10.

1177/0363546503261738

The Posteromedial Corner of the Knee

Medial-Sided Injury Patterns Revisited
William F. Sims* and Kurt E. Jacobson* From the *Hughston Clinic, Columbus, Georgia, and the Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana

Background: Medial-sided knee injury patterns have been poorly defined in the available literature. The lack of definition can be attributed to the differing anatomic perspectives of physician authors and the functional significance they assigned to the posteromedial structures of the knee. Hypothesis: Many so-called medial collateral ligament injuries can involve significant damage to the posteromedial corner structures that may not be appreciated. Study Design: Retrospective cohort study. Method: The authors reviewed the charts of 93 patients (93 knees) with operatively treated isolated and combined medial-sided knee injuries and described the associated medial injury patterns. Results: Ninety-nine percent of the knees were found to have an injury of the posterior oblique ligament. In the series, 70% of the knees also had an injury of the semimembranosus capsular attachment, and 30% were found to have complete peripheral detachment of the meniscus. Injury to the posterior oblique ligament was the common injury, but other sites of disruption capable of disabling this dynamic meniscocapsular complex were present. Conclusions: Before assigning function to the various posteromedial structures of the knee, we must better define medial-sided injury patterns, the purpose of the current work. From this review of medial-sided injuries in this series of patients, the authors have come to realize that a subgroup of these knee injuries involves injuries to the posteromedial structures that are underappreciated. Keywords: posterior oblique ligament; posteromedial knee injury; medial knee injury; medial collateral ligament

The anatomy of the medial side of the knee has been well described.1,9,28 Anatomically, the medial supporting structures can be divided into layers28 or regions.9 Functionally, the division between static (capsular and noncapsular ligaments) and dynamic (musculotendinous units and their aponeuroses) stabilizers must be made. The contributions of the dynamic stabilizers of the knee and the effects of coupled motion on resultant injury patterns are often overlooked because they are impossible to assess with ligament sectioning studies, which dominate the available biomechanical literature on the topic. Nonetheless, as surely as we understand the dynamizing effect of the vastus medialis obliques on patellar tracking, we must also be aware of the dynamic role of the semimembranosus, which is to pro-

Address correspondence to Kurt E. Jacobson, the Hughston Clinic, 6262 Veterans Parkway, Columbus, GA 31909. The American Journal of Sports Medicine, Vol. 32, No. 2 DOI: 10.1177/0363546503261738 2004 American Orthopaedic Society for Sports Medicine

vide motor function to the posteromedial meniscocapsular complex. The work of Warren and Marshall28 focused on the concept of layers with little emphasis on the supporting structures posterior to the superficial medial ligament. Given the lack of emphasis on the posteromedial aspect of the knee, other related functional studies have emphasized the role of the superficial medial ligament.26,27 As a result, when the topic of medial-sided knee injury arises, the reference has become synonymous with injury to the superficial medial collateral ligament. The description of the posterior oblique ligament (POL) by Hughston and Eilers as a discrete anatomical thickening of the capsular ligament9 and later reports assigning both static and dynamic function to the posterior medial knee structures5,8 introduced the concept of the posteromedial corner. This concept was echoed by Mller who stated, One thing is certain: despite its close topographic relation to the medial collateral ligament, the posteromedial corner is fundamentally different in nature and function 20 from the tibial collateral ligament itself.

337

338

Sims and Jacobson

The American Journal of Sports Medicine

Anatomic structures that contribute to the function of the posteromedial corner of the knee are the posterior horn of the medial meniscus, the POL, the semimembranosus expansions, the meniscotibial ligaments, and the oblique popliteal ligament. This dynamic meniscocapsular complex, working in a coordinated fashion, is believed to function throughout the normal range of coupled motion in both a static and dynamic fashion as a restraint to anteromedial rotatory instability (AMRI).

