The Presence of the Arthroscopic “Floating Meniscus” Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury

doi:10.1016/j.arthro.2018.10.114

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 35, Issue 3, March 2019, Pages 930-937

https://doi.org/10.1016/j.arthro.2018.10.114 Get rights and content

Purpose

To compare the outcomes of patients with an arthroscopic floating meniscus sign at 24-month follow-up when treated with and without medial compartment reconstruction surgery. Another aim of the present study was to compare magnetic resonance imaging and arthroscopic findings directly related to the characterization and localization medial collateral ligament (MCL) injuries.

Methods

A total of 112 patients diagnosed with combined anterior cruciate ligament (ACL)–MCL grade II injuries to be treated with ACL reconstruction surgery were included in the study. During arthroscopy, patients diagnosed with the “floating meniscus” sign were divided into 2 groups: group 1 (n = 58) was treated with ACL and medial compartment reconstruction surgery and group 2 (n = 54) was treated with ACL reconstruction and nonsurgical medial compartment treatment. Return to competitive sports (Tegner score), Lysholm scores, ACL reconstruction failure, and residual MCL laxity were evaluated 6, 12, and 24 months after surgery.

Results

After 24 months, patients from group 1 (n = 58) had an average Tegner score of 8.98 and Lysholm score of 89.67; 2 patients presented with ACL reconstruction failure and none presented with residual MCL laxity. Patients from group 2 (n = 54) had an average Tegner score of 6.7 and Lysholm score of 78.12; 16 patients presented with ACL reconstruction failure and 13 presented with residual MCL laxity.

Conclusions

In the presence of a floating meniscus arthroscopic sign, patients with combined ACL and grade II MCL injuries treated with ACL and MCL reconstruction surgery had significantly lower frequency of ACL reconstruction failure, residual MCL laxity, and better Tegner and Lysholm scores at 24 months' follow-up (P < .05). Additionally, magnetic resonance imaging and arthroscopy differed significantly (P < .05) in their ability to identify mid-substance and tibial site MCL injuries.

Level of Evidence

Level I, randomized clinical trial.

Section snippets

Methods

Institutional review board approval was obtained before initiation of research. A total of 196 patients with combined ACL and MCL injuries were enrolled in this randomized controlled trial between January 2004 and January 2016. The inclusion criteria for patients were as follows: (1) confirmed ACL injury, (2) patient age 16 to 65 years, (3) confirmed grade II valgus laxity during clinical examination, (4) medial compartment grade II injury confirmed by MRI, (5) normal lower limb alignment

Surgical Procedure

All ACL and MCL reconstruction surgeries were performed by the same surgeon (L.F.Z.F.) between 3 and 6 weeks after knee injury, at the same time. Direct inspection of the anteromedial structures was performed during a standard arthroscopic examination before ACL reconstruction surgery. In all cases, bone, patellar tendon, bone, or quadriceps tendon s were the graft choice for anatomic ACL reconstruction with independent femoral drilling. The grafts were fixed in the tibial and femoral tunnel

Results

Fifty-eight patients were treated with medial compartment reconstruction (group 1) and 54 with nonoperative treatment of the medial compartment (group 2). The mean age of group 1 patients was 29.7 years; group 2, 32.5 years (P < .001). Most injuries to the ACL occurred in sports that require high-intensity rotations at the knee such as soccer (55%) and jiu-jitsu (22%). A total of 62.5% of these injuries were noncontact injury mechanism, 65% of injuries occurred on the right side, and 76% on the

Discussion

The most important finding of this study was that the incidences of ACL reconstruction failure and residual MCL laxity were significantly higher in patients who underwent ACL reconstruction without medial compartment reconstruction in the presence of an arthroscopic floating meniscus sign. Additionally, Tegner and Lysholm scores were higher in patients with combined ACL-MCL grade II injuries treated with ACL and MCL reconstruction in the presence of an arthroscopic floating meniscus sign (P <

Conclusion

In the presence of a floating meniscus arthroscopic sign, patients with combined ACL and grade II MCL injuries treated with ACL and MCL reconstruction surgery had significantly lower frequency of ACL reconstruction failure, residual MCL laxity, and better Tegner and Lysholm scores at 24 months' follow-up (P < .05). Additionally, MRI and arthroscopy differed significantly (P < .05) in their ability to identify mid-substance and tibial site MCL injuries.

