Evaluation of Knee Outcomes and Anterior Cruciate Ligament Graft Failure When Comparing Medial Collateral Ligament Reconstruction Versus MCL Repair in Patients With Multiple Ligament Knee Injuries: A Systematic Review

Abstract

Background:

A paucity of data exists to guide surgical management of the medial collateral ligament (MCL). High-grade MCL injuries are often treated with surgical repair or reconstruction; however, guidelines for choosing one or the other technique remain unclear.

Purpose:

To systematically review the literature to determine whether repair versus reconstruction of the MCL in multiligament knee injuries results in improved outcomes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed between January 1980 and January 2024. The initial search yielded 85 studies. Exclusion criteria included <2 years of follow-up, technical/case reports, articular fractures, and undifferentiated multiligament results. Extracted data included patient characteristics, ligaments injured, chronicity of injury, incidence of failure, arthrofibrosis, patient-reported outcome scores, and stress radiographs. Failure was included as reported by studies and included clinical failure (graft laxity), failure of the repair or reconstruction, or the need for a lysis of adhesions or manipulation under anesthesia. Statistical analysis included unpaired t tests and chi-square goodness-of-fit tests.

Results:

In total, 30 studies were included in the final analysis (458 repairs, 590 reconstructions). The mean patient age for the repair group was 33.1 years (SD, 5.11 years) with a mean follow-up time of 4.2 years (SD, 2.59 years) and the mean patient age for the reconstruction group was 33.4 years (SD, 4.40 years) with a mean follow-up time of 3.1 years (SD, 1.41 years). There was no significant difference found between the reconstruction and repair groups of the MCL for the Lysholm, subjective International Knee Documentation Committee, Tegner scores, and stress radiographs (P > .05). Arthrofibrosis rates for MCL reconstruction (5.4%) were determined to be significantly less than those within the repair group (11.6%) (P < .001). Failure rates for MCL reconstruction (2.9%) were determined to be significantly less when compared with the MCL repair group (5.7%) (P = .024). Anterior cruciate ligament (ACL) failure rates for MCL reconstruction (0.2%) were determined to be significantly less than those within the repair group (2.3%) (P = .002).

Conclusion:

This systematic review showed that MCL reconstructions demonstrated decreased postoperative arthrofibrosis compared with MCL repairs across all studies. Studies reporting on failures reported decreased clinical failures and ACL graft failures in the setting of concomitant ACL and MCL reconstructions compared with MCL repairs. Future randomized controlled studies are needed to further determine the best surgical technique for patients with multiligament knee injuries.

Keywords

knee ligaments MCL MCL reconstruction MCL repair multiligament injuries

Injuries to the medial collateral ligament (MCL) are the most frequent ligament knee injuries.^30,38 In the United States, the incidence of injuries to the superficial MCL (sMCL) and other medial knee stabilizers (the deep MCL and posterior oblique ligament) has been reported to be 0.24 per 1000 persons annually.⁵ Moreover, in a recent epidemiological study of 6343 patients with 7769 sports-related knee injuries, the incidence of MCL tears was 7.9%.³⁶ The mechanism of injury typically involves valgus loading of the knee, with or without a tibial external rotation force.^30,35,37,46 Nearly 78% of grade 3 MCL tears occur as part of a multiligament knee injury, of which, approximately 95% have a concomitant anterior cruciate ligament (ACL) tear.^14,16 In the setting of ACL reconstruction (ACLR), preoperative medial-sided knee instability is a risk factor for ACLR graft failure, highlighting the importance of proper repair or reconstruction of the MCL.¹

It is generally accepted that grade 1 and 2 MCL tears, as well as select cases of isolated grade 3 tears, can be treated nonoperatively with bracing and early functional rehabilitation.^{7,13,30,37,57} However, the management of grade 3 MCL tears with persistent valgus instability remains controversial. Surgical intervention may be indicated either when patients do not respond to initial nonoperative measures or when they have chronic valgus instability or in the face of a multiligament knee injury.^12,30,57

Reconstruction and primary operative repair of the MCL have been described, but there remains a paucity of outcome data comparing these treatments to help guide surgical decision-making.^6,57 Notably, a systematic review by Kovachevich et al²⁶ found that both MCL repair and reconstruction produced satisfactory results in the setting of multiligament injuries. However, there is still some concern of postoperative arthrofibrosis after both MCL reconstruction and repair.⁴¹ The heterogeneity and retrospective quality of the data available prevented any formal comparison or meta-analysis.²⁶

Our aim was to determine whether sufficient evidence has become available regarding MCL repair versus reconstruction. Therefore, the purpose of this study was to systematically review the literature to determine whether repair or reconstruction of the MCL results in improved outcomes. Our null hypothesis was that there would be no significant difference in failure rate, arthrofibrosis, and patient-reported outcomes between patients who underwent MCL reconstruction versus MCL repair in multiligament knee injuries.

