1. Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee
by Coen A. Wijdicks, Chad J. Griffith, Steinar Johansen, Lars Engebretsen, and Robert F. LaPrade
J Bone Joint Surg Am
Volume 92(5):
May 1, 2010
©2010 by The Journal of Bone and Joint Surgery, Inc.

2. A: Posteromedial view of the right knee, demonstrating the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL).
A: Posteromedial view of the right knee, demonstrating the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). B: Medial view of the left knee, showing the meniscofemoral and meniscotibial divisions of the deep medial collateral ligament. (Reprinted 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;89: )‏
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

3. Anteromedial view of the left knee, showing the injury grading scale established by the American Medical Association Standard Nomenclature of Athletic Injuries20.
Anteromedial view of the left knee, showing the injury grading scale established by the American Medical Association Standard Nomenclature of Athletic Injuries20. Isolated grade-I injuries present with localized tenderness and no laxity. Isolated grade-II injuries present with a broader area of tenderness and partially torn medial collateral and posterior oblique fibers. Isolated grade-III injuries present with complete disruption, and there is laxity with an applied valgus stress.
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

4. Illustration of a medial knee reconstruction procedure (medial view of a left knee).
Illustration of a medial knee reconstruction procedure (medial view of a left knee). The superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) are reconstructed with use of two separate grafts and four reconstruction tunnels. Note that the proximal tibial attachment of the superficial medial collateral ligament, which is primarily to soft tissues and is located just distal to the joint line, was recreated by suturing the superficial medial collateral ligament graft to the anterior arm of the semimembranosus muscle. (Reproduced, with permission, from: Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38: )‏
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

5. A: A valgus load is applied at 20° to 30° of knee flexion to detect medial joint opening.
A: A valgus load is applied at 20° to 30° of knee flexion to detect medial joint opening. The patient’s thigh is allowed to rest on the examination table in order to relax the thigh muscles. While the valgus force is being applied through the foot and ankle, the examiner palpates the medial joint area to determine the amount of medial joint line gapping. B: Complete injury to the medial structures increases external rotation at both 30° and 90° of knee flexion, resulting in a positive dial test41,48. As demonstrated, the patient’s lower limb is placed in 90° of knee flexion and the amount of external rotation is compared with that of the normal, contralateral knee.
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

6. Illustrations (A) and lateral knee radiographs (B) demonstrating the placement of the reference lines for correlating radiographs with the known anatomic attachment sites of the primary structures of interest in a medial knee reconstruction.
Illustrations (A) and lateral knee radiographs (B) demonstrating the placement of the reference lines for correlating radiographs with the known anatomic attachment sites of the primary structures of interest in a medial knee reconstruction. MPFL = medial patellofemoral ligament attachment, POL = posterior oblique ligament attachment, sMCL = superficial medial collateral ligament attachment, DASM = direct arm of semimembranosus muscle attachment, quadrant 1 = anteroproximal, quadrant 2 = posteroproximal, quadrant 3 = anterodistal, and quadrant 4 = posterodistal. (Reprinted from: Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L. Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am. 2009;91:521-9.)‏
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

7. Valgus stress radiographs demonstrating a grade-III injury of the left knee to the superficial medial collateral ligament and posterior oblique ligament.
Valgus stress radiographs demonstrating a grade-III injury of the left knee to the superficial medial collateral ligament and posterior oblique ligament. When a clinician applied a load at 20° of knee flexion, medial compartment gapping increased by 7.3 mm compared with that in the normal, right knee.
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

8. Proton-density-weighted magnetic resonance image showing an acute avulsion of the superficial medial collateral ligament and the meniscotibial division of the deep medial collateral ligament off their tibial attachments.
Proton-density-weighted magnetic resonance image showing an acute avulsion of the superficial medial collateral ligament and the meniscotibial division of the deep medial collateral ligament off their tibial attachments. A trabecular microfracture of the lateral epicondyle, most likely caused by an impaction force, can be seen. The arrowhead indicates the distal attachment of the superficial medial collateral ligament, which has been avulsed from its tibial attachment.
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

9. A: Intraoperative photograph demonstrating a single anteromedial incision performed on a left knee to access the anatomic femoral and tibial attachment points of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL).
A: Intraoperative photograph demonstrating a single anteromedial incision performed on a left knee to access the anatomic femoral and tibial attachment points of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). The anatomic reconstruction requires two separate grafts with four reconstruction tunnels46. The superficial medial collateral ligament and posterior oblique ligament grafts have been fixed into their femoral reconstruction tunnels. B: In this image, the superficial medial collateral and posterior oblique ligament grafts have been passed along their natural course under the sartorius fascia and the posterior oblique ligament graft has been fixed into its tibial tunnel. The superficial medial collateral ligament graft is about to be passed into its reconstruction tunnel and fixed at 30° of knee flexion.
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

10. Anteroposterior plain radiograph of a right knee, showing posttraumatic ossification known as the Pellegrini-Stieda syndrome.
Anteroposterior plain radiograph of a right knee, showing posttraumatic ossification known as the Pellegrini-Stieda syndrome. This is typically characterized by intraligamentous calcification in the region of the femoral medial collateral ligament attachment (arrowheads).
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.

11. Diagrammatic representation of the medial side of the knee and the course of the saphenous nerve and its sartorial and infrapatellar branches.
Diagrammatic representation of the medial side of the knee and the course of the saphenous nerve and its sartorial and infrapatellar branches. The distance measurements are in relation to the described landmarks. (Reproduced, with permission, from: Wijdicks CA, Westerhaus BD, Brand EJ, Johansen S, Engebretsen L, LaPrade RF. Sartorial branch of the saphenous nerve in relation to a medial knee ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc Oct 27 [Epub ahead of print].)‏
Coen A. Wijdicks et al. J Bone Joint Surg Am 2010;92:
©2010 by The Journal of Bone and Joint Surgery, Inc.