Distal Medial Collateral Ligament Repair With Suture Augmentation

The medial collateral ligament (MCL) is considered to have superior healing and has classically been treated nonoperatively in low-grade MCL injuries. The MCL injury in the setting of concomitant anterior cruciate ligament (ACL) injury is usually treated with a delay of surgery to allow for nonoperative MCL treatment. Recent studies have shown that even with grade II MCL injury there may be residual laxity which may affect place greater strain on an ACL graft in the multi-ligamentous setting and can be corrected for with early primary repair of the MCL which also allows for early definitive treatment of concurrent ipsilateral ligamentous injuries. All patients are potential candidates given sufficient tissue quality for repair; however, this procedure is preferably performed acutely to avoid scarring, quadriceps strength loss, and allow for early intervention to any concurrent ipsilateral ligamentous knee injury. This technique may be performed on both proximal and distal MCL injuries with the same anchor positioning in either case. The torn superficial and deep MCL are sutured using a Bunnell-type pattern. The superficial proximal MCL is then fixed to its anatomic footprint using a suture anchor preloaded with an internal suture tape augmentation. A second small incision is made over the tibial insertion of the MCL and a passing suture is channeled from the distal to proximal incision under a skin bridge to retrieve the suture tape. The suture tape is then deployed with appropriate tensioning to the anatomic distal insertion point of the superficial MCL using a second suture anchor. There is currently no published data regarding patient outcomes after MCL primary repair with suture augmentation. Our preliminary unpublished data with 49 patients treated with this technique and a variety of concomitant ligamentous injury with average follow-up of 1.7 years showed no MCL repair failures. Four patients experienced more than 10° of flexion range of motion loss, and 3 had residual valgus laxity of grade 1 at 0° and 30° of flexion. Primary MCL repair provides a minimally invasive treatment option for medial laxity, while the suture augmentation allows for early range of motion. Furthermore, this approach avoids delayed definitive surgical intervention of concomitant ligamentous injuries in the setting of combined multi-ligamentous injuries.

To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears. In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P= .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P= .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P= .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001). The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5%+ 24.8%= 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries. Level III, retrospective cohort study.

PurposeIn knee dislocation with bicruciate ligament and medial side injury (KDIIIM), treatment method of medial side injuries is controversial. The purpose of this study was to evaluate the outcomes of non-operative treatment of proximal and midsubstance and operative treatment of distal avulsion medial collateral ligament (MCL) ruptures in patients with early bicruciate reconstruction.MethodsOne-hundred and forty-seven patients with a knee dislocation and bicruciate ligament injury (KDII-KDV) were identified. Sixty-two patients had KDIIIM injury. Of these, 24 patients were excluded and 13 were lost to follow-up. With a minimum of 2 years of follow-up, IKDC2000 (subjective and objective), Lysholm and Tegner scores and stress radiographs were recorded.ResultsTwenty-five patients were available for follow-up: 18 had a proximal or midsubstance grade-III MCL rupture (proximal MCL group) and 7 had a distal MCL avulsion (distal MCL group). In the proximal MCL and distal MCL groups, respectively, median IKDC2000 subjective scores were 80 (range 57–99) and 62 (range 39–87), and median Lysholm scores were 88 (range 57–99) and 75 (range 40–100). The median medial opening (side-to-side difference) was 2.4 mm (range 0.1–9.2) in the proximal MCL group and 2.5 mm (range 0.2–4.8) in the distal MCL group.ConclusionWe found acceptable recorded outcomes in patients who underwent non-operative treatment of proximal and midsubstance grade-III MCL rupture and operative treatment of distal MCL avulsion with early bicruciate ligament reconstruction.Level of evidenceLevel IV

IntroductionAnterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2.MethodsAMRI was assessed using the Feagin-Thomas test in 7 isolated ACL (iACL) injured participants, 3 combined ACL and superficial fibre MCL (sMCL) injuries, 5 combined ACL and deep fibre MCL injuries, and 21 healthy controls. Displacement values were recorded using an optical motion capture (OMC) system and bespoke processing pipeline which map and model the knee's anterior displacement values relative to the medial compartment. Since absolute values (mm) of rotational laxity vary dependant on the person, values were recorded as a proportion of the rotational laxity obtained from the subject's contralateral leg. Values were compared between each patient group using an ANOVA test and Tukey's honesty significant difference post hoc test. 3.ResultsThe healthy control group had a median proportion of 0.97 (3SF), whilst the iACL was 1.12 (3SF), a 12% increase in rotational laxity in the injured leg. The sMCL group yielded a result of 1.64 (3SF), a 64% increase in rotational laxity in the injured leg; finally, dMCL resulted in a proportion of rotational laxity of 1.90 (3SF), a 90% increase in rotational laxity [table 1]. Whilst all groups showed differences in the increase of rotational laxity, dMCL was significantly different from the healthy control group (P value 0.0041). 4.ConclusionACL injuries with MCL involvement led to an increase in anterior medial rotary laxity and this is more evident in patients where deep MCL fibres are involved. The Feagin-Thomas test appears to be sensitive in detecting differences in AMRI and should be considered when performing comprehensive clinical knee examination.For any figures or tables, please contact authors directly.