Methods

Article Identification and Selection

This study was conducted using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and registered on the PROSPERO international prospective register of systematic reviews. Searches were performed of the MEDLINE, Embase, Cochrane, and PubMed databases between January 1980 and January 2024; article identification was performed in January 2024.⁴⁰ The following search terms were used: medial collateral ligament, repair, reconstruction, superficial medial collateral ligament, and tibial collateral ligament. The search strategy utilized was as follows: (((Medial collateral ligament) AND (repair)) OR ((medial collateral ligament) AND (reconstruction)) OR (superficial medial collateral ligament) OR (tibial collateral ligament)).

All studies from each database were uploaded to EndNote Reference Manager for duplicate article deletion.⁴⁰ Articles from EndNote were then transferred to Rayyan QCRI (Qatar Computer Research Institute, Hamad Bin Khalifa University, Qatar) for further evaluation.⁴⁴ Four authors (E.R.F., L.V.T., K.L.F., and G.D.S.) reviewed all abstracts for inclusion criteria. Inclusion criteria consisted of articles that published results on patients (1) ≥15 years of age, (2) with MCL ligament injuries requiring surgical management (repair or reconstruction) with or without an ACL injury requiring surgical management, (3) having at least 1 subjective outcome score with at least 2 years of follow-up (Knee injury and Osteoarthritis Outcome Score, Lysholm score, International Knee Documentation Committee [IKDC] score, and Tegner score), (4) with ≥1 forms of objective outcome measurement (including IKDC objective scores, valgus stress examination, or valgus stress radiographs), and (5) with level of evidence 1 to 4. Exclusion criteria included patients <15 years of age, <10 patients in the study, technique papers, case reports, patients with fractures associated with the MCL injury, studies that only treated the MCL nonoperatively, studies with revision cases, studies reporting on MCL injuries with posterior cruciate ligament or posterolateral corner injuries (MCL and ACL were included), and studies addressing multiligament injuries to the knee that did not identify the MCL as a separate cohort. It should be noted that articles included both acute (<6 weeks) and chronic (>6 weeks) ligament injuries. Four reviewers (E.R.F., L.V.T., K.L.F., and G.D.S.) examined all full texts of abstracts meeting the inclusion criteria. Any disagreement in full texts to include in the analysis was decided by the senior author (R.F.L.). Furthermore, all systematic reviews found in the database were examined for additional relevant studies that may have been missed.

Primary repairs were defined as suture repairs of the native MCL, while reconstructions were defined as any reconstruction or augmentation with an auto- or allograft. For our purposes, sMCL augmentations with autografts or allografts were considered reconstruction procedures.

Data Collection

Patient characteristics, level of evidence, chronicity of injury, follow-up time, available patient-reported subjective and objective scores, reports of failures and development of arthrofibrosis, reconstruction techniques, and concomitant ACL graft failure were collected from each study. Arthrofibrosis was included as reported by the studies, or if not directly discussed, it was correlated with reports of decreased postoperative range of motion (flexion deficits ≥10° and extension deficits ≥5°), the need for a lysis of adhesions (LOA), the need for manipulation under anesthesia (MUA), or formation of scar tissue leading to pain or limitations in movement within the individual studies. Reports of failure were included as reported by studies and included clinical failure of the MCL repair or reconstruction (significant laxity still present after surgery), failure of the repair or reconstruction (graft or fixation failure), and the need for an LOA or MUA. Failure of the ACL was defined as clinical failure (significant postoperative laxity), graft failure, or graft fixation failure. Numeric values including age, subjective patient-reported outcomes, and stress radiographs (with preoperative and postoperative values of side-to-side differences), as available, are reported as a mean.

Statistical Analysis

After data extraction, RStudio (RStudio, PBC)⁴⁸ was utilized to perform a t test and to determine whether there was a statistically significant difference (P < .05) for Lysholm scores, IKDC subjective scores, Tegner scores, and stress radiograph means between the repair and reconstruction groups. Failures were defined by the author of each study. A chi-square goodness-of-fit test was conducted using RStudio to determine if there was a significant difference (P < .05) in arthrofibrosis rates and failure rates between the repair and reconstruction groups.

Studies in the analysis considered selection bias, small sample sizes, and lack of comparative controls. In many cases, it was not possible to provide controls because of the heterogeneous nature of the multiligament injuries, reconstruction techniques, and surgical choices made based on concomitant injuries. The authors ensured that the studies examined considered such limitations to minimize bias and recognize the constraints presented by the nature of the data.

Risk of Bias Assessment

The Methodological Index for Non-Randomized Studies (MINORS) was used to assess the included studies for risk of bias. This index uses 8 questions for noncomparative studies and 12 questions for comparative studies. Each category is given a score from 0 to 2. A perfect score is 16 for noncomparative studies and 24 for comparative studies. All studies describing both MCL reconstruction and repair were graded with the comparative study grading, and all other studies were graded with the noncomparative grading.