Anatomy and Function

The anatomy of the medial aspect of the knee extends from the medial edge of the patella to the medial border of the posterior cruciate ligament. The medial-sided structures can be divided roughly into thirds (Figure 1). The medial meniscus is intimately attached to the capsule via the meniscotibial and meniscofemoral contributions of the deep capsule and ligamentous structures within the various regions. The structures of the anteromedial third include the loose, thin capsular ligaments covered superficially by the extensor retinaculum of the quadriceps mechanism. The mid-medial structures are the deep medial capsular ligament and the superficial medial collateral ligament. Both ligaments originate from the medial femoral epicondyle. The deep medial capsular ligament inserts just below the tibial articular margin and may be conceptually divided into meniscotibial (coronary) and meniscofemoral complements. The more superficial tibial collateral ligament has a broad, elongated insertion on the proximal medial tibia. The more superficial tibial collateral ligament reinforces the deep ligament and is separated by a bursa (Figure 2). Brantigan and Voshell1 described 2 portions of the tibial collateral ligament, an anterior parallel arrangement of fibers and a more posterior oblique portion of this ligament. It is this more oblique group of fibers that Hughston and Eilers9 described as the POL (ligamentum popliteum obliquum). This anatomically separate structure originates from the adductor tubercle, posterior to the medial epicondyle. Distally, the ligament fans out, having 3 separate arms or expansions: (1) the tibial arm, inserting close to the margin of the articular surface;

(2) the capsular arm, continuous with the posterior capsule, blending with the oblique popliteal ligament; and (3) the superficial arm associated with the semimembranosus tendon (Figure 3). This structure, which was described by Meyer19 in 1853 as the posterior medial collateral ligament, is intimately attached to the medial meniscus. Nonetheless, approximately two thirds of its fibers pass uninterrupted from the femur to the tibia.20 Unlike the tibial collateral ligament, the POL is not separated from the meniscus by a bursa but has firm meniscal attachments and blends intimately with the capsule of the knee joint posteriorly.20 As stated earlier, the POL and tibial collateral ligament do not share the same origin. The posteromedial one third of the knee extends from the posterior edge of the tibial collateral ligament to the medial edge of the posterior cruciate ligament. The major components are the POL, the semimembranosus expansions, the oblique popliteal ligament, and the posteromedial horn of the meniscus. Mller20 described the posteromedial corner as the semimembranosus corner because of the functional significance of the contribution of the semimembranosus muscle. Five expansions have been described: (1) the pars reflexa, passing anteriorly beneath the tibial collateral ligament and inserting directly on the tibia; (2) the direct posteromedial tibial insertion; (3) the oblique popliteal ligament insertion; (4) the expansion to

Figure 1. Anterior, middle, and posterior capsuloligamentous divisions.

Figure 2. The relationships between the tibial collateral ligament, deep medial ligament, and meniscus. Note the space between the tibial collateral ligament and deep medial capsular ligament that houses a bursa.

Vol. 32, No. 2, 2004

The Posteromedial Corner of the Knee

339

Figure 3. The posterior oblique ligament (POL). Note the more posterior origin, expansile insertions, and relationship with the posteromedial capsule and semimembranosus expansions.

the POL; and (5) the popliteus aponeurosis expansion (Figure 4).20 Although static sectioning studies do not address the function of the dynamic stabilizers of the knee, it has been theorized that by its attachment to the POL and the tibia, the semimembranosus contributes to the dynamic stabilization of the posteromedial corner and allows for posterior meniscal retraction during knee flexion.6,20,22 This dynamizing effect tightens the posteromedial structures at a time when they would normally be lax and at the same time helps to prevent posteromedial meniscal impingement during knee flexion (Figures 5 and 6). Based on work by Levy et al,16 Paulos et al22 echoed Mllers description of the brake stop function of the posteromedial meniscal horn and emphasized its function as a secondary restraint to anterior tibial translation in the ACL-deficient knee. The intimate relationships that exist between the posteromedial meniscus, the POL, and the semimembranosus expansion are critical for dynamic stability of the medial side of the knee. Injury at any level of this intricate cascade can result in loss of this coordinated balance. Hughston et al7 described the resultant functional instability as follows: Anteromedial rotatory instability (AMRI) is an abnormal excess opening of the medial joint space in abduction at 30 of knee flexion, with a simultaneous anteromedial rotatory subluxation of the medial tibial condyle on the central axis of the intact posterior cruciate

