Abstract
The medial collateral ligament (MCL) is the most commonly injured ligament in the knee. Historically, nonsurgical management for these injuries has been favored for a majority of grade I-III sprains, particularly femoral-based. However, when coupled with other injuries such as meniscotibial ligament tears or distal Stener type avulsion tears, early surgical management for these cases is recommended. This will allow for stabilization and protection of the meniscus in addition to preventing residual valgus laxity, especially related to more severe Stener-like avulsions of the superficial MCL that can be seen with meniscotibial ligament tears. Utilizing an open approach, meniscotibial repair with suture anchors with internal brace augmentation for the MCL repair can provide a strong final construct, and a safe and fast recovery.
Technique Video
The following technique describes an open medial meniscotibial repair with concomitant open superficial MCL repair with InternalBrace augmentation. The patient is a 14-year-old boy who suffered a football injury when he had a valgus impact on his right knee. He felt a pop and had immediate pain and swelling. On physical examination with valgus stress testing, he was noted to have stability at 0° flexion but valgus laxity at 30° without a firm end point. On magnetic resonance imaging, he was noted to have a complete tear of the superficial MCL and the meniscotibial ligament injury. On examination under anesthesia, he was again noted to be stable at 0° but had grade III laxity at 30° with valgus stress testing. His diagnostic arthroscopy demonstrated a meniscotibial ligament tear in the setting of a positive drive through sign with a high-riding medial meniscus. Following the diagnostic arthroscopy, a longitudinal incision was made just proximal to the joint line along the course of the sMCL and extended 6 cm distal to the joint line. The sartorial fascia was carefully incised and a complete avulsion of the sMCL from its tibial insertion was noted consistent with a Stener-type lesion. The infrapatellar branch of the saphenous nerve and the pes anserine tendons were dissected and protected throughout the case. In addition to the sMCL injury, the patient also had a complete disruption of the medial meniscotibial ligament, which was easy to visualize. Using fluoroscopy, the femoral MCL insertion was identified and a 4.75-mm bioabsorbable anchor with 2-mm suture tape was placed for our internal brace construct. Following this, we performed the meniscotibial fixation. 2× doubly loaded 1.3-mm suture anchors were inserted into the proximal tibia just below the joint line. Each limb of the loaded suture tapes was passed into the peripheral aspect of the medial meniscus in a horizontal fashion and were subsequently tied reducing the medial meniscus back to the tibia. The sMCL was then carefully placed under the infrapatellar branch of the saphenous nerve and extended to the tibial insertion. The 2 suture tape ends previously passed through the femur were then brought down into a 4.75-mm bioabsorbable anchor with the knee positioned in 15° of flexion. A probe was placed underneath the suture tape to prevent overtensioning of the internal brace. The repair suture of the knotless anchor was then passed in a horizontal mattress fashion through the distal fibers of the MCL and was subsequently tensioned through the knotless mechanism. Next, the suture attached to the femoral anchor was passed through the proximal MCL, further placating and tensioning the MCL. Following final fixation, we were able to obtain an anatomic reduction of both our meniscotibial ligament and superficial MCL with good tension and internal brace augmentation. With the knee at 30° flexion, a valgus stress was applied, demonstrating good stability following the repair. The incision was then copiously irrigated and the wound was closed in a layered fashion, with care taken to preserve the infrapatellar branch of the saphenous nerve. The arthroscope was then placed back into the joint, confirming our reduction of the meniscotibial ligament with elimination of our drive-through sign and high-riding medial meniscus. (MCL, medial collateral ligament; sMCL, superficial medial collateral ligament.)
