The combined ACL/ MCL tear recommendation was downgraded one level due to imprecision of evidence.
Level 1 evidence:
Funchal (2019) in a prospective randomized trial demonstrated that when a combined ACL / MCL injury resulted in an arthroscopic finding of a “floating meniscus”, those patients randomized into the MCL reconstruction group had lower ACL reconstruction failure and better Tegner and Lysholm scores compared to the MCL non-operative group. This study supports that combined ACL/MCL injuries with greater MCL laxity may benefit from MCL reconstruction at time of ACL reconstruction.
Level 3 evidence:
Svantesson (2019) – Swedish registry study of 19,457 patients comparing the ACL revision incidence and KOOS scores of isolated ACL reconstructions and ACL reconstructions with concomitant MCL injuries treated with or without surgery. At 5 years, isolated ACL reconstructions had fewer revisions compared to the ACL/MCL combined injuries with MCL treated non-operatively; while the ACL/MCL combined injuries with the MCL treated surgically did not demonstrate increased ACL revision compared to isolated ACL reconstructions. This study provides evidence that surgical treatment of the MCL in some ACL/MCL injured knees may be beneficial to decrease the risk of subsequent ACL graft failure.
Benefits/Harms of Implementation
MCL repair/reconstruction may decrease risk of recurrent ACL laxity/re-tear. MCL surgery may result in an early delay in return in quad strength and ROM but this normalizes by 2 years post op (Halinen 2009). Also, surgical treatment of MCL may decrease KOOS scores (Svantesson 2019).
Outcome Importance
Decreasing the risk of ACL reconstruction failure.
Cost Effectiveness/Resource Utilization
There is increased cost and time for surgical treatment of MCL injury. How these procedures impact the cost of postoperative rehabilitation and treatment of re-injury is unknown.
Acceptability
Likely.
Feasibility
In patients with combined ACL and MCL tears, non-operative treatment is feasible.
Future Research
Prospective studies to determine which MCL tears need to be repaired/reconstructed while controlling for confounders such as severity and location of MCL injury.
- Funchal, L. F. Z., Astur, D. C., Ortiz, R., Cohen, M. The Presence of the Arthroscopic "Floating Meniscus" Sign as an Indicator for Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury. Arthroscopy 2019; 3: 930-937
- Halinen, J., Lindahl, J., Hirvensalo, E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. Journal of Bone & Joint Surgery - American Volume 2009; 6: 1305-12
- Svantesson, E., Hamrin Senorski, E., Alentorn-Geli, E., Westin, O., Sundemo, D., Grassi, A., Custovic, S., Samuelsson, K. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surgery, Sports Traumatology, Arthroscopy 2019; 8: 2450-2459