ABSTRACTPurposeCombined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are common and present challenges in management. While ACL reconstruction has been established, the optimal approach for combined ACL and MCL injuries remains debatable owing to the varying severity and chronicity of MCL injuries. This study aimed to describe a novel surgical technique for chronic ACL and grade III MCL injuries and assess whether simultaneous ACL and MCL reconstruction improves chronic MCL instability.MethodsA total of 41 patients diagnosed with combined ACL and MCL injuries were included in the study. Twenty‐five patients were allocated into the simple ACL reconstruction (SAR) group while 16 patients were allocated into the simultaneous ACL and MCL reconstruction (SAMR) group according to MCL injury severity. The surgical technique utilized a single ipsilateral hamstring autograft for both ACL and MCL reconstruction. Clinical assessments, including range of motion (ROM), functional score, Lachman test, and valgus instability, were conducted before and after surgery. Postoperative magnetic resonance imaging (MRI) was used to evaluate graft quality.ResultsPostoperative outcomes revealed significant improvements in ROM, functional scores, Lachman test, and valgus instability in both groups. There were no significant differences between the SAR and SAMR groups, suggesting that patients with combined ACL rupture and severe MCL injuries can achieve similar stability outcomes as those with ACL rupture and mild MCL injuries. The MRI results revealed high‐quality grafts in both groups.ConclusionThis study introduces a novel technique using simple hamstring autografts for simultaneous ACL and MCL reconstruction, and this surgical technique can achieve knee stability comparable to that of low‐grade MCL injuries and can be used for single ACL reconstruction. Further research with larger sample sizes and long‐term follow‐up is needed to confirm these findings.

The purposes of this study are to describe the sonographic findings of the injured medial collateral ligament (MCL) of the knee, to perform a sonographic valgus stress test, and to correlate these findings in order to advance the proper treatment for these patients. We examined 23 patients with clinical diagnosis of MCL injury. We evaluated proximal and distal MCL thickness, free fluid, and avulsion fractures. In addition, we performed a sonographic valgus stress test in the stress and rest positions. We also examined the knee joint on the same side in 18 sex- and age-matched patients with no history of knee injury as a control. The average thickness of proximal MCL was 6.4 mm (range, 4.2–8.1 mm) in injured MCL and 4.3 mm (range, 3.2–6.2 mm) in normal MCL. The average thickness of distal MCL was 4.4 mm (range, 2.4–6.1 mm) in injured MCL and 3.1 mm (range, 2.1–4.1 mm) in normal MCL. The average joint space width of the injured knee at rest was 6.1 mm (range, 4.0–8.5 mm) and increased to 10.5 mm (range, 7.6–14.0 mm) after stress. The average joint space width of the normal knee at rest was 6.7 mm (range, 5.0–7.7 mm) and increased to 9.6 mm (range, 7.7–10.4 mm) after stress. In conclusion, the combination of the sonographic findings in MCL injury and the real-time sonography valgus stress test can support the clinical diagnosis and pinpoint the exact location of isolated MCL injury, thus advancing the proper treatment of the patient.

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.

Background:There is a need for an increased understanding of the way a concomitant medial collateral ligament (MCL) injury may influence outcome after anterior cruciate ligament (ACL) reconstruction.Hypothesis:Patients with a concomitant MCL injury would have inferior clinical outcomes compared with a matched cohort of patients undergoing ACL reconstruction without an MCL injury.Study Design:Matched registry-based cohort study; case-control.Level of Evidence:Level 3.Methods:Data from the Swedish National Knee Ligament Registry and a local rehabilitation outcome registry were utilized. Patients who had undergone a primary ACL reconstruction with a concomitant nonsurgically treated MCL injury (ACL + MCL group) were matched with patients who had undergone an ACL reconstruction without an MCL injury (ACL group), in a 1:3 ratio. The primary outcome was return to knee-strenuous sport, defined as a Tegner activity scale ≥6, at the 1-year follow-up. In addition, return to preinjury level of sport, muscle function tests, and patient-reported outcomes (PROs) were compared between the groups.Results:The ACL + MCL group comprised 30 patients, matched with 90 patients in the ACL group. At the 1-year follow-up, 14 patients (46.7%) in the ACL + MCL group had return to sport (RTS) compared with 44 patients (48.9%) in the ACL group (P = 0.37). A significantly lower proportion of patients in the ACL + MCL group had returned to their preinjury level of sport compared with the ACL group (10.0% compared with 25.6%, adjusted P = 0.01). No differences were found between the groups across a battery of strength and hop tests or in any of the assessed PROs. The ACL + MCL group reported a mean 1-year ACL-RSI after injury of 59.4 (SD 21.6), whereas the ACL group reported 57.9 (SD 19.4), P = 0.60.Conclusion:Patients with a concomitant nonsurgically treated MCL injury did not return to their preinjury level of sport to the same extent as patients without an MCL injury 1 year after ACL reconstruction. However, there was no difference between the groups in terms of return to knee strenuous activity, muscle function, or PROs.Clinical Relevance:Patients with a concomitant nonsurgically treated MCL injury may reach outcomes similar to those of patients without an MCL injury 1 year after an ACL reconstruction. However, few patients return to their preinjury level of sport at 1 year.