The medial collateral ligament (MCL) is the most commonly injured knee ligament, accounting for approximately 40% of all ligamentous knee injuries.1,2 Despite it being the most commonly injured, it is not the most common knee ligament treated operatively due to the inherently stable nature of a majority of MCL sprains occurring without other ligamentous injury.3 However, for certain grade III MCL tears, especially distal Stener-type MCL avulsions off the tibia, surgical intervention is necessitated to restore proper knee biomechanics by correcting persistent valgus instability.4,5 In addition, injury to the meniscus through its meniscotibial attachment further destabilizes the medial side.4, 5, 6, 7 Injury to the medial meniscotibial ligament (MTL) may be seen on magnetic resonance imaging as meniscal extrusion with possible entrapment of the MCL underneath it.4 Arthroscopically, an MTL injury has been described as a “meniscal rise.”8 If left untreated, this may lead to the accelerated progression of osteoarthritis in the medial compartment due to excess contact pressures shifting from the medial meniscus to the medial tibial plateau (MTP).5, 6, 7 Therefore, restoring proper medial meniscal anatomy and function is necessary, as the MTL plays a crucial role in meniscal stability and intra-articular chondral preservation.5, 6, 7,9
The described technique is based on independent fixation of both the MTL injury and the distal superficial medial collateral ligament (sMCL) avulsion. Specifically, the MTL injury is first fixated with 2 suture anchors placed into the proximal tibia followed by repair of the sMCL with a combination of suture anchor and internal brace fixation. This procedure provides an additional technique to address the concurrent MTL and sMCL lesions with a strong construct that is restores normal anatomy (Video 1 and Table 1).
Table 1.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
|
|
MT, meniscotibial; sMCL, superficial medial collateral ligament.
Surgical Technique (With Video Illustration)
Step 1: Patient Setup and Diagnostic Arthroscopy
The patient is positioned supine on a standard operative table. Following thorough examination under anesthesia, the knee is prepped and draped in the normal fashion with 2 g of Kefzol (cefazolin) administered before surgical timeout.
Standard anterolateral and anteromedial arthroscopy portals are created, and a diagnostic joint assessment is performed. Immediately upon entering the medial compartment, a positive “drive-through” (Fig 1A) sign is noted with an associated high-riding meniscus consistent with combined MTL and sMCL injury (Fig 1B).
Fig 1.
Arthroscopic viewing of the right knee from the anterolateral portal demonstrating (A) a positive drive-through sign (≥1-cm medial compartment opening) and (B) a “high-riding” medial meniscus (MM) and a hemorrhagic meniscotibial ligament (asterisk) suggestive of complete disruption. (MFC, medial femoral condyle. MTP, medial tibial plateau.)
Step 2: MCL, MTL Dissection
A longitudinal incision is made just proximal to the medial joint line along the sMCL and is extended 6 cm distal to the joint to the expected sMCL footprint.9 The sartorius fascia is carefully incised and the infrapatellar branch of the saphenous nerve is identified and protected for the remainder of the procedure (Fig 2).
Fig 2.
Intraoperative photo of the right medial knee demonstrating the infrapatellar branch of the saphenous nerve (asterisk) following medial dissection. (P, probe; sMCL, superficial medial collateral ligament.)
Typically, findings include a complete avulsion of the sMCL off its tibial insertion consistent with a Stener-type lesion with associated meniscotibial disruption. As the sMCL is elevated, a complete disruption of the medial MTL is easily visualized (Fig 3).
Fig 3.
Intraoperative photograph of the right medial knee demonstrating a (A) distal Stener avulsion lesion (asterisk) of the superficial medial collateral ligament (sMCL) off the tibia, and of a (B) complete disruption of the meniscotibial ligament with no attachment of the meniscus body (M) to the tibia (T).
Step 3: Meniscotibial Fixation
Using a 1.35-mm K-wire drill, a double-loaded 1.3-mm anchor (DX FiberTak with 0.9-mm SutureTape with needles; Arthrex, Naples, FL) is inserted into the proximal tibia at the posterior aspect of the MTL defect just below the joint line. The 2 SutureTape ends are passed through the peripheral aspect of the medial meniscus in a horizontal mattress fashion and left untied. These steps are repeated with a second anchor placed more anteriorly. The SutureTapes are then tied reducing the medial meniscus back to the tibia (Fig 4).
Fig 4.
Intraoperative photograph of the right medial knee following meniscotibial ligament repair (asterisk) using 2 anchors and 4 sutures.
Step 4: Femoral MCL Fixation
Next, using fluoroscopy, the isometric point for MCL femoral fixation is identified on the true lateral projection of the knee located at the junction of the posterior femoral cortical line and the upper aspect of Blumensaat’s line (Fig 5).
Fig 5.