Results

After completing a literature search and removing duplicate articles, 4403 entries matched the search criteria. The 4403 entries were reduced to 85 articles after abstract review and to 42 after initial full-text review. A total of 30 articles were included in the final analysis (Figure 1).^‖

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart outlining the process of screening and selection.

The 30 studies included 1048 total patients, 458 MCL repairs, and 590 MCL reconstructions. All but 91 MCL injuries (8.7%) in this cohort were part of multiligament injuries. For the studies in which chronicity was mentioned, interventions were performed in the acute phase (<6 weeks) for 406 patients (50.4%) and in the chronic phase (>6 weeks) for 400 patients (49.6%). The mean patient age was 33.3 years (SD, 5.11 years) in the repair cohort and 33.4 years (SD, 4.40 years) in the reconstruction cohort. The mean follow-up time was 4.2 years (SD, 2.59 years) in the repair cohort and 3.1 years (SD, 1.41 years) in the revision cohort (minimum, 2 years). There was a significant difference in acute and chronic cases per group, with the repair group having significantly more acute cases (306/406; 75.4%) and the reconstruction group having significantly more chronic cases (334/400; 83.5%) (P < .001). The number of procedures performed, mean age, chronicity, type of reconstruction, and mean follow-up time for each specific procedure can be found in Table 1.

Table 1

Characteristics of Patients With MCL Repair and Reconstruction^a

Surgical Technique	No.	Age, y	Chronicity (if Given)		Multiligament Injuries	Follow-up, y
Surgical Technique	No.	Age, y	Acute	Chronic	Multiligament Injuries	Follow-up, y
Repair	458	33.3 (5.11)	306 (82.3)	66 (17.7)	435 (95.0)	4.2 (2.59)
Reconstruction	590	33.4 (4.40)	100 (23.0)	334 (77.0)	522 (88.5)	3.1 (1.41)

Data are reported mean (SD) or n (%) unless otherwise indicated. MCL, medial collateral ligament.

Outcomes including stress radiographs, patient-reported outcomes, arthrofibrosis, failure, and ACLR from each individual study were documented and are reported in Table 2. The overall outcomes comparing MCL repair with MCL reconstruction are reported in Table 3. There was no significant difference in postoperative Lysholm scores between the 13 MCL repair studies, with a mean score of 91.9 (SD, 4.24), and the 10 MCL reconstruction studies, with a mean score of 86.8 (SD, 10.46) (P = .122). There was no significant difference in postoperative IKDC scores between the 7 MCL repair studies, with a mean score of 83.5 (SD, 5.88), and the 10 MCL reconstruction studies, with a mean score of 78.6 (SD, 11.29) (P = .303). There was no significant difference between the postoperative Tegner scores between the 5 MCL repair studies, with a mean score of 5.6 (SD, 0.89), and the 6 MCL reconstruction studies, with a mean score of 5.3 (SD, 1.07) (P = .602).