The MCL apprehension sign: A novel test for MCL instability

BackgroundCombined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injury is the most common combination of ligamentous knee injury. Many authors support the conservative treatment of MCL tears. This study aimed to compare the outcomes of simultaneous ACL reconstruction (ACL-R) and MCL reconstruction with ACL-R and conservative MCL treatment in cases of combined ACL and grade III MCL injuries.MethodsIn this retrospective cohort study, we evaluated consecutive patients with combined ACL and MCL injuries who underwent surgical treatment over five years in two private hospitals in Tehran, Iran. We compared postoperative knee range of motion (ROM), pain intensity (visual analog scale [VAS]), functional outcomes (Tegner-Lysholm and International Knee Documentation Committee Subjective Knee Form [IKDC] scores), time to and proportion of return to sports, time to return to work, activity level (Marx activity rating scale), and graft failure rate between ACL-R and conservative MCL treatment (ACL-R + conservative MCL group) and ACL-R and MCL reconstruction (ACL-R + MCL-R group). All patients were followed for at least twelve months.ResultsOverall, 110 patients, comprising 92 men (83.6%) and 18 women (16.4%), were included, consisting of 67 (60.9%) in the ACL-R + conservative MCL group and 43 (39.1%) in the ACL-R + MCL-R group. The mean age of the patients was 27.5 ± 9.0 years. Age, sex, side, and follow-up period were comparable between the groups (P > 0.05 for all). Graft failure occurred in 6 patients (9.0%) in the ACL-R + conservative MCL group, but in none of the patients in the ACL-R + MCL-R group (P = 0.046). Range of extension and flexion of the knee, VAS, Tegner-Lysholm score, IKDC score, time to return to sports, time to return to work, proportion of return to sports, and activity level did not differ significantly between the groups (P > 0.05 for all).ConclusionACL-R and MCL reconstruction resulted in similar knee ROM, pain intensity, functional outcomes, time to return to work and sports, and activity level to ACL-R and conservative MCL treatment in patients with combined ACL and MCL injury. However, ACL-R and MCL reconstruction significantly reduced graft failure rates, suggesting the potential benefit of surgical MCL management in conjunction with ACL reconstruction.

Medial collateral ligament (MCL) injury is the most commonly encountered ligament injury following knee trauma. The MCL and posterior oblique ligament (POL) are the primary stabilizers against valgus stress in the knee. Most isolated MCL injuries are treated with a brace and early mobilization. However, in cases where complex injuries accompany the MCL injury, such as femoral avulsion fractures, open injuries, MCL injury with meniscus tear and joint dislocation, and distal MCL ruptures involving the pes anserinus tendon insertion area, surgical treatment is necessary. Additionally, cases involving posterior cruciate ligament (PCL) tears and combined anterior and posterior cruciate ligament (ACL and PCL) tears require surgical intervention. In cases where MCL injury occurs alongside anterior cruciate ligament (ACL) injury, conservative treatment is initially recommended, with potential ACL repair in the later stages. Recurrent medial instability after conservative treatment can lead to secondary ACL injury, muscle weakness, and osteoarthritis.

PurposeTo determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction.MethodsPatients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively.ResultsA total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41–0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3–23.9], p = 0.005).ConclusionNon-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction.Level of evidenceCohort study, Level III.

