Bouguennec Nicolas, Marty-Diloy Thibault, Colombet Philippe, Graveleau Nicolas, Robinson James
Clinique du Sport, Bordeaux-Merignac, France.
Knee Specialists, Bristol, UK.
Video J Sports Med. 2023 Oct 5;3(5):26350254231204385. doi: 10.1177/26350254231204385. eCollection 2023 Sep-Oct.
Chronic combined medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries are frequent. Medial residual laxity is a risk factor for ACL rerupture. It should be treated at the same time as the ACL reconstruction (ACLR) if necessary, but there are still questions surrounding the indications for abstention or surgery of the medial plan, especially for grade 2 MCL injuries of the Fetto and Marshall classification.
The purpose is to come back to a simple test, the "Rotatory Instability Test" as described by Slocum and Larson in 1968 for systematic clinical examination of the knee to improve the sensitivity and accuracy of the deep MCL (dMCL) and superficial MCL (sMCL) examination and to propose a decision-making algorithm for the treatment of the chronic combined ACL/MCL injuries based on the assessment of anteromedial rotatory instability (AMRI).
Examination of the ACL with Lachman test, anterior drawer in neutral rotation, and pivot shift test confirm the ACL injury. Valgus laxity is tested in extension and at 20° of flexion. Then, an anterior drawer test at 90° of flexion with external rotation is done (the anterior drawer in external rotation [ADER] test) allowing to identify isolated dMCL, dMCL + sMCL, or MCL + posterior oblique ligament (POL) injuries.
As persistent medial laxity is a risk factor for ACL graft failure and there is no reliable method of instrumented laxity assessment, careful clinical examination remains essential. Systematic examination of the medial side with valgus laxity testing at 0° and 20° flexion combined with the ADER test assessment of AMRI can guide treatment of the MCL injury component. Where there is no valgus laxity and the ADER test is negative, isolated ACLR is indicated. If there is significant medial laxity at 0°, this suggests combining sMCL and POL reconstruction with ACLR. Where the knee is stable at 0° but there is valgus laxity at 20° and a positive ADER test, the dMCL can be reconstructed using a gracilis graft or a combined sMCL and dMCL reconstruction can be added to the ACLR depending on the degree of laxity.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
慢性内侧副韧带（MCL）和前交叉韧带（ACL）联合损伤很常见。内侧残余松弛是ACL再次断裂的危险因素。如有必要，应在进行ACL重建（ACLR）的同时进行治疗，但对于内侧方案的保守治疗或手术治疗的适应症仍存在疑问，尤其是对于Fetto和Marshall分类中的2级MCL损伤。
目的是回归到一种简单的检查方法，即1968年Slocum和Larson所描述的“旋转不稳定试验”，用于膝关节的系统临床检查，以提高深层MCL（dMCL）和浅层MCL（sMCL）检查的敏感性和准确性，并基于对前内侧旋转不稳定（AMRI）的评估，提出一种治疗慢性ACL/MCL联合损伤的决策算法。
通过Lachman试验、中立旋转位的前抽屉试验和轴移试验检查ACL，以确认ACL损伤。在伸直位和屈膝20°时测试外翻松弛度。然后，在屈膝90°并外旋时进行前抽屉试验（外旋前抽屉试验[ADER]），以确定单纯dMCL、dMCL + sMCL或MCL +后斜韧带（POL）损伤。
由于持续的内侧松弛是ACL移植物失败的危险因素，且目前尚无可靠的仪器测量松弛度的评估方法，仔细的临床检查仍然至关重要。在0°和20°屈膝位进行外翻松弛度测试并结合ADER试验评估AMRI，对内侧进行系统检查，可指导MCL损伤部分的治疗。如果没有外翻松弛且ADER试验为阴性，则建议进行单纯ACLR。如果在0°时有明显的内侧松弛，则提示应将sMCL和POL重建与ACLR相结合。如果膝关节在0°时稳定，但在2°时有外翻松弛且ADER试验阳性，则可根据松弛程度，使用股薄肌移植物重建dMCL，或在ACLR基础上增加sMCL和dMCL联合重建。
作者证明已获得本出版物中出现的任何患者的同意。如果个体可被识别，作者已随本投稿附上患者的豁免声明或其他书面形式的批准，以供发表。