Table 2

Summary of Outcome Data for Each Included Study^a

Study	Level of Evidence	Surgical Technique	No. of Patients	Stress Radiographs, mm^b			Mean Postop Lysholm Score	Mean Postop IKDC Score	Mean Postop Tegner Score	No. With Arthrofibrosis	No. of Failures	No. of ACLR Failures
Study	Level of Evidence	Surgical Technique	No. of Patients	Mean Preop	Mean Postop	ΔSSD	Mean Postop Lysholm Score	Mean Postop IKDC Score	Mean Postop Tegner Score	No. With Arthrofibrosis	No. of Failures	No. of ACLR Failures
Canata et al³	4	Repair	36	NR	NR	NR	93	94	6	0	0	0
Desai et al⁸	4	Repair	20	NR	NR	NR	91.5	88.8	7	2	0	0
Frolke et al¹⁵	4	Repair	22	NR	NR	NR	NR	NR	NR	0	1	0
Halinen et al¹⁷	1	Repair	23	10	0.9	9.1	92	NR	NR	1	1	0
Hirschmann et al¹⁹	3	Repair	54	NR	2.8	NR	84	NR	4.85	20	1	0
Holuba et al²⁰	4	Repair	20	NR	NR	NR	95	82.2	5	1	2	4
Noyes and Barber-Westin⁴²	4	Repair	34	NR	NR	NR	NR	NR	NR	2	6	0
Osti et al⁴³	4	Repair	22	NR	NR	NR	96	NR	NR	0	0	0
Pandey et al⁴⁵	4	Repair	15	NR	NR	NR	91.1	77.6	NR	6	1	0
Pandey et al⁴⁵	4	Repair	20	NR	NR	NR	94.6	83.3	NR	6	0	0
Piatkowski et al⁴⁷	4	Repair	27	NR	NR	NR	90.6	79.8	NR	3	5	0
Shirakura et al⁵¹	4	Repair	14	NR	NR	NR	98.5	NR	5.2	0	0	0
Tzurbakis et al⁵⁵	4	Repair	17	NR	NR	NR	90.3	NR	NR	2	1	0
Barrett et al²	4	Reconstruction	32	NR	NR	NR	NR	67.6	NR	0	1	0
Dhollander et al⁹	4	Reconstruction	23	2.1	0.1	2.0	NR	NR	NR	0	0	0
Dong et al¹¹	4	Reconstruction	56	10.1	2.9	7.2	NR	NR	NR	6	1	0
Kim et al²⁴	3	Reconstruction	24	7.8	1.1	6.7	91.9	NR	NR	0	2	0
Kitamura et al²⁵	4	Reconstruction	30	NR	0.5	NR	94.8	NR	NR	7	0	0
LaPrade et al²⁸	1	Reconstruction	25	4.1	0.2	3.9	80	72	5	0	0	0
LaPrade et al²⁸	1	Reconstruction	29	3.4	0.2	3.2	90	85	5.5	0	0	0
LaPrade and Wijdicks²⁹	4	Reconstruction	28	6.2	1.3	4.9	NR	76.2	NR	0	0	0
Lee and Kim³¹	4	Reconstruction	23	8.5	1.2	7.3	93.4	90.5	7	0	1	0
Lind et al³³	4	Reconstruction	50	NR	NR	NR	NR	NR	4.4	1	3	0
Liu et al³⁴	4	Reconstruction	16	8.9	1.1	7.8	88.6	84.3	NR	4	1	0
Van der Wal et al⁵⁶	4	Reconstruction	10	5.6	2.6	3.0	92	80	4	0	1	0
Xu et al⁵⁹	3	Reconstruction	26	NR	NR	NR	90.4	87.9	5.8	0	3	0
Yoshiya et al⁶⁰	4	Reconstruction	24	4.1	0.2	3.9	NR	NR	NR	0	0	0
Zhang et al⁶¹	4	Reconstruction	21	8.0	0.8	7.2	NR	87.7	NR	1	0	0
Dong et al¹⁰	2	Repair	32	11.1	2.9	8.2	NR	NR	NR	5	2	4
Dong et al¹⁰	2	Reconstruction	32	11	3.2	7.8	NR	NR	NR	5	2	0
Hanley et al¹⁸	3	Repair	25	NR	NR	NR	83.8	79.1	NR	0	0	0
Hanley et al¹⁸	3	Reconstruction	9	NR	NR	NR	59.4	54.3	NR	0	0	0
Stannard et al⁵³	4	Repair	25	NR	NR	NR	94	NR	NR	5	5	0
Stannard et al⁵³	4	Reconstruction	48	NR	NR	NR	87	NR	NR	8	2	0
Svantesson et al⁵⁴	4	Repair	52	NR	NR	NR	NR	NR	NR	0	1	2
Svantesson et al⁵⁴	4	Reconstruction	84	NR	NR	NR	NR	NR	NR	0	0	1

ACLR, anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee; NR, not reported; Preop, preoperative; Postop, postoperative; SSD, side-to-side difference.

Stress radiographs refer to the medial-sided gapping of the tibia relative to the femur under an applied stress. Typically, a physician applies valgus stress while an anterior radiograph is obtained to measure the gapping.

Table 3

Summary of Results for MCL Repair Versus Reconstruction^a

Surgical Technique	Stress Radiographs, mm		Mean Lysholm Score	Mean IKDC Score	Mean Tegner Score	No. With Arthrofibrosis	No. of Failures	No. of ACLR Failures
Surgical Technique	Mean Preop	Mean Postop	Mean Lysholm Score	Mean IKDC Score	Mean Tegner Score	No. With Arthrofibrosis	No. of Failures	No. of ACLR Failures
Repair	10.6 (0.78)	2.2 (1.13)	91.9 (4.24)	83.5 (5.88)	5.6 (0.89)	53 (11.6)	26 (5.7)	10 (2.3)
Reconstruction	6.8 (2.88)	1.2 (1.05)	86.8 (10.46)	78.6 (11.29)	5.3 (1.07)	32 (5.4)	17 (2.9)	1 (0.2)

Data are reported mean (SD) or n (%). ACLR, anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee; MCL, medial collateral ligament; Preop, preoperative; Postop, postoperative.

For postoperative arthrofibrosis (decreased range of motion or stiffness requiring LOA or MUA, flexion deficits ≥10°, and extension deficits ≥5°), 53 of 458 repairs (11.6%) resulted in arthrofibrosis and 32 of 590 reconstructions (5.4%) resulted in arthrofibrosis. Arthrofibrosis rates for MCL reconstruction were determined to be significantly less than the repair group (χ² = 13.078; P < .001). For failures, 26 of 458 repairs (5.7%) resulted in failures and 21 of 590 reconstructions (2.9%) resulted in failures. Failure rates for MCL reconstruction were determined to be significantly less than the repair group (χ² = 5.121; P = .024). For ACLR failures, 10 of 435 repairs (2.3%) resulted in ACL failure and 1 of 522 (0.2%) reconstructions resulted in ACL failure. ACL failure rates for MCL reconstruction were determined to be significantly less than the repair group (χ² = 9.273; P = .002).

