Introduction
Materials and methods
Search strategy
Study selection
Data extraction
Study quality assessment
Results
Literature selection
Study characteristics
References | Patient knees/controls | Age (mean, range) | Medial joint space opening | MRI findings/main findings | Intraobserver/interobserver reliability | Sensitivity (%)/specificity (%) | PPV/NPV |
---|---|---|---|---|---|---|---|
Garvin et al. 1993 (RS) [41] | 23/– | n.r., 16–53 | n.r | Match between surgery findings and MRI: Partial rupture (low signal intensity interrupted by areas of high signal intensity): 13 of 7 cases identified Complete rupture (low signal intensity interrupted across entire width): 8 of 14 cases identified | n.r | 100/n.r.c | n.r |
Yao et al. 1994 (RS) [35] | 41/22 | 31, 16–85 | n.r | Match between clinical examinations and MRI Normal MCL: 18 of 22 cases, grade I: 7 of 13 cases, grade II: 9 of 18 cases, grade III: 7 of 10 cases | n.r | n.r | n.r |
Mirowitz et al. 1994 (PS) [31] | 64/10 | 35, 14–69 | n.r | Match between clinical examinations and MRI: Grade I: 31 of 46 cases, grade II: 8 of 14 cases, grade III: 1 of 4 cases | n.r | 81–100/40–95d | 0.25–0.63/ 0.93–1.00d |
Rasenberg et al. 1995 (PS) [32] | 21/21 | 18, 17–50 | n.r | Match between instrumented clinical examinations and MRI: Grade I: 13 of 14 cases, grade II: 5 of 5 cases, grade III: 1 of 2 cases | n.r | n.r | n.r |
Schweitzer et al. 1995 (PS) [33] | 76/25 | 26, 18–60 | n.r | Correlation between MRI grade and clinical examination: Grade I (subcutaneous oedema): pain 44%, tenderness 56%, swelling 56%, instability 33% Grade II (morphologic disruption and/or internal high signal intensity and/or fluid in the MCL bursa): pain 80%, tenderness 87%, swelling 59%, instability 26% grade III (MCL discontinuity): pain 64%, tenderness 64%, swelling 50%, instability 18% | n.r./0.76–0.93 | 7–81/95–100e (different signs) | n.r |
Lundberg et al. 1996 (PS) [40] | 69/– | 26, 13–57 | n.r | match between arthroscopy and MRI: 14 of 69 cases true positive, 41 of 69 cases true negative, 3 of 69 cases false positive, 11 of 69 cases false negative | n.r | 56/93b | 0.82/0.79b |
De Maeseneer et al. 2001 (CS) [50] | 7/6 | n.r., 50–91 Control group n.r., 16–48 | n.r | bursa could not be detected via MRI in cadaveric knees without contrast injection On anatomic section MCL bursa was observed in five of seven cases in the femoral and in seven of seven cases in the tibial component | n.r | n.r | n.r |
Wen et al. 2007 (RS) [34] | 6/12 | 47, n.r | n.r | Traumatic MCL-oedema: oedema deep and superficial: in six of six cases, oedema fibers: in four of six cases, bone marrow oedema: in three of six cases, medial meniscal tears: in three of six cases, medial meniscal extrusion: in one of six cases Atraumatic MCL-oedema: oedema deep and superficial: in 12 of 12 cases, oedema fibers: in 5 of 12 cases, marginal osteophytes: in 6 of 12 cases, articular cartilage thinning: in 6 of 12 cases, bone marrow oedema: in 5 of 12 cases, subchondral cysts: in 1 of 12 cases, medial meniscal tears: in 11 of 12 cases, medial meniscal extrusion: in 6 of 12 cases | n.r | n.r | n.r |
Halinen et al. 2009 (PS) [39] | 44/– | 39, 21–64 | n.r | Match between MRI and surgical treated MCL (n = 21): Identification of tear grade: 18 of 21 cases, identification of tear location: 11 of 21 cases | n.r | 86a/n.r | n.r |
Studler et al. 2011 (PS) [30] | 10/10 | 35, 17–51 | MCL injury: grade I: 2.3 mm, grade II: 2.9 mm (1.9–4.9 mm) control group: 1.7 mm (0.7–3.3 mm) | Grade I (n = 1): edema around an intact MCL Grade II (n = 9): partial tear of the ligament with internal high signal | n.r./ ICC: 0.89–0.94 | n.r | n.r |