Figure 4. The semimembranosus expansions. The 5 insertions: (1) pars reflexa, (2) direct posteromedial tibial insertion, (3) oblique popliteal ligament insertion, (4) expansion to posterior oblique ligament (POL), and (5) popliteus aponeurosis expansion. Note the investment into the POL. ligament. Although subtle, this additional rotatory instability must be distinguished from isolated open-book instability in response to abduction stress testing of the flexed knee. The coupling of this AMRI component with abduction stress has been suggested by Haimes et al4 as being possibly responsible for the functional instability seen in some patients who present with what appears to be minimal joint looseness. In their study, the superficial medial collateral ligament is credited as the primary restraint to external rotation of the tibia; nonetheless, we do not see the effect of a combined ACL posteromedial corner injury as many patients in our study demonstrated. ACL injury can accentuate this instability pattern; yet instrumented laxity testing falls short in detecting the rotatory component of this injury. Although MRI evaluation of the posteromedial and posterolateral corner structures continues to improve, a careful physical examination continues to remain the most reliable diagnostic tool. In addition to the subjective findings of medial and posteromedial knee pain and tenderness in patients with acute injuries, consistent objective physical examination findings are increased laxity to abduction stress testing in 30 of knee flexion with coupled anterior rotatory subluxation of the medial tibial plateau

340

Sims and Jacobson

The American Journal of Sports Medicine

Figure 7. Disruption of the meniscotibial ligament. Abduction stress (left) results in lateral translation of the medial meniscus, whereas adduction stress (right) pushes the medial meniscus medially. Figure 5. Birds-eye view of the proposed dynamizing action of the semimembranosus. The large arrow represents tension created in the posterior meniscocapsular complex by the semimembranosus. Note the ability of the semimembranosus to tension the posterior oblique ligament (POL) and aid in posterior meniscal retraction, represented by the small arrow.

test performed in external rotation7,24 while the examiner specifically looks for anterior subluxation of the medial tibial plateau with the medial femoral condyle as a reference and observes a relatively normal relationship between the lateral aspect of the tibia and femoral articulations. Finally, in conjunction with these positive tests, focal tenderness along the posteromedial aspect of the joint line in the area of the meniscotibial ligament, medial meniscal instability with abduction stress testing (lateral subluxation of the meniscus), and adduction stress testing (medial subluxation of the meniscus) may be present if the meniscotibial ligament is injured (Figure 7).13 In an attempt to further describe injury patterns to the medial side of the knee, we report the incidence and anatomic location of injuries in this surgically treated patient population with AMRI.

MATERIALS AND METHOD

We reviewed a consecutive 6-year operative experience of the senior author. A database search was conducted for medial-sided knee injuries from the years 1987 through 1992. There were 93 operatively treated medial-sided injuries in 93 patients, which was approximately 15% of all medial-sided knee injuries treated during this time period. Indications for operative treatment were either clinical or functional AMRI. Knee injuries that were treated acutely were those in patients who had clinical findings of medial and posteromedial knee pain and subjective sensations of valgus instability combined with objective findings of significant abduction laxity and associated AMRI as defined by Hughston.6 Symptomatic, functional AMRI was an indication for the operative treatment of medial knee injuries with a greater than 6-week interval from the time of injury. Both isolated and combined (ie, injury involving additional ligamentous structures apart from the anatomic structures of the medial side of the knee) ligament

Figure 6. Intracapsular orientation of the posteromedial corner structures showing the proposed dynamizing action (arrow) of the semimembranosus. Note the relationship of the semimembranosus capsular expansion, the posterior oblique ligament, and the posteromedial meniscus.

on the medial femoral condyle. This finding is aided by holding the limb by the plantar surface of the foot instead of the distal portion of the leg during abduction to allow for appreciation of the rotatory component. The examiner can appreciate anteromedial rotation of the tibial plateau on the medial femoral condyle with slight rotatory stress in this position. Another useful finding is the anterior drawer

Vol. 32, No. 2, 2004

The Posteromedial Corner of the Knee

341

TABLE 1 Injured Structures in 93 Knees

Injuries Anatomic Structure Posterior oblique ligament Tibial collateral ligament Deep medial ligament Semimembranosus tendinous expansions Meniscotibial ligament and meniscofemoral ligament Meniscus Number 92 31 23 65 77 40 Percentage 99 33 25 70 83 43

TABLE 3 Tibial Collateral Ligament Injuries in 93 Knees

Injuries Anatomic Structure Focal Femoral attachment Interstitial Tibial attachment Multifocal Femoral and tibial attachment Femoral attachment and interstitial Tibial attachment and interstitial Total 2 2 2 31 2 2 2 33 10 1 14 11 1 15 Number Percentage