Risk of bias assessment using the MINORS criteria is listed in Appendix Tables A1 and A2. A mean score of 18.5 of 24 (range, 15-21) was reported for the comparative studies and 11.4 of 16 (range, 9-16) for the noncomparative studies.

Discussion

The most important finding of this study was that patients with direct repair of the MCL demonstrated significantly higher rates of arthrofibrosis (11.6% vs 5.4%; P < .001) and concomitant ACL graft failure in multiligament cases (2.3% vs 0.2%; P = .003) postoperatively than patients with a reconstruction of the MCL. These findings were found to be significant across 30 studies, which reported outcomes for MCL repairs, MCL reconstructions, or both. Arthrofibrosis has been reported to be a significant source of morbidity after MCL surgical treatment, and our results may provide support for the notion that MCL reconstruction leads to a significantly lower rate of stiffness and range of motion loss.^22,30

This study found that the combined results between all studies evaluated reported an increased rate of arthrofibrosis in patients undergoing MCL repair compared with MCL reconstruction, and almost all patients were treated for multiligament knee injuries. Conventional wisdom has long held that the MCL has sufficient healing capacity to mend well in most circumstances with nonoperative treatment without the need for reconstruction or repair.^37,38,57 When surgical intervention of the MCL is required, complications including arthrofibrosis and surgical site morbidity have been suggested for both repairs and reconstructions.^12,38 However, 78% of grade 3 MCL tears occur as part of a multiligament knee injury, and delaying surgery to allow the MCL to heal on its own is not always the pragmatic choice.¹⁴ Various studies have reported improved clinical and functional outcomes for acute surgery of multiligament knee injuries compared with delayed surgery.^32,39,49 A systematic review by Sheth et al⁵⁰ reported that patients with acute surgery for multiligament knee injuries reported significantly increased Lysholm scores and Meyers ratings, with no difference in patients undergoing an MUA compared with delayed cases when an early range of motion protocol was used. Additionally, a recent study by Shultz et al⁵² reported no significant difference between nonoperative and operative treatment of MCL injuries for patient-reported outcomes, range of motion, or quadriceps strength. Together, these findings suggest that performing an acute MCL reconstruction in place of an MCL repair, including in the case of a multiligament knee injury, paired with a rehabilitation protocol emphasizing early motion, may help prevent arthrofibrosis and improve patient-reported outcomes.

Another finding from this study was that when the ACL is reconstructed along with an MCL repair or reconstruction, the ACL graft is significantly more likely to fail when performed concomitantly with an MCL repair versus an MCL reconstruction. Studies by Dong et al¹⁰ and Svantesson et al⁵⁴ had similar findings with the MCL repair group, reporting more ACL graft failures than the MCL reconstruction group. This finding is especially important because approximately 78% of all MCL tears include other ligament tears, and 95% of these cases are reported to have a concomitant ACL tear.¹⁶ Clinically, this highlights the importance of analyzing ACL and MCL tears concomitantly as MCL injuries are typically not isolated. Residual valgus laxity has been reported as a potential risk factor for ACL failure, which could suggest that MCL repair does not restore valgus stability as well as an MCL reconstruction.²¹ A biomechanical study by Wijdicks et al⁵⁸ compared anatomic augmented repairs (functionally a reconstruction, using a semitendinosus autograft left attached distally) and anatomic reconstruction (semitendinosus graft with distal and proximal tunnels) for MCL tears and reported no significant differences between the 2 states; additionally, the study reported that both techniques improve knee stability and prevent >2 mm of medial opening compared with the native state. These findings suggest that in the case of a grade 3 MCL tear, an MCL reconstruction may be better to properly restore the knee biomechanics, prevent residual valgus laxity, and protect the knee from concomitant ACL graft failure.

Limitations

This study is not without potential limitations, which include the heterogeneity of multiligament injury comparisons, diagnostic tests used in diagnosis and postoperative evaluation, surgical methods, and rehabilitation techniques used. For example, Dong et al¹⁰ used a triangular medial reconstruction rather than anatomic reconstructions; thus, results may or may not be directly comparable to anatomic reconstructions. Some authors used different methods of repair for distal MCL avulsions, including the “MCL Stener-like lesion,” versus midsubstance tears in the acute setting.^8,55 Additionally, there was no differentiation across studies regarding whether a patient had a full posteromedial corner injury (MCL plus posterior oblique ligament) or just an MCL tear. Also, for valgus stress examinations, different types of measurements were utilized across the studies, which can be inaccurate and make comparisons between stress varues across studies difficult. Another limitation was that the majority of MCL tears occurred as combined, multiligament injuries rather than as isolated MCL tears. Furthermore, we were not able to perform an analysis on the effect of acute versus chronic injuries because most MCL repairs were in the acute phase and most MCL reconstructions were in the chronic phase.

