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Document Title: Halinen-AJSM-Jul06.shtml
Article Title: Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture With Early Anterior Cruciate Ligament Reconstruction -- A Prospective Randomized Study
Authors: Jyrki Halinen, MD, Jan Lindahl, MD, Eero Hirvensalo, MD, PhD and Seppo Santavirta, MD, PhD
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: July 2006
Volume 34, pages 1134-1140
Keywords: ACL, anterior cruciate ligament, MCL, medial collateral ligament, multiligament injury, combined instability, treatment routes, use of bracing in short-term.
(Reference-denoting numbers appear in the same font and point size as the document text. Like all Knee Library documents, this article is provided in full-text form. This articles has tables, but no figures.)
Comments: This study shows that, in a combined-ACL-MCL-injury knee, when the fully torn ACL is reconstructed promptly, the MCL does not require surgical treatment. The MCL is the only major knee ligament that is capable of self-healing via a scarring-over process (which generally brings satisfactory results, assuming that the injured MCL is protected from reinjury situations such as inwards forcing of the knee). The authors recommend continual (24 hours per day) use of a hinged knee brace initially for 3 fortnights, and thereafter during daily activities for an additional fortnight. Physiotherapy is to be pursued during this time, and also subsequently. Given that an MCL does not heal perfectly (i.e. "scarring-over" would be a more appropriate term and actual healing), and also given that a recently reconstructed ACL does not have embedded nerve endings (and thus is more injury-vulnerable than a natural ACL), and also given the agony associated especially with knee re-injuries (i.e. revision reconstruction is far more difficult than first-time reconstruction, and each injury event heightens the ominous spectre of osteoarthritis), an appropriate recommendation would be the use of a functional brace during knee-demanding activities, indefinitely afterwards.
ABSTRACT
Background: The apparent consensus is that solitary medial collateral ligament rupture can be treated nonoperatively, but treatment of severe combined ruptures of the medial collateral ligament and anterior cruciate ligament remains controversial.
Hypotheses: Nonoperative and early operative treatments of grade III medial collateral ligament rupture lead to similar results when the anterior cruciate ligament is reconstructed in the early phase.
Study Design: Randomized controlled clinical trial; Level of evidence, 1.
Methods: Forty-seven consecutive patients with combined anterior cruciate ligament and grade III medial collateral ligament injuries were randomized into 2 groups. The medial collateral ligament injury was treated operatively in group 1 (n = 23) and non-operatively in group 2 (n = 24). In both groups, the anterior cruciate ligament injury was treated with early reconstruction, using bone–patellar tendon–bone graft and interference screw. Two years postoperatively, knee stability was measured with a KT-1000 arthrometer and Telos valgus radiography and knee extension strength with a Biodex dynamometer and a 1-legged hop test. An International Knee Documentation Committee evaluation form and Lysholm score were completed.
Results: All 47 patients were available for clinical evaluation for a mean of 27 months (range, 20–37 months) after surgery. There were no statistically significant differences between the 2 groups with respect to subjective function of the knee, postoperative stability, range of motion, muscle power, return to activities, Lysholm score, and overall International Knee Documentation Committee evaluation. The subjective outcome and Lysholm score were good and anteroposterior knee stability excellent in both groups.
Conclusion: Nonoperative and operative treatments of medial collateral ligament injuries lead to equally good results. Medial collateral ligament ruptures need not be treated operatively when the anterior cruciate ligament is reconstructed in the early phase.
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