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34 (); 21-30
doi:
10.1016/j.jor.2022.07.024

The management of combined ACL and MCL injuries: A systematic review

, , , ,
Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom

∗Corresponding author: Raunak Rao. raunak.rao@kcl.ac.uk

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies.

A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score.

52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury.

Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.

Keywords

Anterior cruciate ligament
Medial collateral ligament
Coleman methodology score
Conservative management
Ligament repair
Ligament reconstruction
1

1 Introduction

Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are the most common type of multiligament knee injury. MCL injuries are concurrent in 20–38% of ACL injuries,1,2 and are common within sports that involve internal and external rotation motions at the knee joint. Other associated mechanisms include forced hyperextension and sharp deceleration. Medial instability is quantified from I to III. A grade I injury has microscopic tearing with no instability or joint widening. Grade II injuries are partial tears with minor joint widening and no instability. Grade III lesions demonstrate total loss of integrity with instability.3

Combined ACL-MCL injuries generate increased knee joint instability when compared to isolated ligamentous lesions. The ACL comprises two bundles: anteromedial and posterolateral. Whilst the anteromedial bundle restricts anterior tibial translation, the posterolateral bundle contributes to rotary control.4 The MCL is composed of superficial and deep components. The superficial component is the primary static stabiliser to valgus stress. The deep portion is a major secondary restraint to anterior tibial translocation, and provides minor static stabilisation against valgus stress.5 When the ACL is insufficient, the MCL must absorb amplified forces.6

Treatment of combined ACL-MCL injuries remains controversial, with several descriptions of surgical and conservative management options. In particular, the optimal management of grade II-III MCL injuries is unclear. Options exist for repair, reconstruction (MCLR) and conservative therapy, yet limited high-quality evidence exists to compare their outcomes in both the short and long-term. Typically, conservative management is reserved for grade I and II MCL injuries, whilst ACL reconstruction (ACLR) is usually recommended if the ACL is torn. Nevertheless, there are multiple reports of successful outcomes from nonsurgical grade III MCL treatment, with return to high-level sporting activities. Even amongst discrete surgical and conservative approaches, many further uncertainties arise over factors such as interval from injury to surgery, choice of graft use and diagnosis of MCL injury grade. A lack of consensus is partly secondary to the heterogeneity of outcome measures and limited prospective data.

The aim of this systematic review is to evaluate the published outcome data on management of combined ACL-MCL injuries. In addition, we aimed to critically assess the methodology of relevant studies using the Coleman methodology score (CMS).7

2

2 Methods

2.1

2.1 Search strategy

A systematic review was performed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, OVID and Cochrane Database of Systematic Reviews were queried from database inception to 24th January 2022. The following search strategy was used: Anterior Cruciate Ligament (MeSH Terms) AND Medial Collateral Ligament (MeSH Terms) AND (Surg* OR Operat* OR Conservative OR Treatment OR Management). In addition, the first 10 webpages of Google Scholar were searched using the above keywords. The references of all included studies were manually searched by two independent reviewers (RR and RB).

2.2

2.2 Inclusion and exclusion criteria

Two independent reviewers screened the titles, abstracts, and full texts of studies. Discrepancies were resolved through discussion until a consensus was reached. Articles were included if they were original studies reporting clinical outcomes in the management of combined ACL-MCL injuries. Only English language articles are included. Exclusion criteria were: (1) non-clinical basic science studies; (2) animal studies; (3) cadaveric studies; (4) singular case reports, expert opinions and editorials; (5) no specific reporting of interventions or outcomes; (6) isolated ACL or MCL injuries; (7) injury to PCL and/or LCL; (8) languages other than English; (9) systematic reviews and meta-analyses. Although excluded, relevant systematic reviews were screened for articles. If 2 separate studies had duplicate patient populations, the reviewers selected one study based on the following qualities: higher level of evidence, greater number of patients, longer follow-up period, or more detailed primary outcome reporting.8

2.3

2.3 Data collection and statistical analysis

Data from the included articles were retrieved by two independent reviewers (RR and RB). The following data were retrieved: year of publication, Coleman methodology score (CMS), mean age, age range, interval time between injury and surgery, study type, level of evidence,9 management, grade of MCL injury, mean follow-up time, outcome measures, outcome measure results and complications. Retrieved data were tabulated and analysed in Microsoft Excel. IBM SPSS Statistics for Windows (Version 27, IBM Corp., Armonk, N.Y., USA) was used to correlate CMS with year of publication (Pearson Correlate, r).

