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Pinheiro VH, Laughlin M, Borque KA, Ngo D, Kent MR, Jones M, Neves N, Fonseca F, Williams A. Career Length After Surgically Treated ACL Plus Collateral Ligament Injury in Elite Athletes. Am J Sports Med 2024; 52:2472-2481. [PMID: 39097768 DOI: 10.1177/03635465241262440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND Limited data are available regarding career length and competition level after combined anterior cruciate ligament (ACL) and medial- or lateral-sided surgeries in elite athletes. PURPOSE To evaluate career length after surgical treatment of combined ACL plus medial collateral ligament (MCL) and ACL plus posterolateral corner (PLC) injuries in elite athletes and, in a subgroup analysis of male professional soccer players, to compare career length and competition level after combined ACL+MCL or ACL+PLC surgeries with a cohort who underwent isolated ACL reconstruction (ACLR). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A consecutive cohort of elite athletes undergoing combined ACL+MCL and ACL+PLC surgery was analyzed between February 2001 and October 2019. A subgroup of male elite soccer players from this population was compared with a previously identified cohort having had isolated primary ACLR without other ligament surgery. A minimum 2-year follow-up was required. Outcome measures were career length and competition level. RESULTS A total of 98 elite athletes met the inclusion criteria, comprising 50 ACL+PLC and 48 ACL+MCL surgeries. The mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Return-to-play (RTP) time was significantly longer for ACL+PLC injuries (12.8 months; P = .019) than for ACL+MCL injuries (10.9 months). In the subgroup analysis of soccer players, a significantly lower number of players with combined ACL+PLC surgery were able to RTP (88%; P = .003) compared with 100% for ACL+MCL surgery and 97% for isolated ACLR, as well as requiring an almost 3 months longer RTP timeline (12.9 months; P = .002) when compared with the isolated ACL (10.2 months) and combined ACL+MCL (10.0 months) groups. However, career length and competition level were not significantly different between groups. CONCLUSION Among elite athletes, the mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Professional soccer players with combined ACL+PLC surgery returned at a lower rate and required a longer RTP time when compared with the players with isolated ACL or combined ACL+MCL injuries. However, those who did RTP had the same career longevity and competition level.
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Affiliation(s)
| | - Mitzi Laughlin
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Dylan Ngo
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Madison R Kent
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Mary Jones
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Nuno Neves
- Orthopaedic Department, Hospital CUF Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
| | | | - Andy Williams
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
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van der List JP, Muscott RK, Parikh N, Waterman BR, Trasolini NA. Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies. Arthroscopy 2024; 40:2322-2336. [PMID: 38242254 DOI: 10.1016/j.arthro.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A..
| | - Rachel K Muscott
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nihir Parikh
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nicholas A Trasolini
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
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Csete K, Baráth B, Sándor L, Holovic H, Mátrai P, Török L, Hartmann P. Does Combined Reconstruction of the Medial Collateral and Anterior Cruciate Ligaments Provide Better Knee Function? A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3882. [PMID: 38999447 PMCID: PMC11242891 DOI: 10.3390/jcm13133882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/16/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Objective: This study aimed to determine if medial collateral ligament reconstruction (MCLR) alongside anterior cruciate ligament reconstruction (ACLR) preserves knee functionality better than isolated ACLR in combined ACL and MCL tears. Methods: MEDLINE, EMBASE, Scopus, CENTRAL, and Web of Science were searched systematically on 31 March 2023. Studies reporting post-operative function after ACLR and ACLR + MCLR in combined injuries were included. Outcomes included International Knee Documentation Committee (IKDC) score, side-to-side difference (SSD), Lysholm, and Tegner scale values. Results: Out of 2362 papers, 8 studies met the criteria. The analysis found no significant difference in outcomes (MD = 3.63, 95% CI: [-5.05, 12.3] for IKDC; MD = -0.64, 95% CI: [-3.24, 1.96] for SSD at 0° extension; MD = -1.79, 95% CI: [-4.61, 1.04] for SSD at 30° extension; MD = -1.48, 95% CI: [-16.35, 13.39] for Lysholm scale; MD = -0.21, 95% CI: [-4.29, 3.87] for Tegner scale) between treatments. Conclusions: This meta-analysis found no significant difference in outcomes between ACLR and ACLR + MCLR, suggesting that adding MCLR does not provide additional benefits. Due to the heterogeneity and quality of the included studies, further high-quality randomized controlled trials are needed to determine the optimal treatment for combined severe MCL-ACL injuries.
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Affiliation(s)
- Károly Csete
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
| | - Bálint Baráth
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
- Doctoral School of Multidisciplinary Medical Sciences, University of Szeged, 6720 Szeged, Hungary
| | - Lilla Sándor
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
| | - Helga Holovic
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
| | - Péter Mátrai
- Institute for Translational Medicine, University of Pécs, 7624 Pécs, Hungary
| | - László Török
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
- Department of Sports Medicine, University of Szeged, 6725 Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, 6725 Szeged, Hungary
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Blaber OK, DeFoor MT, Aman ZA, McDermott ER, DePhillipo NN, Dickens JF, Dekker TJ. Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis. JBJS Rev 2024; 12:01874474-202406000-00007. [PMID: 38913807 DOI: 10.2106/jbjs.rvw.24.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.
