Question: In patients with combined anterior cruciate ligament (ACL)
and medial collateral ligament (MCL) injuries, are outcomes different if the
MCL is treated operatively or nonoperatively?
Design: Randomized (allocation
concealed)*,
unblinded, controlled trial with 2-year follow-up.
Information provided by author.
Setting: Helsinki University Central Hospital, Helsinki,
Finland.
Patients: 47 patients who were =18 years of age (mean age range,
38 to 40 y; 57% women) with complete ACL rupture and rupture of most of the
medial ligament structures (grade-III MCL rupture) and no other ligamentous
deficiency. Patients with posterior cruciate ligament, lateral collateral
ligament, or only grade-I or II MCL injury were excluded. Follow-up was
100%.
Intervention: All patients had ACL reconstruction within 4 to 23
days. On the day of surgery, patients were allocated to operative (n = 23) or
nonoperative (n = 24) treatment of MCL injuries. ACL reconstruction was done
with use of the single-incision transtibial technique and a bone-patellar
tendonbone autograft. MCL structures were repaired with suture anchors or were
sutured through bone tunnels and completed with direct suturing. The posterior
oblique ligament or superficial MCL were not reefed, and the range of motion
was checked before closing.
Main outcome measures: Lysholm knee score (<65 = poor, 65 to 83 =
fair, 84 to 94 = good, and 95 to 100 = excellent). Secondary outcomes were
measures of subjective function of the knee, stability, range of motion (ROM),
and muscle power. The study had 90% power to detect a 10-point difference
between the groups in Lysholm score.
Main results: At 2 years, there was no difference between operative
and nonoperative groups in Lysholm score (excellent to good scores, 83% vs
83%). Operative and nonoperative groups were not different in measures of ROM
(2° vs 1°, p = 0.4), mean side-to-side difference in anteroposterior
displacement (1.3 vs 1.2 mm, p = 0.8), mean side-to-side difference in medial
opening tested with valgus radiography (0.9 to 1.7 mm, p = 0.067), or
quadriceps muscle function tested with the isokinetic Biodex dynamometer (14.4
vs 9.7, p = 0.2) or the single-leg hop test (90.2% vs 93.4% of uninvolved
side, p = 0.15). Stability was normal or nearly normal in 96% of the patients
in the operative group and 100% of the patients in the nonoperative group. 70%
of the operative patients and 83% of the nonoperative patients had normal or
nearly normal results on the overall International Knee Documentation
Committee (IKDC) evaluation. The groups had no differences with respect to
change in the levels of activity.
Conclusion: In patients with combined anterior cruciate ligament and
medial collateral ligament injuries, outcomes at 2 years were not different
whether the MCL was treated operatively or nonoperatively.
Halinen and colleagues found no difference between nonoperative and
operative MCL repair for patients with grade-III MCL injuries receiving early
ACL reconstruction. Of interest, the surgery was performed between 4 and 23
days after the injury, which is quite early. Grade-III MCL injuries take at
least 4 weeks to heal. The thinking behind the standard practice of allowing
the MCL to heal before proceeding with ACL reconstruction is to avoid abnormal
valgus stress on the newly reconstructed ligament, which can lead to graft
failure.
There are two potential reasons why the nonoperative group may have fared
well. First, the mean age in the operative and nonoperative groups was 40 and
38 years, respectively, with associated low activity levels before and 2 years
after the injury. The mean IKDC formula for activity level before the injury
for the 2 groups was 2.7 and 2.8, respectively, and after the injury it was
2.3 and 2.5, respectively. Because a level of 3 is graded as heavy work,
skiing, or tennis, and a level of 2 is graded as light manual work, jogging,
or running, the patient population included many relatively low-demand
patients. Second, patients were treated with continuous use of a hinged knee
brace for 6 weeks after surgery (and for an additional 2 weeks of daytime
use).
In summary, Halinen and colleagues showed that patients with complete ACL
and MCL injuries who undergo surgery early after the injury may do well
without surgical treatment of the MCL, although patients should be treated
with a hinged brace. Furthermore, these results should be applied with caution
to high-demand athletes.