Background:Deep medial collateral ligament (dMCL) injuries are a known cause of medial knee pain, which can result from either trauma or degenerative conditions. While conservative management, including bracing and physical therapy, remains the first-line treatment, persistent symptoms may necessitate additional interventions. Platelet-rich plasma (PRP) therapy has emerged as a promising treatment modality due to its ability to enhance ligament healing by promoting collagen synthesis and tissue regeneration. Recent studies highlight PRP's potential to improve pain and function in patients with medial collateral ligament injuries, particularly when guided by ultrasound for precise delivery.Indications/Technique Description:This study presents 2 cases of dMCL injury with different causes. The first case involves a 25-year-old male athlete with a traumatic valgus injury, while the second case is a 63-year-old man with nontraumatic medial knee pain and underlying degenerative changes. Both patients underwent ultrasound-guided PRP injections after not responding to conservative management. The PRP preparation involved centrifugation of autologous blood to obtain leukocyte-rich PRP, which was then injected into the meniscotibial ligament (MTL) under ultrasound guidance. The injection was performed using a high-frequency linear transducer to visualize the dMCL and guide the needle precisely into the injured area of the MTL. The in-plane approach ensured optimal placement, minimizing the risk of inadvertent tissue damage.Results:Both patients demonstrated significant pain reduction and functional improvement within 4 weeks postinjection. The athlete successfully returned to football, and the older patient resumed brisk walking without discomfort. Follow-up showed no recurrence of symptoms. Key considerations for PRP therapy include careful patient selection, individualization of PRP therapy, familiarity with the different PRP preparation systems, and proper patient education for managing expectations regarding treatment outcomes. Technical proficiency in ultrasound-guided injections is essential for accurate PRP delivery, minimizing procedural errors, and maximizing therapeutic benefits.Discussion/Conclusion:dMCL injuries can cause persistent medial knee pain that is unresponsive to conservative treatment. PRP therapy presents a promising option for promoting ligament healing, with ultrasound guidance improving precision and potentially optimizing outcomes. However, further research is needed to establish standardized protocols for PRP formulation, dosing, and long-term efficacy.Patient Consent Disclosure Statement: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.

The incidence of posterior cruciate ligament (PCL) injuries in isolation is uncommon, but rather more regularly found with concurrent injuries, while medial-sided injuries are the most frequent among knee structures. The medial collateral ligament (MCL), spanning between the medial aspect of the femur and tibia, consists of a superficial medial (tibial) collateral ligament (sMCL) and a deep medial collateral ligament (dMCL) and provides stabilization from abnormal valgus motion and internal/external rotation. The PCL is composed of two bundles, the anterolateral bundle (ALB) and the posteromedial bundle (PMB), and is the strongest of the intra-articular knee ligaments. The PCL predominantly provides restraint to posterior tibial translation and external/internal tibial rotation. The most effective means in determining MCL injury is by severity of medial joint space gapping by valgus stress testing; PCL deficiency is evaluated relative to the posterior sag sign, the quadriceps active test, and the posterior drawer test. Injuries to either the PCL or MCL (Grade III) are suggestive for reconstruction. In the instance of concomitant injuries, tunnel convergence is frequently encountered among the tunnels drilled per structure, and coronal angulation of 40° for the MCL tunnel is beneficial for avoidance of the PCL tunnels. Surgical techniques using anatomic procedures for attachment sites are the most effective means for subsequently restoring kinematics of the knee joint, ultimately yielding greater outcome scores. Although single-bundle (SB) reconstructions are able to restore subjective outcomes, a high incidence of osteoarthritis (OA) progression is seen in patient outcomes. While double-bundle (DB) techniques show promising outcomes, long-term studies are needed to further define outcomes, as well as studies documenting treatment of concomitant MCL and PCL injuries.

This study aimed to describe an anatomic medial knee reconstruction technique for combined anterior cruciate ligament (ACL) and grade III medial collateral ligament (MCL) injuries and to assess knee function and stability restoration in patients who underwent primary MCL reconstruction compared with primary repair. A total of 105 patients who had undergone anatomic ACL reconstruction between 2008 and 2017 were enrolled in this retrospective study and divided into two groups according to concomitant MCL ruptures. Group A included patients with isolated ACL ruptures without MCL injuries. Group B included patients with both ACL and MCL injuries, and it was subdivided into three groups according to the severity of the MCL injury and treatment modality: B-1, grade I or II MCL injury treated conservatively; B-2: grade III MCL injury treated by primary MCL repair; and B-3: grade III MCL injury treated by primary reconstruction. Knee stability was measured via Telos valgus radiography at 6-month and 2-year postoperative. The Lysholm score, Tegner activity level, Likert scales (satisfaction), and return to previous sports were evaluated at 2-year postoperative. At 6-month postoperative, there was no significant difference in medial laxity between the B-2 and B-3 groups. However, at 2-year postoperative, medial laxity were significantly higher both at 30° of flexion (5.2° versus 2.2°, p = 0.020) and at full extension (3.4° versus 1.1°, p < 0.001) in patients in B-2 group compared to those in B-3 group. There were no statistically significant differences between the two groups with respect to Lysholm scores, Tegner activity levels, Likert scales (satisfaction), and returning to previous sports at the 2-year follow-up. Primary medial reconstruction combined with severely injured MCL in ACL reconstruction may decrease residual medial laxity more than primary repair. Retrospective observational study, IV.