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Affiliation(s)
- Olivia K Blaber
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Zachary A Aman
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Emily R McDermott
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | | | | | - Travis J Dekker
- Department of Orthopaedics Surgery, 10th Medical Group, US Air Force Academy, Colorado Springs, Colorado
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Zee MJM, Pijpker PAJ, Kraeima J, Viddeleer AR, Diercks RL. Patient specific instrumentation in ACL reconstruction: a proof-of-concept cadaver experiment assessing drilling accuracy when using 3D printed guides. Arch Orthop Trauma Surg 2024; 144:289-296. [PMID: 37773534 PMCID: PMC10774211 DOI: 10.1007/s00402-023-05072-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/05/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Accurate positioning of the femoral tunnel in ACL reconstruction is of the utmost importance to reduce the risk of graft failure. Limited visibility during arthroscopy and a wide anatomical variance attribute to femoral tunnel malposition using conventional surgical techniques. The purpose of this study was to determine whether a patient specific 3D printed surgical guide allows for in vitro femoral tunnel positioning within 2 mm of the planned tunnel position. MATERIALS AND METHODS A patient specific guide for femoral tunnel positioning in ACL reconstruction was created for four human cadaveric knee specimens based on routine clinical MRI data. Fitting properties were judged by two orthopedic surgeons. MRI scanning was performed both pre- and post-procedure. The planned tunnel endpoint was compared to the actual drilled femoral tunnel. RESULTS This patient specific 3D printed guide showed a mean deviation of 5.0 mm from the center of the planned femoral ACL origin. CONCLUSION In search to improve accuracy and consistency of femoral tunnel positioning in ACL reconstruction, the use of a patient specific 3D printed surgical guide is a viable option to explore further. The results are comparable to those of conventional techniques; however, further design improvements are necessary to improve accuracy and enhance reproducibility.
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Affiliation(s)
- Mark J M Zee
- Department of Orthopedic Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, PO Box 30.001, 9700RB, Groningen, The Netherlands.
| | - Peter A J Pijpker
- 3D Lab, Department of Orthopedic Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, PO Box 30.001, 9700RB, Groningen, The Netherlands
| | - Joep Kraeima
- 3D Lab, Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, PO Box 30.001, 9700RB, Groningen, The Netherlands
| | - Alain R Viddeleer
- Medical Imaging Center, Department of Radiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, PO Box 30.001, 9700RB, Groningen, The Netherlands
| | - Ronald L Diercks
- Department of Orthopedic Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, PO Box 30.001, 9700RB, Groningen, The Netherlands
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Holuba K, Vermeijden HD, Yang XA, O'Brien R, van der List JP, DiFelice GS. Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous. Arthroscopy 2023; 39:1099-1107. [PMID: 35817377 DOI: 10.1016/j.arthro.2022.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.
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Affiliation(s)
- Kurt Holuba
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Harmen D Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.; Department of Orthopaedic Surgery, Amsterdam UMC Location, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences-Sports, Amsterdam, the Netherlands
| | - Xiuyi A Yang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Robert O'Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.; Department of Orthopaedic Surgery, Amsterdam UMC Location, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Movement Sciences-Sports, Amsterdam, the Netherlands
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A..
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Kim MB, Lee JH, Lee YH. Arc center distance as a novel quantitative radiographic parameter for volar Barton fractures. Arch Orthop Trauma Surg 2022; 142:3765-3770. [PMID: 34739580 DOI: 10.1007/s00402-021-04240-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The aims of this study were to investigate conventional radiographic parameters and introduce a novel parameter (arc center distance, ACD) for volar Barton fractures. METHODS Twenty-four cases of volar Barton fracture were retrospectively analyzed. We measured volar tilt angle (VTA), anteroposterior distance (APD), teardrop angle (TDA), and capitate-to-axis-of-radius distance (CARD) on lateral plain radiographs. The ACD was measured on the sagittal images of computed tomography scans. VTAs, APDs, TDAs, and CARDs were compared between the fractured and normal contralateral wrist. The area under the receiver operating characteristic curve was calculated for each parameter. RESULTS TDAs did not differ significantly between the fractured wrists and the controls. On the other hand, VTAs, APDs, and CARDs were all significantly greater in the fractured wrists (mean values were 17.25°, 20.70 mm, and - 3.40 mm, respectively). The area under the curve value was highest (0.943) for the ACD. When a cutoff value of 1.02 mm was used as a threshold, a sensitivity of 100% and specificity of 80.95% were achieved. CONCLUSIONS The mean values of conventional parameters (VTA, APD, TDA and CARD) in volar Barton fractures were presented. The ACD can be useful parameter for quantitatively evaluating volar Barton fractures.
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Affiliation(s)
- Min Bom Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jeong Hyun Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea.
| | - Young Ho Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101, Dae-hak road, Jongro-gu, Seoul, 03080, Republic of Korea
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Rao R, Bhattacharyya R, Andrews B, Varma R, Chen A. The management of combined ACL and MCL injuries: A systematic review. J Orthop 2022; 34:21-30. [PMID: 35992613 PMCID: PMC9382135 DOI: 10.1016/j.jor.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 10/31/2022] Open
Abstract
Background The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies. Methods A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score. Results 52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury. Conclusions Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.
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Affiliation(s)
- Raunak Rao
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Rahul Bhattacharyya
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Barry Andrews
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Rajat Varma
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Alvin Chen
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
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