Lateral fluoroscopic image of a right knee in a near skeletally mature individual demonstrating the guide pin (asterisk) placed at the junction of the posterior cortical line and the upper aspect of Blumensaat’s line (B) for isometric positioning for the femoral sMCL attachment. (sMCL, superficial medial collateral ligament; P, distal femoral growth plate.)
If the patient is not skeletally mature, care is taken to ensure that the guidepin position is just distal to the growth plate with fluoroscopic confirmation. A 2.4-mm guidepin is then inserted to a depth of 25 mm and over-reamed with a 4-mm reamer to a depth of 20 mm. To breach the femoral cortex, a 4.75-mm anchor tap is used for at least 3 turns. A 2-mm-wide suture tape (FiberTape; Arthrex) is passed through the eyelet of a 4.75-mm bioabsorbable anchor (BioComposite SwiveLock; Arthrex), thus creating the internal brace construct (InternalBrace; Arthrex).10 The SwiveLock is tapped with a mallet into the femoral socket until the eyelet is fully seated and then screwed to just below the femoral cortex.
Step 5: Tibial MCL Fixation/Closure
Next, at the distal aspect of the incision, the pes tendons are retracted inferiorly, allowing visualization of where the sMCL had avulsed from its normal tibial footprint. A 2.4-mm guidepin is inserted here at a depth of 25 mm. A 4-mm reamer is used to over-ream at this point the same way as described previously for the femur. A 4.75-mm anchor tap is used to completely tap this hole. Using a curved hemostat, the sMCL is carefully passed under the infrapatellar branch of the saphenous nerve and extended toward the tibial bone socket as is the suture tape that laid superficial to the ligament but deep to the nerve. The 2 FiberTape ends are passed through the eyelet of a 4.75-mm bioabsorbable anchor with a knotless mechanism (DX Knotless SwiveLock, BC, 4.75-mm; Arthrex). With the knee positioned at 15° of flexion, the anchor is pushed through the sMCL and into the tibial bone socket, repairing the sMCL avulsion in the process as it is screwed down. As the anchor is inserted, a probe is placed under the FiberTape just distal to the nerve to prevent excessive tension of the internal brace. The repair suture of the knotless mechanism is then passed in a horizontal mattress fashion through the distal sMCL fibers and then further secured to the bone underneath the suture tape by passing this same suture through the loop of the knotless mechanism creating a splice as it is tightened down with the remaining free suture. The #2 FiberWire (Arthrex) suture attached to the femoral anchor is passed through the sMCL proximally to plicate and tighten its femoral attachment. With the knee held at 30° of flexion, valgus stress is applied to the knee confirming adequate stability following the repair. Final anatomic sMCL repair can be seen in Figure 6.
Fig 6.
Intraoperative photograph of the right medial knee demonstrating final anatomic superficial medial collateral ligament (sMCL) repair with suture tape augmentation (asterisk). (P, probe; S, infrapatellar branch of the saphenous nerve.)
With the arthroscope in the anterolateral portal and the probe in the anteromedial portal, the final repair of the MTL is inspected. The medial meniscus laid flush against the MTP confirms normal anatomical positioning. It is also noted that the “drive-through” sign is eliminated, confirming adequate repair of the MCL (Fig 7)
Fig 7.
Arthroscopic view of the right knee from the anterolateral portal demonstrating a reduced medial meniscus (MM) and negation of drive-through sign following open repair of the meniscotibial ligament and superficial medial collateral ligament. (MFC, medial femoral condyle. MTP, medial tibial plateau.)
The tourniquet is released, and the medial incision is adequately irrigated with Betadine followed by antibiotic saline solution. The wound is then closed in a standard, layered fashion and a sterile, bulky compressive dressing is applied to the knee along with a long leg hinged knee brace locked in full extension.
Step 6: Rehabilitation
An accelerated rehabilitation protocol is implemented following the procedure. A long-leg brace locked in extension is used for the first 2 weeks to allow for protected weight-bearing. Range of motion for flexion along with quad sets and straight leg raises begins postoperative week 1. Use of the stationary bike and addition of leg press and hamstring curls begins postoperative week 2 along with protected weight-bearing in the same long-leg brace with the hinges open to 90°. Continued supervised physical therapy in a smaller hinged brace begins postoperative month 2 with a focus on closed-chain strengthening. Swimming (without leg kicking) with a floatation device between legs is permitted at this point. Jogging is typically allowed by postoperative month 3, with more intense running and cutting allowed at month 4 per physical therapy’s recommendation. Full return to sport in a functional knee is in the range of 4 to 6 months.