Taketomi et al. 2014 (RS) [47] | 12/– | 25, 16–40 | n.r | Wave sign: in all cases Identification of the ruptured end: in 9 of 12 cases Identification of entrapment: in 2 of 2 cases | n.r | n.r | n.r |
Alaia et al. 2019 (RS) [48] | 65/– | Only subgroups reported | n.r | Distal tibial grade III sMCL tear: in 20 of 65 cases Isolated tibial attachment tears: in 16 of 20 cases Femoral and tibial attachment tears: in 4 of 20 cases SLL: in 12 of 20 cases Borderline SLL: 6 of 20 cases | n.r | n.r | n.r |
Brimmo et al. 2019 (PS) [45] | 7/– | 24, 16–32 | n.r | SLL: redundant distal MCL fibers, displaced superficial to the pes anserinus Clinical examination: grade II in 1 of 7 cases, grade III in 6 of 7 cases | n.r | n.r | n.r |
Boutin et al. 2020 (RS) [49] | 51/– | 28, n.r | n.r | SLL: in 20 of 51 sMCL tears Wave sign: in 18 of 20 SLL-cases and in 21 of 31 non-SLL-cases Proximal sMCL stump is located more distal and medial in cases with SLL | n.r | n.r | n.r |
References | Patient knees/control group | Age (mean, range) | Medial joint space opening | Morphological findings | Intraobserver/interobserver reliability | Sensitivity (%)/specificity (%) | PPV/NPV |
---|---|---|---|---|---|---|---|
De Flaviis et al. 1988 (PS) [43] | 10/– | n.r | Grade I rupture (n = 3): 7.0–10.0 mm Grade II rupture (n = 3): 9.0–18.0 mm Grade III rupture (n = 4): 12.0–23.0 mm | Grade I rupture: intraarticular hemorrhage Grade II rupture: inhomogenity of the ligament without a clear cut Grade III rupture: irregular hypoechoic fissure | n.r | n.r | n.r |
Friedl et al. 1991 (PS) [42] | 84/– | 32, n.r | No rupture (n = 21): 2.9 ± 1.4 mm Partial rupture (n = 9): 5.2 ± 1.3 mm Complete rupture (n = 54): 6.6 ± 1.6 mm | n.r | n.r | 63–87/96a | 63–94/80 |
Lee et al. 1996 (PS) [36] | 16/20 | 32, 21–52 control group: n.r., 23–28 | n.r | Injured MCL (n = 16): “thickened, heterogenous hypoechoic lesion on the tender points” Attachment thickness: femoral 8.3 mm (6.1–12.5 mm), tibial 3.9 mm (3.7–4.1 mm) Normal MCL (n = 20): “homogenous hypoechotic band” Attachment thickness: femoral 4.3 mm (3.3–5.6 mm), tibial 2.3 mm (1.3–3.2 mm) | n.r | n.r | n.r |
Ghosh et al. 2017 (PS) [27] | 9/– | 53, n.r | n.r | grade I rupture (n = 2): “stretching of the ligament without discontinuity of the fibers and associated edematous changes” Old rupture (n = 1): “Thickening of proximal MCL Normal MCL (n = 6): “thick hyperechoic and fibrillar structure, extending from the medial femoral condyle to the proximal tibia” | n.r | 67/83b | 67/83 |
Slane et al. 2017 (CS) [52] | –/8 | n.r., 68–101 | Unloaded: 8.7 ± 2.4 mm Loaded (10 Nm valgus): 10.7 ± 2.2 mm | n.r | n.r./ Unloaded: 0.95 Loaded: 0.93 | n.r | n.r |
Lutz et al. 2020 (PS) [44] | –/79 | 35, 20–63 | Unloaded 0°: 5.7 ± 1.2 mm Loaded 0°: 7.4 ± 1.4 mm Unloaded 30°: 6.1 ± 1.1 mm Loaded 30°: 7.8 ± 1.2 mm | n.r | n.r./ ICCs: loaded and unloaded 0.89 | n.r | n.r |
References | Patient knees/controls | Age (mean, range) | X-ray method | Medial joint space opening/main findings | Intraobserver/interobserver reliability | Sensitivity (%)/specificity (%) | PPV/NPV |
---|---|---|---|---|---|---|---|
Jacobsen et al. 1977 (PS) [25] | 153/151 | n.r., 13–67 | Bilateral comparison with simultaneous stress at 20° flexion (9 kg) | Match between stress radiography and operative findings (not defined), medial gap difference of 2.0 mm was defined an upper limit: 63 of 89 cases true positive, 21 of 89 cases true negative, 0 of 89 cases false positive, 5 of 89 cases false negative | n.r./n.r | 93/100a | 1.00/0.81a |
Sawant et al. 2004 (PS) [37] | 23/23 | 33, 17–50 | Bilateral comparison with simultaneous stress | MCL injury: Mean overall injuries: 16.0 mm, range: 10.0—29.0 mm Mean isolated MCL injury: 15.0 mm, range: 10.0—18.0 mm Mean combined MCL with ACL/PCL injury: 17.0 mm, range: 10.0—29.0 mm Mean control group: 8.0 mm, range: 5.0—11.0 mm | 0.96/0.95 | 94/86b | 0.94/0.86b |