Conclusion

This systematic review showed that MCL reconstructions demonstrated decreased postoperative arthrofibrosis compared with MCL repairs across all studies. Studies reporting on failures indicated decreased clinical failures and ACL graft failures in the setting of concomitant ACL and MCL reconstructions compared with MCL repairs. Future randomized controlled studies are needed to further determine the best surgical technique for patients with multiligament knee injuries.

Footnotes

Appendix

Appendix Table A2

MINORS for Noncomparative Studies^a

	Clearly Stated Aim	Inclusion of Consecutive Patients	Prospective Data Collection	Endpoints Appropriate to Study Aim	Unbiased Assessment of Study Endpoint	Follow-up Period Appropriate to Study Aim	Loss to Follow-up <5%	Prospective Calculation of Study Size	Total
Barrett et al²	2	2	1	2	1	2	2	1	13
Canata et al³	1	1	2	2	1	2	2	0	11
Desai et al⁸	2	1	0	2	1	2	1	0	10
Dhollander et al⁹	2	1	1	2	2	2	2	0	12
Dong et al¹¹	2	1	1	2	1	1	2	0	10
Frolke et al¹⁵	1	2	1	1	1	2	2	0	10
Halinen et al¹⁷	2	2	2	2	1	2	2	1	14
Hirschmann et al¹⁹	2	1	1	2	1	2	1	0	10
Holuba et al²⁰	2	1	1	2	1	2	1	1	11
Kim et al²⁴	2	2	1	2	2	2	1	0	12
Kitamura et al²⁵	2	1	1	2	1	2	1	0	10
LaPrade et al²⁸	2	2	2	2	2	2	2	2	16
LaPrade and Wijdicks²⁹	1	2	2	2	1	2	2	0	12
Lee and Kim³¹	2	1	1	2	1	2	2	2	13
Lind et al³³	2	1	1	1	1	2	1	0	9
Liu et al³⁴	2	2	1	2	1	2	1	1	12
Noyes and Barber-Westin⁴²	2	2	1	1	1	2	2	0	11
Osti et al⁴³	2	1	2	2	1	2	2	0	12
Pandey et al⁴⁵	2	1	1	2	1	2	1	0	10
Piatkowski et al⁴⁷	2	2	1	2	1	2	1	0	11
Shirakura et al⁵¹	1	2	1	2	1	2	2	0	11
Tzurbakis et al⁵⁵	2	2	1	2	1	2	1	0	11
Van der Wal et al⁵⁶	2	1	1	2	1	2	2	0	11
Xu et al⁵⁹	2	2	1	2	1	2	2	0	12
Yoshiya et al⁶⁰	1	1	2	2	1	2	2	0	11
Zhang et al⁶¹	2	2	1	2	1	2	2	0	12

This assessment determines the reliability of studies with a scoring system out of 16 points for noncomparative studies. Scores 0 to 8 are considered poor, 9 to 12 are considered fair, and 12 to 16 are considered good. MINORS, Methodological Index for Non-Randomized Studies.

One or more of the authors has declared the following potential conflict of interest or source of funding: G.B.C. has received education payments from Gemini Mountain Medical and Arthrex and hospitality payments from Smith+Nephew. R.F.L. has received royalties from Arthrex and Smith+Nephew, education payments from Foundation Medical, nonconsulting fees from Smith+Nephew, and consulting fees from Smith+Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Final revision submitted June 9, 2024; accepted June 18, 2024.

ORCID iD

Edward R. Floyd

‖

References 2, 3, 8 -11, 15, 17 -20, 24, 25, 28, 29, 31, 33, 34, 42, 43, 45, 47, 51, 53 -55, 56, 59 -.

References

Alm

Krause

Frosch

Akoto

Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020;28(8):2458-2467.

Barrett

Krych

Pareek

, et al. Short- to mid-term outcomes of anatomic MCL reconstruction with Achilles tendon allograft after multiligament knee injury. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):2952-2959.

Canata

Chiey

Leoni

Surgical technique: does mini-invasive medial collateral ligament and posterior oblique ligament repair restore knee stability in combined chronic medial and ACL injuries?

Clin Orthop Relat Res. 2012;470(3):791-797.

Cinque

Chahla

Kruckeberg

DePhillipo

Moatshe

LaPrade

RF.

Posteromedial corner knee injuries: diagnosis, management, and outcomes: a critical analysis review. JBJS Rev. 2017;5(11):e4.

Daniel

Pedowitz

O’Connor

Akeson

Daniel

DM.

