Summary

A combined ACL-MCL grade II lesion could be non-operatively treated without long term consequences.

Abstract

Introduction

Anterior cruciate ligament (ACL) ruptures are often associated with other ligament injuries and subsequent clinical instability. Various studies on the mechanism of ACL injury emphasize the importance of additional medial collateral ligament (MCL) injuries.However, there is a lack of long term comparative studies of combined ACL and MCL grade II lesions. Currently this pattern of lesions are treated with isolated ACL-reconstruction This clinical practice is supported by short-term studies that highlighted no difference regarding the outcomes however, the long term consequences of this pattern of lesion has not been investigated yet.

The present study represent the third evaluation of two groups of patients (one with isolated ACL lesion and the other with combined ACL and MCL grade II lesions) at minumum 14 years of follow-up.

Methods

57 patients (37 isolated ACL lesions and 20 ACL MCL grade II injury) underwent isolated ACL reconstruction with a double bundle technique. At the last follow-up, 49 patients were evaluated with clinical scores ( 31 isolated ACL and 19 combined ACL and MCL). The 3 years follow-up values of IKDC , Womac and Tegner score were obtained were retrieved from the original data. At the final follow-up, patients were contacted, and the same PROMs were obtained. Patients were also inquired regarding complications and reoperations on the same knee and at the contralateral during the considered follow-up. The minimum follow-up was 14 years (range 14-16).

Results

There were no clinical difference between the two groups in terms of clinical score and failure in all the PROMs analyzed. Moreover, there was a significant reduction of all the scores analyzed between the 3 years follow-up and the current analysis. The clinical scores for the ACL+MCL group and isolated ACL were respectively:
Lysholm: 91,4±6,2 and 89,0±6,6 (P=.23)

IKDC: 86.0 ±8,8 and 86,1±6,2 (p=.97)

WOMAC 93,1±5,0 and 94,0±2,6 (p=.49)

Tegner: 4.8±1,3 and 4,9±1,0 (p=0.80)

The number of failure were 1 out of 18 in the combined group (5.5%) and 3 cases out of 31 (9.7%) in the isolated group, however this difference was not significative. 3 patients underwent contralateral ACL lesion in the combined group and 5 patients in the isolated group.

Discussion And Conclusion

In the first studies we intraoperative evaluted the patients with the navigation system and we found that the patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. Moreover we reavaluated the same cohort of patients at 3 years and we found no difference in terms of clinical scores and KT-1000, while valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (SD 0.9) versus 0.9 mm (SD 0.7), respectively, p = 0.013), while no statistically significant difference was found between the AP laxity and the other clinical parameters. Therefore, the aim of the present study was to revaluate the patients in order to assess if this chronic anteromedial instability led to different ouctomes at the a long term follow-up.

At a minimum 14 years, no clinical difference or increased failure rate was observed, suggesting that no additional surgical procedure is needed for the medial collateral ligament in combined lesions.