3

3 Results

3.1

3.1 Search results

The literature search initially generated 1030 articles (Fig. 1). Amongst these, 390 duplicates were eliminated. The predetermined inclusion and exclusion criteria were applied to the remaining 640 articles. After application of these criteria, 71 articles were subject to full-text screening. 52 studies were included for analysis.

Flow chart of study selection according to PRISMA guidelines for reporting systematic reviews and meta-analyses.
Fig. 1 Flow chart of study selection according to PRISMA guidelines for reporting systematic reviews and meta-analyses.
3.2

3.2 Demographics and study characteristics

The mean age of all included patients (excluding eight studies in which the mean ages were not documented) was 31.0. The age range of included patients was 13–77. Interval time from injury to treatment was reported in 26 studies (50%), ranging from <1 week to 37 months. In total 3655 patients were included – the mean number of patients per individual study was 83.1 (range 5–793). Mean latest follow-up time ranged from 9 to 264 months.

Out of 52 included articles, three (5.8%) were randomised controlled trials (Level I), eight (15.4%) were prospective comparative studies (Level II), seventeen (32.7%) were retrospective comparative studies (Level III), and twenty-four (46.1%) were case series (Level IV). The mean modified CMS was 55 (range 30–87). There was no evidence of a statistically significant association between the CMS and year of publication (r = 0.016, P = 0.911).

3.3

3.3 Management, outcome measures and study summaries

We classified investigated management type using the following system: C = Conservative management of both ACL and MCL, S = Surgical (repair or reconstruction) management of both ACL and MCL, A = Surgical (repair or reconstruction) management of ACL + Conservative management of MCL, M = Conservative management of ACL + Surgical (repair or reconstruction) management of MCL. The outcome measures and study summaries are included in Table 1. Assessment methods and outcome measures were heterogeneous amongst studies. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity (Table 2). Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. These included: graft failure, infection, transient hypoesthesia, arthrofibrosis and haematomas.

