Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture Were Not Different in Combined Medial Collateral and Anterior Cruciate Ligament Rupture

Question: In patients with combined anterior cruciate ligament (ACL) and medial collat- eral ligament (MCL) injuries, are outcomes different if the MCL is treated operatively or nonoperatively?

Design: Randomized (allocation con- cealed)*, unblinded, controlled trial with 2-year follow-up.

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 liga- mentous deficiency. Patients with posterior cruciate ligament, lateral collateral ligament, or only grade-I or II MCL injury were ex- cluded. Follow-up was 100%.

Intervention: All patients had ACL recon- struction 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 tendon- bone autograft. MCL structures were repaired with suture anchors or were sutured through bone tunnels and completed with direct su- turing. The posterior oblique ligament or su- perficial 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 func- tion of the knee, stability, range of motion (ROM), and muscle power. The study had 90% power to detect a 10-point difference be- tween the groups in Lysholm score.

Main results: At 2 years, there was no differ- ence between operative and nonoperative groups in Lysholm score (excellent to good scores, 83% vs 83%). Operative and nonoper- ative 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 val- gus 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 non- operative patients had normal or nearly nor- mal results on the overall International Knee Documentation Committee (IKDC) evalua- tion. The groups had no differences with re- spect to change in the levels of activity.

Conclusion: In patients with combined ante- rior cruciate ligament and medial collateral ligament injuries, outcomes at 2 years were not different whether the MCL was treated operatively or nonoperatively.

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