TABLE 2 Posterior Oblique Ligament Injuries in 93 Knees

Injuries Anatomic Structure Focal Femoral attachment Interstitial Tibial attachment Multifocal Femoral and tibial attachments Femoral attachment and interstitial Tibial attachment and interstitial Total 14 9 4 92 15 10 4 99 29 11 25 32 12 27 Number Percentage

TABLE 4 Deep Medial Capsular Ligament Injuries in 93 Knees

Injuries Anatomic Structure Focal Femoral attachment Interstitial Tibial attachment Multifocal Femoral and tibial attachment Femoral attachment and interstitial Tibial attachment and interstitial Total 2 0 0 23 2 0 0 25 11 2 8 12 2 8 Number Percentage

injuries were included in our sample. We reviewed the operative notes and the associated operative injury diagrams completed at the time of the surgical procedure. In some patients, intraoperative photographs were also available for review. We also reviewed each patients chart for the results of the examination under anesthesia and the arthroscopic examination findings. An independent party created a data sheet containing the description of injury patterns for each patient. The senior author confirmed the findings by reviewing the operative summaries. Arthroscopic examination findings were reviewed in an attempt to identify intracapsular findings that were indicative of more extensive posteromedial corner injury. There were 67 men and 26 women in our series. Fiftyfour percent (50/93) of their injuries were treated operatively within 6 weeks of the time of injury. At the time of surgery, the average patients age was 26 years old. The most common mechanism of injury had been a sporting injury (72%). Approximately 13% resulted from a fall and an additional 13% from motor vehicle accidentrelated injuries. Further breakdown of the sporting injuries revealed that most patients had been injured while participating in football (27%), basketball (14%), or skiing (9%). Table 1 shows the number of injuries to the various anatomic structures.

TABLE 5 Meniscotibial and Meniscofemoral Ligament Injuries in 93 Knees

Injuries Injured Structure Focal Meniscotibial ligament Meniscofemoral ligament Combined Meniscotibial and meniscofemoral ligaments Total 28 77 30 83 44 5 47 5 Number Percentage

RESULTS
We found that combined injuries had occurred in 82 of the 93 knees (88%). Associated ACL injuries were found in 73 knees and associated posterior cruciate ligament injuries in 2 knees. Of the 93 knee injuries reviewed, 92 knees had

342

Sims and Jacobson

The American Journal of Sports Medicine

Figure 8. A, Three major injury patterns (injury to the posterior oblique ligament [POL] is common to all): (1) injury to the POL with semimembranosus disruption, (2) injury to the POL with complete peripheral meniscocapsular detachment, and (3) POL injury with semimembranosus injury and peripheral meniscocapsular detachment. Disruption at any level is capable of disabling the dynamizing function of the semimembranosus. B, Lateral view shows injury to the semimembranosus and POL. PMD, peripheral meniscal detachment.

a documented injury to the POL; 65 were focal injuries (ie, a single point of injury to the named structure), and 27 were multifocal injuries (ie, multiple points of injury to the named structure) (Table 2). The tibial collateral ligament was injured in 31 of 93 knees; 25 of these disruptions were focal injuries (Table 3). The deep medial capsular ligament was injured in 23 knees, and focal injuries were more common than multifocal injuries (Table 4). Injury to the meniscotibial and meniscofemoral ligaments was also recorded (Table 5). To qualify as an injury, the disruption had to involve greater than one third of the medial compartment with extension of the injury posterior to the deep medial capsular ligament. In the case of combined injury, the operative note reported complete peripheral detachment of the meniscus. Disruption of the semimembranosus tendon had occurred in 65 (70%) patients, and most commonly involved the capsular arm (64/65). Meniscal injuries had been recorded in 40 knees20 peripheral tears, 17 body tears, and 3 tears that involved both the body and periphery. Although almost all of the knees in our study had injury to the POL, not all had injury to the semimembranosus, and fewer yet exhibited peripheral meniscal detachment. It is clear that injury to the POL ligament is the common injury, but other sites of disruption, also capable of disabling this dynamic meniscocapsular complex, may be present. From a functional standpoint, 3 basic injury patterns were discovered, with injury to the POL being common to

them all: (1) POL injury and associated injury to the capsular arm of the semimembranosus (70%), (2) POL injury and complete peripheral meniscal detachment (30%), and (3) POL injury and disruption of the semimembranosus and peripheral meniscal detachment (19%) (Figure 8). (The percentages of these 3 injury patterns were not additive. Rather, the third pattern is one in which the first 2 injury patterns occurred together.)

