Document Title: Noyes-AJSM-Jul95.shtml
Article Title: The Treatment of Acute Combined Ruptures of the Anterior Cruciate and Medial Ligaments of the Knee
Authors: Frank R. Noyes, MD, and Sue D. Barber-Westin
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: Jul-Aug 1995
Volume 23, Number 4, pages 380-391
Keywords: MCL, ACL, combined ligament tearing, ACL-MCL, MCL-ACL, MCL self-healing, ACL reconstruction.

(Reference-denoting numbers appear in the same point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)

Comments: This excellent article shows that the best way to deal with MCLs is to give them time to scar-over and self-heal, with surgery being pursued only if said conservative treatment does not work out. A rigorous and thorough study, complemented by a thought-provoking discussion filled with penetrating insight. (The points raised in this study are still very much valid ten years later, and so this article clearly qualifies as a classic in its field.) Note that amongst the knee's four main ligaments, only the MCL has the ability to self-heal. This attribute arises from the MCL's being surrounded by the joint capsule (actually, structurally, the MCL is considered to be part of the joint capsule); this keeps the torn MCL ends close enough together to make useful scarring-over and subsequent self-healing viable. (Note that some of the ACL allografting in this study was supplemented by synthetic ligament-augmentation devices. Due to problems with structural fatigue and the strain-shielding effect, synthetic ACL-graft-augmentation devices are almost never used today.) (Note that for people who have incurred MCL-only injury, this article also shows that it is well worthwhile to allow the damaged MCL time to scar-over and self-heal; this takes roughly 4-6 weeks. Sue Barber-Westin indicates that for MCL injuries, the typical protocol is as follows: long-leg rehabilitative brace, locked at 0°, initially worn after the injury; brace is removed a few times daily for gentle flexion exercises; exercises are limited to straight leg raises and isometrics. As with all knee-rehabilitation programs, this is done under the supervision of a knee-experienced physiotherapist and orthopedic surgeon. Only in cases where the MCL does not self-heal satisfactorily is surgery indicated.)

ABSTRACT

We performed a prospective study of 46 patients with ruptures of the anterior cruciate ligament and medial ligamentous structures. All patients had anterior cruciate ligament allograft reconstructions. Group I com- prised 34 patients in whom all of the medial structures were ruptured (parallel and oblique fibers of the superficial medial collateral ligament and the posteromedial capsule) and were treated operatively. In Group II (12 patients), the superficial medial ligament fibers only were ruptured and these were treated nonoperatively. All patients started an immediate motion and rehabilitation program. Forty-four patients returned for followup at a mean of 5.3 years (range, 2 to 8.9) postoperatively. The results were assessed using the Cincinnati Knee Rating System. At followup, 20 knees (59%) in Group I and 9 knees (73%) in Group II had less than 3 mm of increased displacement on KT-1000 arthrometer testing (134 N). The overall rate of anterior cruciate ligament graft failure was 15%: six (18%) in Group I and one (8%) in Group II. No patient had more than 2 mm of increase on valgus stress testing at 50 degrees or 25 degrees of knee flexion. The overall ratings were as follows: Group 1,20 knees (58%) excellent or good and 14 knees (42%) fair or poor; and Group II, 11 knees (91%) excellent or good and one knee (9%) fair. Knee motion complications and patellofemoral symptoms were common in the patients rated fair or poor in Group I.

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