LaPrade et al. 2010 (CS) [26] | 18/– | 76, 66–86 | a.p. radiographs at 0° and 20° knee FL with a fluoroscopy C-arm, clinical valgus and 10Nm two cutting sequences: 1. intact—proximal sMCL—MF—POL—distal sMCL—MT—ACL—PCL 2. intact—distal sMCL—MT—proximal sMCL—MF—POL—PCL—ACL | Sectioning of proximal sMCL: Increase of MG by 1.5 mm (at 0° knee FL) and 3.2 mm (20° knee FL) in clinical examination Sectioning of distal sMCL: Increase of MG by 2.0 mm (at 0° knee FL) and 3.1 mm (20° knee FL) in clinical examination 1. Complete meniscofemoral injury without cruciate ligament: increase of MG by 4.3 mm (at 0° knee FL) and 6.7 mm (20° knee FL) in clinical examination 2. Complete meniscotibial injury without cruciate ligament: Increase of MG by 3.6 mm (at 0° knee FL) and 5.4 mm (20° knee FL) in clinical examination | 0.99/0.98 | n.r./n.r | n.r./n.r |
Quality assessment
Evaluation of imaging modalities
Intraobserver and interobserver reliability
Sensitivity and specificity, positive and negative predictive values
Medial gapping
References | Imaging modality | Measurement method | Medial joint space opening |
---|---|---|---|
De Flaviis et al. 1988 (PS) [43] | Ultrasonography | With and without valgus stress Gap width measurement: width of intraarticular space along the anterior third, the middle, and the posterior third of the internal face of the joint | Grade I rupture: 7.0–10.0 mm Grade II rupture: 9.0–18.0 mm Grade III rupture: 12.0–23.0 mm |
Friedl et al. 1991 (PS) [42] | Ultrasonography | In 20° of flexion, with and without valgus stress Gap width measurement: distance between the end of the femoral condyle and tibia | No rupture: 2.9 ± 1.4 mm Partial rupture: 5.2 ± 1.3 mm Complete rupture: 6.6 ± 1.6 mm |
Slane et al. 2017 (CS) [52] | Ultrasonography | Without MCL injury, in 20° of flexion, with and without valgus stress (loaded) Gap width measurement: distance between distal femur and proximal tibia relative to the skin | Unloaded: 8.7 ± 2.4 mm Loaded (10 Nm valgus): 10.7 ± 2.2 mm |
Lutz et al. 2020 (PS) [44] | Ultrasonography | In 0° and 30° of flexion, unloaded and loaded valgus stress (15 daN) Gap width measurement: distance between the most medial corresponding points on the femoral condyle and tibial plateau | Unloaded 0°: 5.7 ± 1.2 mm Loaded 0° (15daN): 7.4 ± 1.4 mm Unloaded 30°: 6.1 ± 1.1 mm Loaded 30° (15daN): 7.8 ± 1.2 mm |
Sawant et al. 2004 (PS) [37] | Radiography | In 10–15° of flexion, with valgus stress Gap width measurement: most medial distance between femoral condyle and corresponding medial tibial plateau | Mean only isolated MCL injury: 15 mm, range: 10–18 mm Mean combined MCL with ACL and/or PCL injury: 17 mm, range: 10–29 mm |
LaPrade et al. 2010 (CS) [26] | Radiography | In 0° and 20° of flexion, with valgus stress (clinical and loaded), before and after sectioning Gap width measurement: shortest distance between the subchondral bone surface of the most distal aspect of the medial femoral condyle and the corresponding medial tibial plateau | Increase of MG in clinical examination 20° knee FL Sectioning of proximal sMCL: by 3.2 mm to 10.6 ± 1.9 mm Sectioning of distal sMCL: by 3.1 mm to 10.6 ± 1.4 mm Complete meniscofemoral injury: by 6.7 mm to 14.1 ± 2.1 mm Complete meniscotibial injury: by 5.4 mm to 12.9 ± 2.2 mm |
Studler et al. 2011 (PS) [30] | dynamic MRI | Clinical examination with valgus stress Gap width measurement: distance between medial tibial margin and the cortex of the medial femoral condyles | Grade I rupture: 2.3 mm Grade II rupture: 2.9 mm (1.9–4.9 mm) |