Table 2.
List of statements reaching consensus after Delphi round 3
| Statement | % Agreement | % Disagreement |
|---|---|---|
| Anatomy | ||
| The key passive restraining structures of the Posteromedial Corner (PMC) of the Knee are the Superficial Medial Collateral Ligament (sMCL), the Deep Medial Collateral Ligament (dMCL) and the Posterior Oblique Ligament (POL) | 100 | 0 |
| The sMCL is the primary restraint to valgus rotation | 100 | 0 |
| Isolated rupture of the dMCL does not cause a clinically discernable increase in valgus laxity | 82.9 | 17.1 |
| The sMCL is the most important restraint to external tibial rotation on the medial side of the knee | 100 | 0 |
| The POL is an important restraint to internal tibial rotation in the extended knee | 100 | 0 |
| The semimembranosus is an important dynamic restraint | 100 | 0 |
| Diagnosis | ||
| Clinical examination, including valgus stress testing, is highly effective in diagnosing a posteromedial corner injury | 97.1 | 2.9 |
| Both valgus and tibiofemoral rotation should be assessed and taken into consideration when planning treatment of posteromedial corner of the knee | 100 | 0 |
| Valgus laxity with the knee in slight flexion (15–30 degrees) indicates injury to the sMCL | 100 | 0 |
| Pronounced valgus laxity, with the knee in extension, indicates a combined injury of the sMCL and POL, and possibly an ACL injury | 97.1 | 2.9 |
| A positive dial test may indicate anteromedial rotatory laxity | 100 | 0 |
| A strongly positive anteromedial draw test, with the knee at 90 degrees of flexion, may indicate combined injury to the dMCL, sMCL and ACL | 94.3 | 5.7 |
| Magnetic resonance imaging should always be performed in the case of suspected grade 3 MCL injury | 100 | 0 |
| Valgus stress radiographs constitute an important diagnostic tool to assess the extent of an MCL injury, particularly in chronic cases (> 6 weeks) | 97.1 | 2.9 |
| Valgus stress radiographs, to assess PMC stability, are a useful assessment tool following a period of non-operative management or following surgery | 88.6 | 11.4 |
| Classification | ||
| A subjective classification system based on valgus laxity findings at 0 degrees and 15–30 degrees of knee flexion (Grade 1 = No laxity, Grade 2 = Laxity at 15–30 degrees, Grade 3 = Laxity at both 0 degrees and 15–30 degrees) is prognostic and guides treatment | 97.1 | 2.9 |
| An objective classification system (e.g. based on joint-line opening on stress radiographs) is prognostic and guides treatment | 91.4 | 8.6 |
| Complete rupture of the POL in addition to sMCL rupture with valgus gapping in full extension is prognostic of residual valgus laxity following conservative treatment | 100 | 0 |
| Improved classification systems are required for posteromedial corner injuries (for example classifying grade of sMCL injury, POL injury and rotational laxities) | 100 | 0 |
| MRI classification of PMC injury should report on the integrity and portions (meniscofemoral and meniscotibial) of the sMCL, dMCL and POL | 100 | 0 |
| Grade 3 injury on MRI is represented by complete ligamentous discontinuity with laxity or waviness, suggesting disruption of all three components of the PMC (sMCL, dMCL and POL) | 100 | 0 |
| MRI of a chronic PMC injury will not provide information as to the extent of injury nor degree of laxity of the anatomic structures | 100 | 0 |
| Isolated PMC treatment | ||
| Isolated Partial ruptures of the sMCL should be treated conservatively with a range-of-motion brace | 94.3 | 5.7 |
| Early, immediate range of motion (0–90 degrees) within the brace should be allowed to prevent stiffness | 94.3 | 5.7 |
| Isolated, complete PMC ruptures that are femoral sided (meniscofemoral) or mid-substance have a more favorable outcome with conservative treatment compared to tibial sided injuries | 100 | 0 |