DISCUSSION
When the topic of medial-sided knee injury arises, most physicians choose to progress to the next topic at hand because they have already made up their minds regarding the optimal treatment. Although it is agreed that the isolated tibial collateral ligament injury can do quite well with a period of activity modification and protective bracing, more extensive injury that involves the meniscus and posteromedial corner may deserve further consideration of operative treatment. Although not currently a widely held concept, we believe there is a subset of patients with medial-sided injuries in whom the injury requires surgical repair. The patient we are referring to is one with either an isolated medial injury or a medial injury with an associated ACL injury who demonstrates AMRI.7 In the case of a patient with AMRI with ACL insufficiency, it is certainly possible to stabilize anterior translation of the knee initially, but the long-term viability of the ACL graft and the long-term function of the

Vol. 32, No. 2, 2004

The Posteromedial Corner of the Knee

343

Figure 9. MRI of a medial-sided knee injury reveals extensive stripping (arrow) of the medial capsular structures from the proximal tibia.

Figure 11. MRI of extensive medial-sided injury. Note lack of meniscal attachment and interstitial stretch of the tibial collateral ligament.

Figure 10. MRI of extensive medial-sided injury with complete peripheral meniscal detachment (arrow), disruption of meniscotibial and meniscofemoral ligaments, deep medial one-third capsular ligament, and tibial collateral ligament. Note orientation of medial meniscus.

kneein particular that of the medial meniscusmay be compromised. In the past, emphasis has been placed on a brake stoptype function of the posteromedial portion of the medial meniscus to straight anterior tibial translation in the ACL-deficient knee. On multiple occasions, we have been able to appreciate the absence of the rotatory constraint function normally seen in patients with intact meniscotibial ligamentous attachments in patients in whom it is deficient. The contour of the superior medial edge of the meniscus engages the medial femoral condyle during weightbearing; this fit combined with intact meniscotibial attachments stabilizes the knee to anteromedial motion of the tibia. If, however, the meniscus is not stable on its tibial platform, the meniscus and femoral condyle move as a unit, sliding over the articular surface of the tibia with no stabilizing function. The meniscotibial ligament insufficiency may contribute to increased stress on other structures that resist anterior and anteromedial subluxation and can place the articular surface of the tibia and the meniscus itself at risk of further injury. The purpose of our study was to prove this injury exists by describing the medial and posteromedial patterns of knee injury. In our review of the current literature,10,11,23 we found references to a medial-sided knee injury as a disruption of the medial collateral ligament. In reality, these injuries can be far more complex (Figures 9-11). The term medial collateral ligament has been used to refer to both the deep medial capsular ligament and the tibial collateral ligament. We have purposefully avoided the term as we

344

Sims and Jacobson

The American Journal of Sports Medicine

Figure 12. During abduction stress testing with the knee in 30 of flexion, elevation of the meniscus off the tibia, or meniscal rise, can be seen.

documented and described injury to these structures and, more important, to the posteromedial corner structures. Whether one chooses to recognize the POL9,19,20 as a separate structure or as a thickening of the posteromedial capsule is a matter of semantics. On the other hand, failing to consider the possibility of the functional contribution that the posteromedial corner structures lend to dynamic knee stability has more serious consequences. We believe that with regard to stability, the posteromedial corner, although it is less complex anatomically, is no less important functionally than the posterolateral corner. These patterns of injury are thought to be significant because in this cascade-type system, in which each structure is dependent on the structure(s) to which it is attached or its attachment, damage at any level is capable of disabling the functional cascade of the posteromedial capsule. The significance of understanding the various sites of injury is that in this dynamic system, reparative POL procedures alone may not reconstitute the meniscocapsuloligamentous complex, leaving the semimembranosus unable to act as the stabilizing muscle of the posteromedial corner. Our review of the arthroscopic examination findings in this consecutive series of patients revealed two intraarticular findings that although not statistically significant, we believe are indicative of more extensive posteromedial corner injury. Only 31 of the 93 patients had had a concurrent arthroscopic examination. However, 19 of these 31 patients had either gross elevation of the meniscus off the tibia during abduction stress testing with the knee in 30 of flexion, which we have called meniscal rise (Figure 12), or posteromedial capsular hemorrhage evident during arthroscopy. There are several pertinent topics related to injuries of the posteromedial corner that should be discussed further:

