference between postoperative results and preoperatively planned values. The study showed that (1) the difference between the postoperative mechanical axis (mean 1.9° varus ± 1.2° SD) and the planned mechanical axis (mean 1.8° varus ± 1.2° SD) was not statistically significant; (2) the difference between the postoperative tibial slope (mean 5.2° ± 0.6° SD) and the planned tibial slope (mean 5.4° ± 0.6° SD) was statistically significant (p = 0.008); and (3) the postoperative component fit to bone in the coronal and sagittal planes was accurate in all cases; nevertheless, in one knee, all components were implanted one size smaller than preoperatively planned. Moreover, in two additional cases, one size thinner and one size thicker of the polyethylene insert were used. This study suggests that overall patient-specific instrumentation was highly accurate in reproducing postoperatively what the surgeon had planned preoperatively in terms of mechanical axis, tibial slope and component fit to bone. IV.

Although various surgical procedures have been described for the medical collateral ligament (MCL) reconstruction, none can accurately reestablish its original anatomy and orientation. The purpose of this study was to present a technique restoring the anatomy and stability of the medial knee with an Achilles tendon allograft using a tibial inlay technique. The bone block was fixed into a cancellous trough created on the medial surface of the tibia with a cancellous screw and washer, while the tendinous portion was fixed into the femoral insertion site of the superficial MCL with a bioabsorbable interference screw. This technique can successfully reproduce the native anatomy and orientation of the MCL.

Both high tibial valgus osteotomy (HTO) and unicompartmental medial knee arthroplasty (UKA) are established methods for the treatment for moderate stages of OA. This is the first global meta-analysis to compare the long-term effects of both methods regarding survival, outcomes and complications of total arthroplasty. Literature research was performed using established medical databases: MEDLINE (via PubMed), EMBASE (via OVID) and the Cochrane register. Criteria for inclusion were as follows: English or German papers, a clinical trial with a clear description of survival, an outcome evaluation using a well-described knee score and a follow-up >5 years. Statistical analysis was performed using the special meta-analysis software called “Comprehensive Meta Analysis” (version 2.0; Biostat, Englewood, NJ, USA). Final meta-analysis after the full-text review included 46 studies about valgus HTO and 43 studies about medial UKA. There were no significant differences between valgus HTO and medial UKA in terms of the number of total required replacements. After a 5- to 8-year follow-up, 91.0% of the valgus HTO patients and 91.5% of medial UKA patients did not need a total replacement. This value was 84.4% for valgus HTOs and 86.9% for medial UKAs after a 9- to 12-year follow-up. Mean survival time to TKA was 9.7 years after valgus HTO and 9.2 years after medial UKA. Clinical outcome was significantly better after medial UKA in a 5- to 12-year follow-up. After more than 12 years, results were comparable in both groups. No significant differences were seen in the complication rates. This meta-analysis aimed to find the advantages and disadvantages of two established methods for the treatment for medial compartment knee osteoarthritis. Valgus HTO is more appropriate for younger patients who accept a slight decrease in their physical activity. Medial UKA is appropriate for older patients obtaining sufficient pain relief but with reduced physical activity. II.

For many years, the anatomy of the medial knee corner has been reported. However, it is not exactly clear how all these structures function together. The purpose of this study is to identify and try to understand the relationship between the posteromedial corners of the knee using three-dimensional visualization techniques. This study comprises of 10 knees from adult corpses. Images were acquired from the dissection of different layers of the posteromedial compartment of the knee using a camera Nikon D40 and AF-S Nikkor 18-55 mm (Nikon Corp., Japan) placed on a slide bar. The pair of images was processed using Callipyan 3D or Anabuilder software (Ana builder, France) that transforms the two different images of the same structure with the intrapupillary distance proportion into one anaglyphic image. During knee dissection, pictures were taken and transformed into three-dimensional images that become more realistic with the use of special glasses. The images were made during the dissection of the three layers of the posteromedial compartment of the knees. Posteromedial corner ligament structures are quite complex and are not always clearly described in the literature. Three-dimensional images of these structures can help better understanding its anatomy.

Surgical approaches to repair or reconstruct the medial knee structures note caution to avoid the sartorial branch of saphenous nerve. However, the approximate area of potential iatrogenic nerve injury has not been previously described in relation to landmarks for a medial knee reconstruction. The purpose of this study was to define the course of the sartorial branch of the saphenous nerve in relation to the superficial medial collateral ligament. A total of ten non-paired, fresh-frozen cadaveric knees, with no evidence of prior injury or disease were utilized. Dissection to identify the medial knee structures was performed. The sartorial branch of the saphenous nerve was identified in all specimens. The perpendicular distance from the anterior border of the superficial medial collateral ligament 2 cm distal from the joint line to the sartorial branch of the saphenous nerve was 4.8 +/- 0.9 cm. The distance from the anterior border of the superficial medial collateral ligament to the sartorial branch of the saphenous nerve decreased as the distance was increased distally with a mean distance of 4 cm (4.1 +/- 0.8 cm) distal from the joint line and 6 cm (3.8 +/- 0.8 cm) distal from the joint line. We have characterized the surgically relevant landmark anatomy of the sartorial branch of the saphenous nerve in regards to performing a repair or reconstruction of the medial knee structures. Familiarity with these anatomic landmarks and associated distances from the sartorial branch of the saphenous nerve, we can assess the potential area of vulnerability to this nerve branch intraoperatively.

This paper reports the amount of medial and lateral knee joint opening in the general population. Knee joint lateral and medial opening at 20 degrees knee flexion was quantified on manual varus and valgus stress test, respectively, with custom made device. One hundred men and women between the ages of 20-60 years were evaluated for their joint openings. Patients with previous knee surgeries or chronic knee pains were excluded from the study. Measurements were done twice by two different orthopedic surgeons who were blinded from each other. The mean age of the study group was 39 years (range 20-60 years) and 43 years for women (range 20-60 years) and 34 years for men (range 20-60). The mean lateral and medial knee joint space opening was 7.0 degrees (range 3-9 degrees ) and 4.1 degrees (range 2-7 degrees ), respectively, in the overall population; in the male population, it was 6.7 degrees (range 3-9 degrees ) and 3.9 degrees (range 2-7 degrees ), respectively, and in the female population, it was 7.2 degrees (range 3-9 degrees ) and 4.3 degrees (range 3-7 degrees ), respectively. Conversion to displacement in millimetres, the overall mean lateral and medial joint displacement was 9.3 mm (range 5.1-13.6 mm) and 4.8 mm (range 3.5-10.7 mm), respectively; for males, it was 9.1 (range 5.1-11.9 mm) and 4.6 mm (range 3.5-7.9 mm), respectively, for females, it was 9.8 mm (range 7.2-13.6 mm) and 4.9 mm (range 3.7-10.7 mm), respectively. The prevalence of the overall population that exceeds 6 mm or more lateral joint space opening was 91% (male 90% and female 92%) and medial joint space was 8% (male 4% and female 12%). Statistically, significant differences were seen between medial and lateral opening in male, female and the overall population (p0.001). The female population exhibited wider opening in both medial and lateral joint opening than the male population (p0.05). The interexaminer reliability showed no significant difference (p0.05). More than 91% of the Korean population showed wide lateral joint space opening in the bilateral knee. However, none complained of functional instability or symptoms except for non-pathologic laxity detected by the physician. We strongly recommend bilateral comparison of the knee that has wide lateral joint opening.