Discussion
MTL lesions lead to meniscal rise and extrusion.4 An extruded meniscus allows contact pressures to shift from the meniscus to the tibial plateau, resulting in the accelerated progression of medial compartmental osteoarthritis.5, 6, 7 Therefore, recognition of these lesions is important based on both magnetic resonance imaging and arthroscopic assessment. Surgical management with repair of MTL tears is necessary to avoid detrimental short-term sequelae.11, 12, 13 When coupled with severe valgus instability due to complete disruption of the sMCL, further strain on other structures such as the anterior cruciate ligament (ACL) may lead to further joint damage.14
The surgical technique described in this report allows for reduction of the medial meniscus through an open repair of a disrupted MTL. In a biomechanical cadaveric study, Smith et al.5 found that not repairing MTL lesions was associated with significant increases in ACL strain; anterior laxity at 0°, 30°, and 90°; valgus laxity; and external rotation laxity. By repairing these MTL lesions, proper intra-articular anatomy can be restored, which may benefit patients, especially in the immediate postoperative period as they begin their rehabilitation protocol.
Isolated grade III sMCL lesions have historically been treated nonoperatively, but caution should be taken with nonoperative management, as in some cases grade III tears may result in residual valgus laxity and so MCL repair or reconstruction would be the better treatment option.15 Distal Stener-type lesions with avulsion of the sMCL off its tibial attachment is a variant of a grade III lesion that needs direct surgical repair to restore valgus stability. In a systematic review including 18 studies (n = 1,534 cases), Shultz et al.16 concluded that those patients with avulsion MCL injuries and Stener-type lesions may benefit from early repair due to the persisting valgus instability that may result from these lesions untreated. Apart from these investigations, a recent case series conducted on professional athletes to assess Stener-type injuries revealed that surgical intervention was linked to a high rate of return to the preinjury level of sports, exceptional functional performance, and minimal chances of recurrence during short-term follow-up.17
Through the same incision, the sMCL can be repaired with a combination of suture anchor fixation and internal brace augmentation, forming a construct that is biomechanically similar to a reconstruction.5,18 In a biomechanical study, Mehl et al.19 evaluated the effects of suture-tape augmentation in primary repair of sMCL and posterior oblique ligament (POL) injuries. The study revealed that cadavers with complete sMCL and POL avulsions that were treated with sMCL and POL repair with augmentation demonstrated nearly native valgus and rotational laxity, along with ACL strain resembling native conditions. Another biomechanical study, focusing on a combined ACL/MCL repair model, reported similar findings. Specifically, cadavers that underwent MCL repair with augmentation showed improved valgus and external rotation laxity compared with those that underwent MCL repair alone, without augmentation.20
In conclusion, this Technical Note describes the anatomic fixation of both the sMCL and medial meniscus in the setting of a grade III sMCL avulsion with concomitant medial MTL injury.21 Not only does it allow for an anatomic reduction, but since this is a completely open technique, there is the benefit of a faster surgical time. Furthermore, MCL biomechanics following internal brace augmentation allows the patient to be able to begin early weight-bearing with an accelerated postoperative rehabilitation program to help minimize muscle atrophy.22,23
The advantages and disadvantages are summarized in Table 2. The main disadvantages of this technique are the need for an open incision, the additional cost of fixation with multiple suture anchors, and loss of range of motion with improper final internal brace fixation.
Table 2.
Advantages and Disadvantages of the Technique
| Advantages | Disadvantages |
|---|---|
|
|
MTL, meniscotibial ligament; sMCL, superficial medial collateral ligament.