Table 1 Study data.
Paper (Level of evidence) N Mean Age CMS Management MCL grade Mean Follow-Up (Months) Results
Jokl 1984 (IV) 29 28 28 44 C III 36 68% returned to previous activity; HSS: 71% good to excellent
Mok 1989 (IV) 30 25 27.6 54 C III 24.2 100% Return to activity; Marshall's score: 100% good-excellent; Medial knee laxity: 16 patients at 12–23 months (8 no laxity, 4 mild, 4 moderate), 9 patients at 24–48 months (All no laxity)
Ballmer 1991 (IV) 41 14 30 47 A: ACLR + NSx MCL III 14 100% Return to activity; Full ROM 12 patients; 2 patients medial opening 3–5 mm at 30° flexion; 5 patients >2 mm AP laxity; Marshall's score: 11 excellent, 2 good, 1 fair
Andersson 1992 (II) 16 45 ND 66 S: ACL Repair + MCL Repair (21), M: NSx ACL + MCL Repair (24) II-III 52 AP laxity - 7/11 mm (S) vs. 10/14 mm (M) (90/180 N); Functional: Hop test + figure-of-8 better in (S); Lysholm: 92 (S) vs. 87 (M)
Shelbourne 1992 (IV) 25 68 ND 57 A: ACLR + NSx MCL ND 25 100% firm end point valgus stress (30° flexion); 2 mm side-side AP laxity difference; Return to activity: 30 patients needing brace for strenuous activity, 38 normal; 100 Full ROM (9 needed MUA, 5 needed surgical scar resection)
Andersson 1993 (II) 42 9 ND 65 C ND 12 AP laxity 12 mm (90 N) 18 mm (180 N); Lysholm 79; 6 Severe instability symptoms, 1 Return to activity, 4 ACL reconstruction needed
Robins 1993 (III) 37 20 23 36 S: ACLR + MCL Repair ND 12.5 Distal MCL tears (vs. proximal MCL tears): Faster return to activity, Greater flexion ROM, Fewer procedures
Schierl 1994 (IV) 43 28 33.1 45 A: ACLR + NSx MCL I-II 28 Medial laxity: 2 (1+); AP laxity: Anterior drawer 1 mm side-side difference; One-leg-hop 95.5% of uninjured side; OAK score 93 (19 excellent, 7 good, 1 moderate, 1 poor); IKDC 4 ‘A’, 19 ‘B’, 5 ‘C’; Lysholm 95; Marshall's score 45
Hughston 1994 (IV) 44 24 ND 38 S: ACL debridement/repair/augmentation + MCL Repair III 264 Medial laxity: 11 (0) 13 (1+); AP laxity: 12 (0) 7 (1+) 5 (2+); Pivot shift: 18 (0) 4 (1+) 1 (2+)
Noyes 1995 (II) 36 46 24.7 80 S: ACLR + MCL Repair (34), A: ACLR + NSx MCL (12) I-III 63 ACL graft failure – S: 18%, A:8%; 0% > 2 mm increase on valgus stress testing (5° or 25° knee flexion); CKRS – (S): 58% excellent or good + 42% fair or poor, (A): 91% excellent or good + 9% fair
Hillard-Sembell 1996 (III) 19 66 35 52 S: ACLR + MCL Repair (11), A: ACLR + NSx MCL (33), C (22) II-III 45 No significant difference between groups
Frölke 1998 (IV) 28 22 33 40 M: NSx ACL + MCL Repair III 30 100% Full ROM; Improvements in: Valgus laxity, AP laxity, and IKDC
Petersen 1999 (III) 45 64 27.5 60 A: ACLR + NSx MCL III 22 Early vs late ACLR: No difference in IK testing, Instability + Tegner; ROM problems + Second arthroscopies greater in early ACLR; Lysholm higher in late ACLR (89.9 v 85.3)
Shirakura 2000 (III) 18 25 32.1 56 C (11), M: NSx ACL + MCL Repair II-III 71 No difference in Valgus laxity, AP laxity and Tegner; Lysholm 98.5 (M) vs. 93.8 (C)
Nakamura 2003 (II) 10 17 23.4 66 S: ACLR + MCLR (6), A: ACLR + NSx MCL (11) II-III 64 No significant difference
Millett 2004 (IV) 46 18 35.7 58 A: ACLR + NSx MCL II-III 45.6 No Valgus laxity; Lysholm 94.5; Tegner 8.4
Yoshiya 2005 (IV) 47 12 25.3 61 S: ACLR + MCLR III 27 AP laxity 0.3 mm; Medial laxity 2.5 mm; IKDC symptoms 92% normal/near normal; IKDC ROM 100% normal/near normal
Halinen 2006 (I) 11 47 39.3 86 S: ACLR + MCL Repair, A: ACLR + NSx MCL III 27 No significant difference
Sankar 2006 (IV) 48 12 15.6 64 A: ACLR + MCL NSx II-III 63.6 No valgus laxity; No AP laxity; ROM 1–145°; 100% Return to activity; Lysholm 96