Daniel’s Knee Injuries: Ligament and Cartilage Structure, Function, Injury, and Repair. Lippincott Williams & Wilkins; 2003.

DeLong

Waterman

BR.

Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: a systematic review. Arthroscopy. 2015;31(11):2258-2272.e1.

Derscheid

Garrick

JG.

Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9(6):365-368.

Desai

Camp

Levy

Stuart

Krych

AJ.

Midterm outcomes following acute repair of grade III distal MCL avulsions in multiligamentous knee injuries. J Knee Surg. 2020;33(8):785-791.

Dhollander

Sellan

Firth

Getgood

Valgus stress radiography following superficial medial collateral ligament reconstruction using a modified LaPrade technique with adjustable loop femoral fixation. Acta Orthop Belg. 2020;86(2):280-286.

10.

Dong

Wang

Men

, et al. Surgical treatment of acute grade III medial collateral ligament injury combined with anterior cruciate ligament injury: anatomic ligament repair versus triangular ligament reconstruction. Arthroscopy. 2015;31(6):1108-1116.

11.

Dong

Chen

Men

, et al. Application of triangular vector to functionally reconstruct the medial collateral ligament with double-bundle allograft technique. Arthroscopy. 2012;28(10):1445-1453.

12.

Duffy

Miyamoto

RG.

Management of medial collateral ligament injuries in the knee: an update and review. Phys Sportsmed. 2010;38(2):48-54.

13.

Ellsasser

Reynolds

Omohundro

JR.

The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically. J Bone Joint Surg Am. 1974;56(6):1185-1190.

14.

Fetto

Marshall

. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res. 1978;(132):206-218.

15.

Frolke

Oskam

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(2):103-106.

16.

Grant

Tannenbaum

Miller

Bedi

Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments. Arthroscopy. 2012;28(1):110-122.

17.

Halinen

Lindahl

Hirvensalo

Santavirta

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(7):1134-1140.

18.

Hanley

Anthony

DeMik

, et al. Patient-reported outcomes after multiligament knee injury: MCL repair versus reconstruction. Orthop J Sports Med. 2017;5(3):2325967117694818.

19.

Hirschmann

Meier

Amsler

Friederich

NF.

Long-term outcome of patients treated surgically for traumatic knee dislocation: does the injury pattern matter?

Phys Sportsmed. 2010;38(2):82-89.

20.

Holuba

Rilk

Vermeijden

O’Brien

van der List

DiFelice

GS.

Acute percutaneous repair of medial collateral ligament with suture augmentation in the multiligamentous injured knee results in good stability and low rates of postoperative stiffness. Arthrosc Sports Med Rehabil. 2023;5(6):100799.

21.

Holuba

Vermeijden

Yang

, et al. Treating combined anterior cruciate ligament and medial collateral ligament injuries operatively in the acute setting is potentially advantageous. Arthroscopy. 2023;39(4):1099-1107.

22.

Jokela

Makinen

Koivikko

Lindahl

Halinen

Lindahl

Treatment of medial-sided injuries in patients with early bicruciate ligament reconstruction for knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2021;29(6):1872-1879.

23.

Keyhani

Mardani-Kivi

Anatomical repair of Stener-like lesion of medial collateral ligament: a case series and technical note. Arch Bone Jt Surg. 2017;5(4):255-258.

24.

Kim

Lee

Kim

Choi

NH.

Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br. 2008;90(10):1323-1327.

25.

Kitamura

Ogawa

Kondo

Kitayama

Tohyama

Yasuda

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(6):1274-1281.

26.

Kovachevich

Shah

Arens

Stuart

Dahm

Levy

BA.

Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc. 2009;17(7):823-829.

27.

Laprade

Bernhardson

Griffith

Macalena

Wijdicks

CA.

Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. 2010;38(2):330-338.

28.

LaPrade

DePhillipo

Dornan

, et al. Comparative outcomes occur after superficial medial collateral ligament augmented repair vs reconstruction: a prospective multicenter randomized controlled equivalence trial. Am J Sports Med. 2022;50(4):968-976.

29.

LaPrade

Wijdicks

CA.

Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012;470(3):806-814.

30.

LaPrade

Wijdicks

CA.

The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther. 2012;42(3):221-233.

31.

Lee

Kim

JG.

Anatomic medial complex reconstruction in serious medial knee instability results in excellent mid-term outcomes. Knee Surg Sports Traumatol Arthrosc. 2020;28(3):725-732.

32.

Levy

Dajani

Whelan

, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25(4):430-438.

33.

Lind

Jakobsen

Lund

Hansen

Abdallah

Christiansen

SE.

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(6):1116-1122.

34.

Liu

Feng

Zhang

, et al. Surgical treatment of subacute and chronic valgus instability in multiligament-injured knees with superficial medial collateral ligament reconstruction using Achilles allografts: a quantitative analysis with a minimum 2-year follow-up. Am J Sports Med. 2013;41(5):1044-1050.