(1) Why do some ACL injuries do quite well when treated nonoperatively? (2) After ACL reconstruction, why does KT-1000 arthrometer testing not always correlate with functional outcome? (3) How can good long-term clinical results after repair of the posteromedial corner without repair of the ACL (such as those reported by Hughston5) be explained? and (4) What is the effect of an unrecognized posteromedial corner injury on ACL reconstruction, and can we compare it with that of an unrecognized posterolateral corner injury? Most orthopaedic surgeons would agree that a small subset of patients with ACL injuries could be treated nonoperatively with excellent functional outcomes.3,12,15,18,21 Jackson et al12 reported on 21 of 62 untreated patients with documented ACL injuries who had favorable clinical outcomes and described several people in the group who were functioning at a high level of competitive amateur or professional athletics at a 10-year average follow-up. In this small subset, 10 of the 21 patients were noted to have complete ACL tears. With complete disruption of the ACL, one would wonder what allowed these patients to function at such a high level without limitation. In addition to an excellent rehabilitative effort, we believe that in these patients, significant posteromedial or posterolateral corner injury does not occur, and the dynamic capsuloligamentous structures and an intact meniscocapsular complex maintain the stability of the knee. In this way, purely isolated function of the ACL seems to be discredited. This concept is further strengthened by the reported lack of correlation between functional ACL reconstruction outcome and KT1000 arthrometer measurements.23,25 In support of the stabilizing effect of the posteromedial corner, Hughston5 reported on 41 patients who had acute repair of the posteromedial capsuloligamentous constraints. Of the 41 patients, 24 had ACL injuries, many of which were not addressed according to accepted current standards. Nonetheless, at an average follow-up of 22 years, the treatment provided good long-term results, and the study focused attention on the functional significance of the posteromedial corner structures. The importance of the semimembranosus corner has been emphasized often by Mller,20 who states, As long as the semimembranosus corner functions efficiently as a stabilizer, even a weak or damaged cruciate ligament can function in a compensated fashion. But if this stabilizing action is lost, the anterior cruciate ligament alone is incapable of compensating and becomes increasingly insufficient. Approaching the topic from the perspective of why ACL reconstructions fail, unrecognized, unaddressed corner injuries have been implicated.2,14,17,20 Just as ACL disruption without significant corner (dynamic capsuloligamentous constraints and meniscocapsular complex) may result in excellent functional outcomes without surgical intervention, dysfunction of the corner structures has been associated with failed ACL reconstructions and persistent rotatory instability. Our purpose in this study was to draw attention to the medial and posteromedial knee structures and to describe associated injury patterns. Although the cases reported are

Vol. 32, No. 2, 2004

The Posteromedial Corner of the Knee

345

only a small percentage of the medial-sided knee injuries treated by the senior author in this 6-year time period, we believe that the extensive injury patterns described here are significant. We have avoided the normal convention of calling all medial-sided knee injuries MCL injuries; instead, we described the injured anatomy. We believe the posteromedial corner structures play an integral role in resisting AMRI of the knee. When they are injured, they sometimes require repair. In our patients, 3 main injury patterns with a POL injury common to all were discovered that revealed disruption of the semimembranosus complex as described by Mller.20 In theory, simple POL repair would be restorative for some knees; yet, in others, reattachment of the semimembranosus or meniscotibial ligament may also be necessary. However, we believe that before we can make recommendations regarding treatment, we must first prove that injuries to these structures exist followed by further work ascribing functional significance. In summary, there are 3 concepts with regard to medialsided knee injuries that the authors believe to be important: (1) Not all medial-sided injuries are created equal; (2) the posteromedial corner structures, motored by the semimembranosus, act in a dynamic fashion to resist AMRI; and (3) although less anatomically complex than the posterolateral corner, the posteromedial corner is no less important functionally. The first is evidenced by the pathoanatomy in the patients described in our series, and the second and third are based on previously published works by Mller20 and Hughston and associates.5,6,8 For knee injuries with resultant functional instability secondary to injury of the medial and posteromedial structures accentuated by ACL disruption, treatment recommendations remain very subjective. The value of intraarticular ACL reconstruction has been firmly established, and it continues to be refined. However, we may come to find that extra-articular reparative procedures can still play a role and have the potential to enhance functional outcomes in both isolated and combined injuries. REFERENCES
1. Brantigan OC, Voshell AF. The tibial collateral ligament: its function, its bursae, and its relation to the medial meniscus. J Bone Joint Surg. 1943;25:121-131. 2. Getelman MH, Schepsis AA, Zimmer J. Revision ACL reconstruction: autograft versus allograft [abstract]. Arthroscopy. 1995;11:378. 3. Giove TP, Miller SJ, Kent BE. Non-operative treatment of the torn anterior cruciate ligament. J Bone Joint Surg. 1983;65A:184-192. 4. Haimes JL, Wroble RR, Grood ES, Noyes FR. Role of the medial structures in the intact and anterior cruciate ligament deficient knee: limits of motion in the human knee. Am J Sports Med. 1994;22(3):402-409. 5. Hughston JC. 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. J Bone Joint Surg. 1994;76A:1328-1344.