Hara 2008 (II) 26 53 23 84 A: ACLR + MCL NSx II 28.7 ROM: 1.9% Knee extension restricted to 5° or more; 92.5% Full flexion; AP laxity: 1.6 mm; Pivot shift: 26.4% positive; IK testing: 82.6% knee extensor; Lysholm 95.5; Return to activity 10.3 months; IKDC ‘A’ 32.1%, ‘B’ 52.8% ‘C’ 15.1%
Osti 2010 (IV) 22 22 29 72 S: ACLR + MCL Repair II 36 Lachman test 95% negative/grade 1; Pivot shift 77% negative; AP laxity 1 mm; Valgus laxity 91% ‘A’, 9% ‘B’; Lysholm 96; IKDC 91% normal/near-normal; Return to activity 91%
Zaffagnini 2011 (II) 49 19 38 52 A: ACLR + NSx MCL II 39 Return to work 2.7 months; Return to sports 4.3 months; Thigh circumference side-side difference 0.3 cm (5 cm from superior pole of patella), 0.5 cm (15 cm from superior pole of patella); Tegner 5.8; Lysholm 96.5; WOMAC 98.5; Subjective IKDC 97.3; AP laxity side-side difference 5.8 mm; Medial joint space opening 1.7 mm side-side difference
Marx 2012 (III) 50 12 29.8 47 S: ACLR + MCLR II-III 36 Primary ACLR: IKDC subjective 91, Lysholm 92, KOOS sports 93, Marx 6, Tegner 6; Revision ACLR: IKDC subjective 73, Lysholm 77, KOOS sports 67, Marx 5, Tegner 5
Dong 2012 (IV) 51 29 36 48 S: ACLR + MCLR ND 33 EKMO 3.1 mm; 13.8% AMRI; IKDC Subjective (16 ‘A’, 9 ‘B’, 3 ‘C’, 1 ‘D’); IKDC Extension ROM (16 ‘A’, 10 ‘B’, 2 ‘C’, 1 ‘D’); Flexion ROM (16 ‘A’, 7 ‘B’, 4 ‘C’, 2 ‘D’)
Kitamura 2013 (IV) 52 16 28.6 38 S: ACLR + MCLR III ND Lysholm 95.3; IKDC 8 ‘A’, 8 ‘B’; IKDC Valgus instability 13 ‘A’, 3 ‘B’; Pivot shift 11 ‘A’, 5 ‘B’
Batista 2014 (IV) 20 30 30.53 30 S: ACLR + MCLR ND 43 Lysholm 91; 63.3% Return to pre-injury sports level; IKDC 26 ‘A’, 3 ‘B’, 1 ‘C’
Aparacio 2014 (IV) 53 14 29 35 S: ACLR + MCLR ND 19.6 Lysholm 93; Return to activity 100%; ROM stable; IDKC 100% A/B
Piatkowski 2014 (IV) 54 27 37 54 S: ACLR + MCL Repair III 21 Lysholm 90.6; IKDC 79.8
Zhang 2014 (IV) 55 21 39.6 62 S: ACLR + MCLR II-III 40 Medial laxity 0.8 mm; AMRI 0%, 95% FROM; IKDC subjective 87.7; 90% Return to activity
Blanke 2015 (IV) 56 5 39.6 48 S: ACLR + MCL Repair II 9 Valgus laxity 100% IKDC A; Medial laxity 100% IKDC A; 100% Full ROM; Lysholm 94.6; 0% AP laxity; 0% Pivot shift
Ateschrang 2016 (IV) 2 16 36.4 47 S: ACLR + MCLR II-III 12 Significant ROM improvement; Knee extension deficit 0.3 mm; All cases valgus laxity improvement in 0° flexion; Lysholm 89.1; Tegner 6.2; Tibial shift 2.6 mm
Westermann 2017 (II) 57 27 ND 39 S: ACLR + MCL Repair (16), A: ACLR + MCL NSx (11) III 24 KOOS + IKDC lower in S; KOOS Sports/Recreation - 88.2 (A) vs. 74.4 (S), KOOS QOL - 81.3 (A) vs. 68.4 (S); IKDC 87.6 (A) vs. 76.0 (S); Marx 10.7 (A) vs 6.5 (S)
Pandey 2017 (III) 13 35 35 72 S: ACLR + MCL Repair (20), M: NSx ACL + MCL Repair (15) II-III 48.3 Lysholm 94.6 (S) vs. 91.06 (M); IKDC 86.3 (S) vs. 77.6 (M); Instability complaint 0% (S) vs. 60% (M); Valgus stability 100% (S) & (M); Loss of flexion ROM no significant difference - 9° (S) vs. 12° (M); ROM - no significant differences in clinical scores
Rai 2018 (III) 58 222 29.6 63 A: ACLR + MCL NSx I-II 49.5 No significant difference between ACLR using 4HT or 2 TA
Sini 2018 (IV) 59 5 27 38 S: ACLR + MCLR III 16 ROM: 100% extension + flexion >100°; Lachman 100% negative; Lysholm 90.8
Nardin 2018 (IV) 60 28 29.5 39 S: ACLR + MCLR ND 19.6 Lysholm 93; 100% IKDC ‘A’/‘B’; 100% Return to activity and sport
Bertona 2018 (IV) 61 20 ND 39 S: ACLR + MCLR III ND IKDC 88.21; Lysholm 90.83; Valgus and sagittal laxity not observed; 100% IKDC normal/near normal mobility; 100% return to sports (90% pre-injury level)