Footnotes
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: P.A.S. reports grants from Arthrex, to institution; royalties, consulting, travel support, and patents from Arthrex, to author; speakers fees from Kairos Surgical and United Orthopedics LLC, to author; and stock or stock options from Spinal Simplicity, to author. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
The following technique describes an open medial meniscotibial repair with concomitant open superficial MCL repair with InternalBrace augmentation. The patient is a 14-year-old boy who suffered a football injury when he had a valgus impact on his right knee. He felt a pop and had immediate pain and swelling. On physical examination with valgus stress testing, he was noted to have stability at 0° flexion but valgus laxity at 30° without a firm end point. On magnetic resonance imaging, he was noted to have a complete tear of the superficial MCL and the meniscotibial ligament injury. On examination under anesthesia, he was again noted to be stable at 0° but had grade III laxity at 30° with valgus stress testing. His diagnostic arthroscopy demonstrated a meniscotibial ligament tear in the setting of a positive drive through sign with a high-riding medial meniscus. Following the diagnostic arthroscopy, a longitudinal incision was made just proximal to the joint line along the course of the sMCL and extended 6 cm distal to the joint line. The sartorial fascia was carefully incised and a complete avulsion of the sMCL from its tibial insertion was noted consistent with a Stener-type lesion. The infrapatellar branch of the saphenous nerve and the pes anserine tendons were dissected and protected throughout the case. In addition to the sMCL injury, the patient also had a complete disruption of the medial meniscotibial ligament, which was easy to visualize. Using fluoroscopy, the femoral MCL insertion was identified and a 4.75-mm bioabsorbable anchor with 2-mm suture tape was placed for our internal brace construct. Following this, we performed the meniscotibial fixation. 2× doubly loaded 1.3-mm suture anchors were inserted into the proximal tibia just below the joint line. Each limb of the loaded suture tapes was passed into the peripheral aspect of the medial meniscus in a horizontal fashion and were subsequently tied reducing the medial meniscus back to the tibia. The sMCL was then carefully placed under the infrapatellar branch of the saphenous nerve and extended to the tibial insertion. The 2 suture tape ends previously passed through the femur were then brought down into a 4.75-mm bioabsorbable anchor with the knee positioned in 15° of flexion. A probe was placed underneath the suture tape to prevent overtensioning of the internal brace. The repair suture of the knotless anchor was then passed in a horizontal mattress fashion through the distal fibers of the MCL and was subsequently tensioned through the knotless mechanism. Next, the suture attached to the femoral anchor was passed through the proximal MCL, further placating and tensioning the MCL. Following final fixation, we were able to obtain an anatomic reduction of both our meniscotibial ligament and superficial MCL with good tension and internal brace augmentation. With the knee at 30° flexion, a valgus stress was applied, demonstrating good stability following the repair. The incision was then copiously irrigated and the wound was closed in a layered fashion, with care taken to preserve the infrapatellar branch of the saphenous nerve. The arthroscope was then placed back into the joint, confirming our reduction of the meniscotibial ligament with elimination of our drive-through sign and high-riding medial meniscus. (MCL, medial collateral ligament; sMCL, superficial medial collateral ligament.)
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The following technique describes an open medial meniscotibial repair with concomitant open superficial MCL repair with InternalBrace augmentation. The patient is a 14-year-old boy who suffered a football injury when he had a valgus impact on his right knee. He felt a pop and had immediate pain and swelling. On physical examination with valgus stress testing, he was noted to have stability at 0° flexion but valgus laxity at 30° without a firm end point. On magnetic resonance imaging, he was noted to have a complete tear of the superficial MCL and the meniscotibial ligament injury. On examination under anesthesia, he was again noted to be stable at 0° but had grade III laxity at 30° with valgus stress testing. His diagnostic arthroscopy demonstrated a meniscotibial ligament tear in the setting of a positive drive through sign with a high-riding medial meniscus. Following the diagnostic arthroscopy, a longitudinal incision was made just proximal to the joint line along the course of the sMCL and extended 6 cm distal to the joint line. The sartorial fascia was carefully incised and a complete avulsion of the sMCL from its tibial insertion was noted consistent with a Stener-type lesion. The infrapatellar branch of the saphenous nerve and the pes anserine tendons were dissected and protected throughout the case. In addition to the sMCL injury, the patient also had a complete disruption of the medial meniscotibial ligament, which was easy to visualize. Using fluoroscopy, the femoral MCL insertion was identified and a 4.75-mm bioabsorbable anchor with 2-mm suture tape was placed for our internal brace construct. Following this, we performed the meniscotibial fixation. 