MCL injuries may be conservatively treated in severe ACL/MCL cases

Patients in the operative and nonoperative MCL groups showed similar Lysholm scores at 2 years.

Issue: January 2008

CALGARY, Alberta — While surgeons have debated the treatment of combined MCL and ACL injuries, new research indicates that MCL ruptures in these cases do not require operative treatment if the ACL is reconstructed early.

Jyrki Halinen (right) receives the Hughston Award for his paper at the AOSSM annual meeting in Calgary, Alberta.

Images: Halinen J

In a Level 1 study, Jyrki Halinen, MD, and colleagues from Finland compared the results of 47 patients with combined MCL and ACL injuries who underwent early ACL reconstruction and were randomized into two MCL-treatment groups. One group received nonoperative care on their MCL and the other group had surgery on the ligament.

The investigators discovered no statistically significant differences between the groups regarding postoperative range of motion, stability, Lysholm scores and International Knee Documentation Committee (IKDC) overall evaluation at 2 years follow-up. They also found that only one patient had abnormal side-to-side difference on KT-1000 arthrometer testing, and 83% of patients in both groups had excellent Lysholm scores, according to the study.

“[We] recommend that combined MCL/ACL injury can be treated by solitary ACL reconstruction,” Jyrki Halinen, MD, said. “MCL ruptures do not need to be treated surgically for combined ACL injuries that are reconstructed in the early phase.” Halinen presented the Hughston Award-winning study at the American Orthopaedic Society for Sports Medicine 2007 Annual Meeting.

Two treatment groups

The study included 47 consecutive adult patients with combined ACL and Grade III MCL injuries. The patients had at least a 10 mm medial opening and had their diagnosis confirmed by MRI. All of the patients underwent early ACL reconstruction using bone-patellar tendon-bone grafts affixed with an interference screw. Investigators randomized 23 patients to receive operative treatment for their MCL injury and 24 patients to the nonoperative MCL-treatment group.

The investigators found that all of the patients in the operative group had superficial MCL ruptures.

“Twenty-two out of the 23 had posterior oblique ligament ruptures, [including] various degrees of posteromedial capsule rupture,” Halinen said. “Eight had total PMC ruptures.”

Both groups followed the same postoperative rehab which permitted immediate full weightbearing and required patients to wear a hinged knee brace.

MRI of a proximal MCL rupture
A proximal MCL rupture that investigators confirmed using MRI.

MRI of a large lateral tibial bone bruise
MRI was also used to detect concomitant injuries and bone bruises such as this large lateral tibial bone bruise.

IKDC overall evaluation

The investigators found no significant differences between the groups regarding patient demographics and all patients were available for 2-year follow-up. KT-1000 arthrometer testing for AP laxity revealed no significant differences between the groups at 2-year postop. The investigators also found no statistically significant difference between the groups on side-to-side difference evaluations. Seventy-nine percent of patients in the nonoperative MCL-treatment group had less than 3 mm of side-to-side difference on maximal manual tests compared to 74% of the operative group, according to the study.

“There was no lack of extension in either group,” Halinen said. “Also, IKDC overall evaluation was equal. There was no difference in any subjective assessment, symptoms, range of motion, ligament examination, compartmental findings or harvest-site abnormality between the groups.”

IKDC overall evaluation revealed that 83% of patients in both groups had excellent Lysholm scores. Seven patients (30%) with surgically-treated MCLs had abnormal or severely abnormal results compared to four patients (17%) in the non-operative group, according to the study.

“In both groups, there were abnormal and severely abnormal IKDC overall evaluations,” Halinen said. “But these must be attributed to the pain in activity and not with the ligament evaluation.”

A postop valgus X-ray showing the side-to-side difference in the medial opening of the treated MCL.

A postop valgus X-ray showing the side-to-side difference in the medial opening of the uninvolved knee.

For more information:

Jyrki Halinen, MD, can be reached at Jorvi Hospital, Department of Surgery, Turuntie 150, Espoo, Finland; +358-9-8611; e-mail: jyrki.halinen@hus.fi.

Reference:

Halinen J, Lindahl J, Hirvensalo E, et al. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction. Presented at the American Orthopaedic Society for Sports Medicine 2007 Annual Meeting. July 12-15, 2007. Calgary, Alberta.