Funchal 2019 (I) 12 112 31.1 87 S: ACLR + MCLR (58), A: ACLR + NSx MCL (54) II 24 Tegner 8.98 (S) vs. 6.7 (A); Lysholm 89.67 (S) vs. 78.12 (A); Residual medial laxity 0 (S) vs. 13 (A)
Shi 2019 (I) 23 38 40.9 74 S: ACLR + MCL Repair III 24 No significant difference between ipsilateral PLT autograft and autologous HT for ACLR
Trung 2019 (II) 62 30 35.4 72 A: ACLR + MCL NSx ND 55 Lysholm 94.27; Anterior drawer test: 96.7% negative; Pivot shift 93.3% negative; AOFAS no difference
Westermann 2019 (III) 13 27 27.9 39 S: ACLR + MCLR (2), ACLR + MCL Repair (14), A: ACLR + NSx MCL (11) III 24 Both groups significantly improved; Surgical chronicity did not affect 2 year outcomes
Svantesson 2019 (III) 14 793 30.8 47 S: ACLR + MCL Repair (52), ACLR + MCLR (84), A: ACLR + NSx MCL (657) ND 60 Lower risk of ACL revision in isolated ACL vs. (A), but not (S); 2-year KOOS - MCL suture repair vs. MCL reconstruction no significant differences
Svantesson 2020 (III) 63 622 29.7 45 A: ACLR + NSx MCL ND 24 3 ACL graft choices (ST, ST-G, PT): No significant difference in risk of ACL revision; ST group greater 2-year mean KOOS sports and recreation than ST-G and PT; ST group superior in achieving PASS in sports and recreation vs. ST-G and PT.
Lind 2020 (III) 21 495 33.2 45 S: ACLR + MCLR ND 12 Significant improvements in KOOS-4 (61); % QOL >40 (63); Tegner (4.2); %Valgus grade A (69), AP laxity side-side difference 1.7 mm
Desai 2020 (IV) 64 16 23.25 47 S: ACLR + MCL Repair III 50.02 Lysholm 93.25; Tegner 6.75; IKDC 89.62; 0% Valgus laxity; 100% satisfactory ROM; 100% Negative pivot shift; 100% negative Lachman and AP laxity
Nagaraj 2020 (IV) 65 22 ND 57 S: ACLR + MCLR ND 12 Lysholm 89.95
Razi 2021 (III) 35 350 28.49 65 S: ACLR + MCLR (69), ACLR + MCL Repair (52), ACLR + MCLR + MCL Repair (8), A: ACLR + NSx MCL (206), C: NSx ACL + NSx MCL (15) I-III 12 15 patients showed spontaneous healing of ACL and entered group (C); 100% pivot shift, Lachman and MCL tests were negative or 1+; Mean healing time for spontaneous healing 8.66 months
Alm 2021 (III) 24 53 31.3 60 S: ACLR + MCLR (36), ACLR + MCL Repair (17) II 28.8 ACLR failure 5.9% in MCLR vs 36.1% in MCL repair group; Rolimeter side-side difference reduced (1.5 mm vs 2.9 mm) and less medial knee instability (18% vs 50%) in MCLR vs repair; MCLR vs repair: only Lysholm showed significant difference (Lysholm 82.9 vs 75.1)
Lutz 2021 (III) 15 40 36.5 65 S: ACLR + MCL Repair (20), A: ACLR + NSx MCL (20) II-III 33.5 Lysholm 75 (S) vs 86 (A); No significant difference in IKDC 74.5 (S) vs 85.6 (A), or Tegner 4 (S) vs. 5 (A)
Lucidi 2021 (III) 66 20 48.1 47 A: ACLR + NSx MCL II 175.2 Lysholm 91.4; IKDC 86; WOMAC 93.1; Tegner 4.8; Reduction in both groups of all outcome scores between the intermediate (3 yrs) and final-follow-up (14 yrs); No differences between the isolated ACL injury group and (A) in graft failures, contralateral lesions, and clinical scores
Chen 2021 (III) 27 41 ND 63 A: ACLR + MCL NSx II 15 (median) Improved AP, medial + rotational instability; IKDC (90.1), Lysholm (92.1); Negative pivot shift lower in DB vs SB - no difference in other outcomes
Sim 2021 (III) 67 61 33.1 65 S: ACLR + MCL Repair (11), ACLR + MCLR (26), A: ACLR + NSx MCL (24) I-III 24 Medial laxity higher in MCL repair vs. MCLR (5.2° vs. 2.2° at 30° flexion, 3.4° vs 1.1° at 0°), Otherwise no significant difference
Table 2 Outcome measures.
Outcome Number of studies
AP laxity 34
Lysholm score 32
Medial/Valgus laxity 30
IKDC Score 25
ROM 20
Tegner activity level 17
Return to activity 15
Pivot shift test 13
Isokinetic testing 12
One-leg hop 4
Marshall score 3
MARX scale 3
WOMAC score 2
3.4