6. Hughston JC. Knee Ligaments: Injury and Repair. St. Louis, Mo: Mosby Year-Book; 1993. 7. Hughston JC, Andrews JR, Cross MJ, et al. Classification of knee ligament instabilities: part I. The medial compartment and cruciate ligaments. J Bone Joint Surg. 1976;58A:159-172. 8. Hughston JC, Barrett GR. Acute anteromedial rotatory instability: longterm results of surgical repair. J Bone Joint Surg. 1983;65A:145153. 9. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg. 1973;55A:923-940. 10. Indelicato PA. Isolated medial collateral ligament injuries in the knee. J Am Acad Orthop Surg. 1995;3:9-14. 11. Indelicato PA. Nonoperative management of complete tears of the medial collateral ligament. Orthop Rev. 1989;18:947-952. 12. Jackson RW, Peters RI, Marczyk RL. Late results of untreated anterior cruciate ligament rupture [abstract]. J Bone Joint Surg. 1980;62B:127. 13. Jacobson KE. Technical pitfalls of collateral ligament surgery. Clin Sports Med. 1999;18:847-882. 14. Johnson DL, Swenson TM, Irrgang JJ, et al. Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop. 1996;325:100-109. 15. Jokl P, Kaplan N, Stovell P, et al. Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. J Bone Joint Surg. 1984;66A:741-744. 16. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg. 1982;64A:883-888. 17. Mayday MG, Harner CD, Fu FH. Revision anterior cruciate ligament surgery: evaluation and treatment. In: Feagin JA Jr, ed. The Crucial Ligaments: Diagnosis and Treatment of Ligamentous Injuries About the Knee. 2nd ed. New York: Churchill Livingstone; 1994:711-723. 18. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg. 1980;62A:696-705. 19. Meyer H. Die mechanik dis kniegelenks. Arch Anat Physiol Wiss Med. 1853;497-547. 20. Mller W. The Knee: Form, Function, and Ligament Reconstruction. Berlin: SpringerVerlag; 1983. 21. Pattee GA, Fox JM, Del Pizzo W, et al. Four to ten year followup of unreconstructed anterior cruciate ligament tears. Am J Sports Med. 1989;17:430-435. 22. Paulos LE, Rosenberg TD, Parker RD. The medial knee ligaments: pathomechanics and surgical repair with emphasis on the externalrotation pivot-shift test. Techniques Orthop. 1987;2:37-46. 23. Sernert N, Kartus J, Kohler K, et al. Analysis of subjective, objective, and functional examination tests after anterior cruciate ligament reconstruction. A follow-up of 527 patients. Knee Surg Sports Traumatol Arthrosc. 1999;7:160-165. 24. Slocum DB, Larson RL. Rotatory instability of the knee. Its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg. 1968;50A:211225. 25. Tyler TF, McHugh MP, Gleim GW, et al. Association of KT-1000 measurements with clinical tests of knee stability 1 year following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 1999;29:540-545. 26. Wang CJ, Walker PS. Rotatory laxity of the human knee joint. J Bone Joint Surg. 1974;56A:161-170. 27. Warren LA, Marshall JL, Girgis F. The prime static stabilizers of the medial side of the knee. J Bone Joint Surg. 1974;56A:665674. 28. Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee. J Bone Joint Surg. 1979;61A:5662.