2× doubly loaded 1.3-mm suture anchors were inserted into the proximal tibia just below the joint line. Each limb of the loaded suture tapes was passed into the peripheral aspect of the medial meniscus in a horizontal fashion and were subsequently tied reducing the medial meniscus back to the tibia. The sMCL was then carefully placed under the infrapatellar branch of the saphenous nerve and extended to the tibial insertion. The 2 suture tape ends previously passed through the femur were then brought down into a 4.75-mm bioabsorbable anchor with the knee positioned in 15° of flexion. A probe was placed underneath the suture tape to prevent overtensioning of the internal brace. The repair suture of the knotless anchor was then passed in a horizontal mattress fashion through the distal fibers of the MCL and was subsequently tensioned through the knotless mechanism. Next, the suture attached to the femoral anchor was passed through the proximal MCL, further placating and tensioning the MCL. Following final fixation, we were able to obtain an anatomic reduction of both our meniscotibial ligament and superficial MCL with good tension and internal brace augmentation. With the knee at 30° flexion, a valgus stress was applied, demonstrating good stability following the repair. The incision was then copiously irrigated and the wound was closed in a layered fashion, with care taken to preserve the infrapatellar branch of the saphenous nerve. The arthroscope was then placed back into the joint, confirming our reduction of the meniscotibial ligament with elimination of our drive-through sign and high-riding medial meniscus. (MCL, medial collateral ligament; sMCL, superficial medial collateral ligament.)
The following technique describes an open medial meniscotibial repair with concomitant open superficial MCL repair with InternalBrace augmentation. The patient is a 14-year-old boy who suffered a football injury when he had a valgus impact on his right knee. He felt a pop and had immediate pain and swelling. On physical examination with valgus stress testing, he was noted to have stability at 0° flexion but valgus laxity at 30° without a firm end point. On magnetic resonance imaging, he was noted to have a complete tear of the superficial MCL and the meniscotibial ligament injury. On examination under anesthesia, he was again noted to be stable at 0° but had grade III laxity at 30° with valgus stress testing. His diagnostic arthroscopy demonstrated a meniscotibial ligament tear in the setting of a positive drive through sign with a high-riding medial meniscus. Following the diagnostic arthroscopy, a longitudinal incision was made just proximal to the joint line along the course of the sMCL and extended 6 cm distal to the joint line. The sartorial fascia was carefully incised and a complete avulsion of the sMCL from its tibial insertion was noted consistent with a Stener-type lesion. The infrapatellar branch of the saphenous nerve and the pes anserine tendons were dissected and protected throughout the case. In addition to the sMCL injury, the patient also had a complete disruption of the medial meniscotibial ligament, which was easy to visualize. Using fluoroscopy, the femoral MCL insertion was identified and a 4.75-mm bioabsorbable anchor with 2-mm suture tape was placed for our internal brace construct. Following this, we performed the meniscotibial fixation. 2× doubly loaded 1.3-mm suture anchors were inserted into the proximal tibia just below the joint line. Each limb of the loaded suture tapes was passed into the peripheral aspect of the medial meniscus in a horizontal fashion and were subsequently tied reducing the medial meniscus back to the tibia. The sMCL was then carefully placed under the infrapatellar branch of the saphenous nerve and extended to the tibial insertion. The 2 suture tape ends previously passed through the femur were then brought down into a 4.75-mm bioabsorbable anchor with the knee positioned in 15° of flexion. A probe was placed underneath the suture tape to prevent overtensioning of the internal brace. The repair suture of the knotless anchor was then passed in a horizontal mattress fashion through the distal fibers of the MCL and was subsequently tensioned through the knotless mechanism. Next, the suture attached to the femoral anchor was passed through the proximal MCL, further placating and tensioning the MCL. Following final fixation, we were able to obtain an anatomic reduction of both our meniscotibial ligament and superficial MCL with good tension and internal brace augmentation. With the knee at 30° flexion, a valgus stress was applied, demonstrating good stability following the repair. The incision was then copiously irrigated and the wound was closed in a layered fashion, with care taken to preserve the infrapatellar branch of the saphenous nerve. The arthroscope was then placed back into the joint, confirming our reduction of the meniscotibial ligament with elimination of our drive-through sign and high-riding medial meniscus. (MCL, medial collateral ligament; sMCL, superficial medial collateral ligament.)