35.

Lorentzon

Wedren

Pietila

Incidence, nature, and causes of ice hockey injuries. A three-year prospective study of a Swedish elite ice hockey team. Am J Sports Med. 1988;16(4):392-396.

36.

Majewski

Susanne

Klaus

Epidemiology of athletic knee injuries: a 10-year study. Knee. 2006;13(3):184-188.

37.

Marchant

Jr Tibor

Sekiya

, et al. Management of medial-sided knee injuries, part 1: medial collateral ligament. Am J Sports Med. 2011;39(5):1102-1113.

38.

Miyamoto

Bosco

Sherman

OH.

Treatment of medial collateral ligament injuries. J Am Acad Orthop Surg. 2009;17(3):152-161.

39.

Moatshe

Vap

Getgood

LaPrade

Engebretsen

Medial-sided injuries in the multiple ligament knee injury. J Knee Surg. 2020;33(5):431-439.

40.

Moher

Liberati

Tetzlaff

Altman

; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

41.

Mowers

Jackson

Condon

, et al. Medial collateral ligament reconstruction and repair show similar improvement in outcome scores, but repair shows higher rates of knee stiffness and failure: a systematic review. Arthroscopy. 2023;39(10):2231-2240.

42.

Noyes

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(4):380-389.

43.

Osti

Papalia

Del Buono

Merlo

Denaro

Maffulli

Simultaneous surgical management of chronic grade-2 valgus instability of the knee and anterior cruciate ligament deficiency in athletes. Knee Surg Sports Traumatol Arthrosc. 2010;18(3):312-316.

44.

Ouzzani

Hammady

Fedorowicz

Elmagarmid

Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.

45.

Pandey

Khanna

Madi

Tripathi

Acharya

Clinical outcome of primary medial collateral ligament-posteromedial corner repair with or without staged anterior cruciate ligament reconstruction. Injury. 2017;48(6):1236-1242.

46.

Peterson

Junge

Chomiak

Graf-Baumann

Dvorak

Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med. 2000;28(5)(suppl):S51-S57.

47.

Piatkowski

Plominski

Sowinski

Piekarczyk

Kwiatkowski

Gołos

Results of two-stage operative treatment of anteromedial instability of the knee. Ortop Traumatol Rehabil. 2014;16(1):33-45.

48.

RStudio Team. RStudio: Integrated Development Environment for R. RStudio, PBC; 2020.

49.

Scheepers

Khanduja

Held

Current concepts in the assessment and management of multiligament injuries of the knee. SICOT J. 2021;7:62.

50.

Sheth

Sniderman

Whelan

DB.

Early surgery of multiligament knee injuries may yield better results than delayed surgery: a systematic review. J ISAKOS. 2019;4(1):26-32.

51.

Shirakura

Terauchi

Katayama

Watanabe

Yamaji

Takagishi

The management of medial ligament tears in patients with combined anterior cruciate and medial ligament lesions. Int Orthop. 2000;24(2):108-111.

52.

Shultz

Poehlein

Morriss

, et al. Nonoperative management, repair, or reconstruction of the medial collateral ligament in combined anterior cruciate and medial collateral ligament injuries—which is best? A systematic review and meta-analysis. Am J Sports Med. 2024;52(2):522-534.

53.

Stannard

Black

Azbell

Volgas

DA.

Posteromedial corner injury in knee dislocations. J Knee Surg. 2012;25(5):429-434.

54.

Svantesson

Hamrin Senorski

Alentorn-Geli

, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2450-2459.

55.

Tzurbakis

Diamantopoulos

Xenakis

Georgoulis

Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):739-749.

56.

Van der Wal

Van Gennip

Heesterbeek

Busch

Wymenga

AB.

Anatomical superficial medial collateral ligament reconstruction with posteromedial capsule reefing successfully restores valgus knee laxity. Acta Orthop Belg. 2020;86(1):69-76.

57.

Wijdicks

Griffith

Johansen

Engebretsen

LaPrade

RF.

Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92(5):1266-1280.

58.

Wijdicks

Michalski

Rasmussen

, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med. 2013;41(12):2858-2866.

59.

Kang

Zhang

, et al. An anatomical-like triangular-vector ligament reconstruction for the medial collateral ligament and the posterior oblique ligament injury with single femoral tunnel: a retrospective study. J Orthop Surg Res. 2017;12(1):96.

60.

Yoshiya

Kuroda

Mizuno

Yamamoto

Kurosaka

Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med. 2005;33(9):1380-1385.

61.

Zhang

Sun

Han

, et al. Simultaneous reconstruction of the anterior cruciate ligament and medial collateral ligament in patients with chronic ACL-MCL lesions: a minimum 2-year follow-up study. Am J Sports Med. 2014;42(7):1675-1681.