| Displaced tibial sMCL avulsions with valgus laxity are best addressed surgically | 97.1 | 2.9 |
| Displaced femoral sMCL avulsion is an indication for acute refixation | 94.3 | 5.7 |
| Intra-articular entrapment is an indication for acute MCL repair/reconstruction | 100 | 0 |
| An “MCL Stener lesion” (The distal sMCL displaced and lying superficial to the Pes Anserinus tendons) is an indication for acute MCL repair/reconstruction | 100 | 0 |
| The evidence for Polyethylene tape re-enforcement (“Internal Bracing”) does not support its use in treatment of isolated, acute, partial sMCL injuries | 94.3 | 5.7 |
| The evidence for Polyethylene tape re-enforcement (“Internal Bracing”) does not support its use in treatment of isolated, complete sMCL injuries | 91.4 | 8.6 |
| Combined PMC treatment | ||
| The treatment of choice for partial PMC injuries, combined with ACL rupture, is a period in a range-of-motion brace before delayed, isolated ACL reconstruction | 100 | 0 |
| The treatment of choice for complete PMC injuries, combined with ACL rupture, is a period in a range-of-motion brace before delayed, isolated ACL reconstruction, if medial stability is reasonably restored | 88.6 | 11.4 |
| Combined ACL rupture and tibial sMCL avulsion is an indication for early MCL repair/reconstruction and ACL reconstruction | 100 | 0 |
| Isolated ACL reconstruction in the presence of valgus laxity of < 3 mm side-to-side laxity is reasonable | 94.3 | 5.7 |
| Combined ACL, PMC reconstruction is indicated for residual medial laxity following conservative treatment of the PMC injury | 100 | 0 |
| The evidence for Polyethylene tape re-enforcement (“Internal Bracing”) does not support combined acute “Internal Bracing” of the Medial side and ACL reconstruction for the treatment of combined, complete ACL and MCL rupture | 91.4 | 8.6 |
| It is reasonable to treat acute PMC injuries with complete PCL rupture with a dynamic PCL brace | 80 | 20 |
| Three ligament ruptures (KD3) involving the MCL (e.g. ACL, PCL, MCL) are best managed by early surgical reconstruction of all ligaments | 94.3 | 5.7 |
| Reconstruction | ||
| Posteromedial corner reconstructions should address both valgus and rotational laxity | 100 | 0 |
| Individual PMC structures should be reconstructed only if lax, avoiding reconstruction of structures that are not damaged/lax | 100 | 0 |
| PMC reconstructions should address the anatomic deficiency based upon combined clinical examination and imaging findings | 100 | 0 |
| Anatomic reconstructions with elements to reconstruct the sMCL and POL are the reconstruction of choice for chronic PMC laxity | 100 | 0 |
| Long limb radiographs should be ordered, in all cases where PMC reconstruction is being considered, to evaluate for the presence of valgus alignment | 97.1 | 2.9 |
| For cases of chronic PMC laxity, valgus alignment (mechanical axis alignment within the lateral compartment) should be corrected before or with PMC reconstruction | 100 | 0 |
| Ipsilateral hamstring autograft is a reasonable option for PMC reconstruction | 80 | 20 |
| Allograft is a valid option for PMC reconstruction | 91.4 | 8.6 |
| Synthetic grafts are NOT a usual first-line option for PMC reconstruction | 100 | 0 |
| Rehabilitation | ||
| A staged rehabilitation is vital for a successful outcome | 100 | 0 |
| A knee brace should be utilized after posteromedial corner reconstruction | 100 | 0 |
| Early (day 1) range of motion should be implemented to avoid stiffness | 97.1 | 2.9 |
| Return to sport following PMC reconstruction should be based on objective functional tests | 100 | 0 |
| Return to sport following PMC reconstruction is not recommended before 6 months after surgery | 100 | 0 |
PMC Posteromedial Corner, sMCL superficial medial collateral ligament, dMCL deep medial collateral ligament, POL posterior oblique ligament, ACL anterior cruciate ligament