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Cited by (29)

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
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up.
A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years’ postoperatively). Continuous variables were reported in median with interquartile range (IQR).
A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0).
In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up.
Level IV, therapeutic case series.
Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Five studies used MCLR as treatment for at least a subset of patients,20,39,41,65,83 but open MCL repair was used in the remaining studies and was the most common procedure reported. MCL tear location was reported in 8 studies,15,20,39,41,42,44,65,84 but a standard grading method for tear location is yet to be established. Nonetheless, proximal MCL tears appeared to be the most common.
Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.
Comparative study of superficial medial collateral ligament reconstruction combined with posterior oblique ligament reconstruction or posteromedial capsule advance in grade III injuries of the medial compartment in a complex knee injury scenario
2022, Knee
The purpose of this study was to compare the combined reconstruction of the superficial medial collateral ligament (sMCL) and the posterior oblique ligament (POL) with the reconstruction of the sMCL associated with the advancement of the posteromedial capsule in a complex knee injury scenario. We hypothesized that both techniques would present similar knee stability and failure rates.
This is a retrospective case–control study designed to compare the results of the two reported techniques for grade III MCL instability. Patients undergoing MCL reconstruction associated with anterior cruciate ligament, posterior cruciate ligament, or both, from 2010 to 2019, were included. The following parameters were evaluated: demographic data, type of graft, time from injury to surgery, associated meniscus injuries, follow up time, mechanism of trauma, postoperative objective IKDC, subjective IKDC and Lysholm scales, range of motion, reconstruction failure and complications.
Seventy-eight patients were evaluated, 37 of whom underwent reconstruction of the sMCL and POL, and 41 of whom underwent reconstruction of the sMCL with advancement of posteromedial structures. There was no difference in any preoperative variable. Patients undergoing reconstruction of the sMCL + advancement had greater loss of flexion (Group 1 3.4 ± 4.6 vs Group 2 8.4 ± 7.9; P = 0.002) and more individuals with flexion loss greater than 10° (Group 1, seven patients (18.9%) vs Group 2, 17 patients (41.5%); P = 0.031). Postoperative knee stability, failures and complications were similar between groups.
Both techniques presented good functional results and low rates of complications. However, the advancement technique showed greater flexion loss, which should be considered when choosing the best surgical option.
The management of combined ACL and MCL injuries: A systematic review
2022, Journal of Orthopaedics
The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies.
A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score.
52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury.
Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.
Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability
2022, Arthroscopy Techniques
The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.
The post-traumatic meniscal extrusion, sign of meniscotibial ligament injury. A case series
2022, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
In acute injury, arthroscopic diagnosis was based on direct signs such as focal area of hemorrhage, bleeding spots or a clear tear of the ligament at medial wall below the inferior surface of meniscus. In chronic injuries, presence of meniscal rise was the main indirect sign of MTL tear [12–15]. Arthroscopically, the authors considered the meniscal rise positive when the meniscus was elevated from the tibial surface for at least 2–3 mm when a valgus stress and external rotation was applied, allowing to insert a probe below the meniscal surface.
Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings.
The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL.
Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity.
All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15–57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (ρ = −0.270; p = 0.202). Neither between having more than 3 mm of extrusion and gender (χ² = 0.80; p = 0.371), acute/chronic lesion (χ² = 0.91; p = 0.341) and primary/revision reconstructions (χ² = 0.83; p = 0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up.
A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes.
IV, retrospective case series.

View all citing articles on Scopus

: See commentary on page 938

: The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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Original ArticleThe Presence of the Arthroscopic “Floating Meniscus” Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Surgical Procedure

Results

Discussion

Conclusion

Arthrosc Tech

Rev Bras Ortop

Arthrosc Tech

MCL injuries of the knee: Current concepts review

Iowa Orthop J

Isolated medial collateral ligament injuries in the knee

J Am Acad Orthop Surg

Medial collateral ligament injuries of the knee: Current treatment concepts

Curr Rev Musculoskelet Med

Acute MCL and ACL injuries: First results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction

Arch Orthop Trauma Surg

Does ACL reconstruction restore knee stability in combined lesions? An in vivo study

Clin Orthop Relat Res

Non-operative treatment of complete tears of the medial collateral ligament of the knee

J Bone Joint Surg Am

Comparison of ACL strain in the MCL- deficient and MCL-reconstructed knee during simulated landing in a cadaveric model

Am J Sports Med

Outcomes following ACL and grade III MCL injuries: Is there a role for MCL repair?

Orthop J Sports Med

Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury

Knee Surg Sports Traumatol Arthrosc

Original Article
The Presence of the Arthroscopic “Floating Meniscus” Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury