ACL & MCL Injuries: Modern Treatment Advances & Surgical Approaches
Treatment approaches for combined ACL and MCL injuries have dramatically evolved over the decades. What was once addressed with extensive open surgery, often resulting in significant knee stiffness, is now approached with a wider range of operative and non-operative options, reflecting advancements in diagnostic tools and surgical techniques.
A History of Treatment
In the 1970s and 1980s, surgeons primarily treated combined ACL and grade 3 medial collateral ligament (MCL) injuries with large, open surgical procedures. “It was terrible,” explained Andy Williams, MBBS, FRCS(Ortho), FFSEM(UK), a consultant knee surgeon at Fortius Clinic in London. “Because we did not understand the anatomy, we cobbled it all together and, the structures we had repaired were not at the right length. You tended to end up with a knee that would not straighten and would not bend, but the MCL remained loose. It was the worst of all worlds.”
The advent of MRI technology proved pivotal. According to Gregory S. DiFelice, MD, an orthopedic surgeon at Hospital for Special Surgery, “MRI came around, which allowed us to take a look and see not only if the ligament was torn, but also how the ligament was torn.” Prior to MRI, surgeons could only assess the extent of ligament damage during open surgery. The introduction of arthroscopy further refined the approach, enabling surgeons to perform procedures through small incisions.
Modern Approaches
Today, the treatment of combined ACL and MCL injuries is more nuanced. Jelle P. Van der List, MD, PhD, MBA, clinical assistant professor of orthopedic surgery at The Ohio State University Wexner Medical Center, notes the approach is “more complicated and less dogmatic.” A systematic review published by van der List and colleagues in Arthroscopy indicated that nonoperative ACL-MCL treatment and acute MCL repair with nonoperative ACL treatment resulted in lower rates of valgus stability at 30° of knee flexion compared to acute ACL reconstruction with either nonoperative MCL treatment, acute MCL repair, or acute MCL reconstruction.
Van der List explained that simply bracing an ACL-MCL injury can hinder proper MCL healing. “Because of that, there is no isometry of the MCL to heal,” he said. “Even though you put the knee in a hinged brace and the MCL cannot stretch sideways, it can still not heal isometrically because of the anterior-posterior translation.”
Matthew T. Provencher, MD, MBA, professor of orthopedics and orthopedic surgeon at The Steadman Clinic, highlighted the impact of technical advancements. “With better understanding of the anatomy, better repair techniques, better anchor techniques, better sutures, better ways to anatomically augment collagen and better ways to use the internal brace, we have been able to minimize arthrofibrosis, yet restore the mechanics of the knee, especially with the MCL.”
Acute Simultaneous Treatment
Many surgeons now consider acute simultaneous surgery for both the ACL and MCL when appropriate, according to DiFelice. A retrospective analysis by DiFelice and colleagues showed that 90% of patients with a grade 3 superficial MCL injury and additional cruciate or bicruciate ligament injury experienced positive outcomes after acute superficial MCL repair and early range of motion rehabilitation.
However, Williams cautioned that a sensible approach is crucial. For average patients, he recommends a 4-6 week brace period followed by reevaluation. Surgery for the ACL, and potentially the MCL (if grade 2 or 3 laxity or a positive dial or Slocum test is present), would then be considered. Professional athletes, however, may require a more immediate surgical intervention, as they cannot tolerate MCL laxity.
The location of the MCL tear is also a significant factor, noted R. Alexander Creighton, MD, Yeargan Professor and chief of sports medicine at UNC Orthopedics. Proximal injuries may heal better than distal injuries, and distal injuries may involve a Stener-like lesion requiring more aggressive repair.
Van der List emphasized the importance of early ACL reconstruction. A systematic review and meta-analysis published in the American Journal of Sports Medicine found that shorter times from injury to ACL reconstruction were associated with a decreased incidence of long-term osteoarthritis, particularly when surgery was performed within 6 to 12 months, and even more so within one month.
Potential Risks and Future Directions
Acute simultaneous treatment carries risks, primarily stiffness, according to van der List, particularly in patients with proximal MCL tears and those who are fearful. Provencher stressed the importance of avoiding “doing too much” to prevent stiffness.
Augmentation techniques, such as collagen-based implants or grafts, are being explored, but van der List noted that the optimal indications for biologic augmentation remain unclear. He suggested that further research, including multicenter studies with larger patient numbers, is needed to refine treatment recommendations and improve clinical outcomes.
Frequently Asked Questions
What was the primary approach to treating combined ACL and MCL injuries in the 1970s and 1980s?
Combined ACL and grade 3 MCL injuries were primarily treated with large, open surgical procedures.
How did the introduction of MRI impact the treatment of these injuries?
MRI allowed surgeons to visualize not only if a ligament was torn, but also *how* it was torn, leading to more informed treatment decisions.
What is a key consideration when deciding whether to perform acute simultaneous surgery on the ACL and MCL?
The location of the MCL tear is a major factor, with distal injuries potentially requiring more aggressive repair.
As orthopedic surgeons continue to refine techniques and deepen their understanding of these complex injuries, the goal remains to provide patients with stable, well-functioning knees and a return to their desired activity levels. What role will continued research and technological innovation play in further optimizing outcomes for individuals facing these challenging injuries?