Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous

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

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.

Editorial Commentary: Combined Anterior Cruciate Ligament/Medial Collateral Ligament Injuries: Surgeons Should Have a Low Threshold to Operate on the Medial Collateral Ligament

Combined anterior cruciate ligament/medial collateral ligament (ACL/MCL) injuries are relatively common, and multiple factors are involved in surgical decision-making, particularly when it comes to the MCL. Historically, most surgeons treated the MCL conservatively and performed staged MCL reconstruction after MCL reconstruction only if there was persistent medial instability. This was followed by a nonoperative approach for the MCL (when reconstructing the ACL) unless there was evidence of extreme (grade III or >1 cm) valgus instability, valgus malalignment, or mid-substance or tibial-sided injury, avulsion, or Stener lesion. However, the most recent research demonstrates that combined ACL/MCL injuries present a higher risk of ACL reconstruction failure and subsequent revision compared to ACL injuries alone. With growing biomechanical and clinical evidence, more surgeons are repairing or reconstructing the MCL in these combined injuries. Although there is no clear consensus, we recommend surgeons consider surgically treating the MCL to avoid not only excessive force on the ACL graft but also persistent valgus laxity, which can lead to ACL failure. For distal MCL avulsions, repairs have shown excellent midterm outcomes, especially if the tissue quality is pristine. If the tissue quality is not repairable, then we would advocate for repairing whatever tissue is repairable and augmenting with an MCL reconstruction. For mid-substance MCL injuries, if surgical intervention is required, we advocate for MCL reconstruction. For proximal tears, the same criteria used for distal tears apply with management based on tissue quality and joint stability after repair. The ACL is a secondary stabilizer to valgus loads, and MCL deficiency results in tremendous strain on ACL graft reconstructions. If the MCL is even mildly incompetent, we strongly advocate for treating the MCL surgically in this setting.

Timing of Anterior Cruciate Ligament Surgery

This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.

Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis

» 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.

Displaced Posterior Cruciate Avulsion Fracture Fixation With Medial Collateral Ligament and Lateral Meniscus Injury Using Combined Open and Arthroscopic Methods

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations.

Two-stage ligament reconstruction with remnant preservation as treatment of knee dislocation

OBJECTIVE

The purpose of this study was to evaluate the clinical outcomes of two-stage reconstruction (peripheral reconstruction in phase I and central anterior cruciate ligament (ACL) / posterior cruciate ligament (PCL) reconstruction in phase II) with remnant preservation for patients with knee dislocation.

METHODS

A total of 70 patients (10 IIIM, 17 IIIL, and 43 IV) with knee dislocation were randomly divided into the remnant-preserved group and the simple reconstruction group. Patients underwent two-stage reconstruction, including the reconstruction of collateral ligament in phase I and the reconstruction of ACL/PCL in phase II (12 weeks after phase I). Grafts were harvested from the semitendinosus and gracilis tendons from both lower limbs. After the surgery, the joint flexion and extension, bone tunnel and ligament healing, and joint stability were evaluated.

RESULTS

After the surgery, the lateral stability recovered in all patients, and X-ray revealed a good position of bone tunnel. Follow-up was performed at 12 months postoperatively and ranged from 24 to 91 months. At the final follow-up, knee flexion angle, IKDC, Lysholm, and Tegner scores were all higher in both groups compared to the preoperative period. Notably, the remnant-preserved group showed superior results in these parameters compared to the simple reconstruction group. There was statistical significance between the two groups in terms of the Lachman test.

CONCLUSION

The knee function was well recovered after two-stage ligament reconstruction with remnant preservation.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness

Purpose

To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up.

Methods

A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR).

Results

A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0).

Conclusions

In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up.

Level of Evidence

Level IV, therapeutic case series.

Revisiting Anterior Cruciate Ligament Repairs in an Athlete With Combined Grade III Medial Collateral Ligament and High-Grade Posterolateral Anterior Cruciate Ligament Tear: A Case Report

Anterior cruciate ligament tears are primarily treated by reconstruction. The development of novel surgical techniques has led to the reconsideration of this approach. Additionally, Grade III tibial-sided medial collateral ligament tears should be treated surgically due to decreased blood flow and poor healing. We describe the surgical repair of a Grade III tibial-sided tear with partial femoral avulsion of the medial collateral ligament and tear of the posterolateral bundle of the anterior cruciate ligament in a competitive high school athlete. A 17-year-old male presented to the Sports Medicine Clinic after injuring his left knee in a football game. Radiographs suggested normal skeletal anatomical alignment with no acute fractures. Magnetic resonance imaging identified a partial injury of the femoral attachment of the medial collateral ligament and a Grade III medial collateral ligament tear where it attached to the tibia. Arthroscopic evaluation of the knee revealed a posterolateral anterior cruciate ligament tear. Operative management included surgical repair of the Grade III tibial-sided medial collateral ligament tear and the posterolateral anterior cruciate ligament tear. Operative repair of medial collateral ligament and anterior cruciate ligament tears provides an alternative approach to the management of surgical reconstruction.

Editorial Commentary: The Timing and Treatment of Combined Anterior Cruciate Ligament-Medial Collateral Ligament Injuries: Conservative Management, Early Repair, Augmentation, and Delayed Reconstruction of the Medial Collateral Ligament

Medial collateral ligament (MCL) injuries are commonly encountered in conjunction with anterior cruciate ligament injuries. MCL tears do not universally heal, and residual MCL laxity is not always well tolerated. Although residual MCL laxity results in excess stress on an anterior cruciate ligament reconstruction and may require additional treatment, relatively little interest has been paid to concomitant treatment. Adherence to the dogma of universal conservative treatment of MCL tears in this setting squanders opportunities for preservation of native anatomy and improvements in patient outcomes. Although we currently lack the necessary information to provide evidence-based decision making for combined injuries, the time has come to renew both clinical interest and research interest in pursuing better management of these injuries in high-demand patients.