3.4 Comparative studies

14 comparative studies between management approaches were included in this systematic review. Nine of these studies compared combined surgical management (S) with surgical ACL and conservative MCL management (A). Nakamura et al. reported on the effects of MCL injury location in complete ACL and MCL tears, as well as comparing outcomes of ACLR with and without MCLR.10 The authors found no significant differences in IKDC scores, valgus laxity and AP laxity. In one of only 3 randomised controlled trials (RCT) included in this review, Halinen et al. compared ACLR with either nonsurgical or open repair management of grade III MCL injuries. The study showed no long-term difference in anteroposterior (AP) laxity, medial laxity, isokinetic (IK) testing, one-legged hop, IKDC scores and Lysholm scores.11

A more recent RCT by Funchal et al. investigated patients with ACL-MCL (grade II) injuries. Patients diagnosed with ‘floating meniscus’ sign during arthroscopy were divided into two groups, treated with or without medial compartment reconstruction surgery. The ‘floating meniscus’ utilised in this study describes abnormal medial meniscus positioning with changes in opening of the medial compartment, when meniscotibial coronary ligaments from the MCL undergo disruption. This trial found that those treated with ACLR and MCLR had superior outcomes in ACLR failure rates, residual MCL laxity, and both Tegner and Lysholm scores at 2-year follow-up.12 Westermann et al. found baseline KOOS and IKDC scores to be lower in patients undergoing operative MCL treatment, with worse outcomes at 2 years.13 However, both operative and nonoperative MCL treatments demonstrated significant clinical improvements, with surgical chronicity having no effect on clinical outcome. The largest study in this systematic review, Svantesson et al. (n = 793), analysed outcomes from the Swedish National Knee Ligament Registry.14 The authors found that an isolated ACL injury treated with reconstruction implied a lower risk of ACL revision compared with the presence of a conservatively managed MCL injury, but not compared with MCL repair or reconstruction. The same study showed no significant differences in 2-year KOOS scores between MCL suture repair and reconstruction. Lutz et al. employed a differentiated treatment concept based on injury patterns.15 Grade II MCL injury with dislocated tibial or femoral avulsions and grade III MCL ruptures were managed with repair, whilst grade II MCL injuries without dislocated avulsions were managed conservatively. There was no significant difference in ultrasound-examined medial knee joint width (side-side difference), subjective IKDC scores and Tegner activity scores. However, MCL repair resulted in lower Lysholm scores.

Two comparative studies compared combined surgical management (S) with conservative ACL and surgical MCL management (M). In their level II evidence study, Andersson and Gillquist reported superior outcomes in the group with both MCL and ACL repaired, for AP laxity, Lysholm score and functional tests (hop test and figure-of-8).16 Pandey et al. compared MCL-PMC repair with or without ACLR in patients with combined MCL-PMC and ACL tears. Mean Lysholm and IKDC scores were greater in patients with ACLR. 60% of patients with conservatively managed ACLs reported instability complaints, compared with none in the combined surgical group. There were no significant differences in ROM scores.17

Shirakura et al. produced the only study to compare conservative ACL and surgical MCL management (M) with conservative management of ACL and MCL (C). They found an increased Lysholm score in the operative group, with no significant differences in AP laxity, valgus laxity and Tegner scores.18

Hillard-Sembell et al. were the only authors to compare three treatment options: ACLR and MCL repair (S), ACLR and non-surgical MCL management (A), and a combined conservative approach (C).19 At a mean follow-up of 45 months, there was no difference in the presence of valgus instability between methods of treatment. The same study also compared outcomes of patients with ACLR and non-surgical MCL management with isolated ACL tears, revealing no difference in laxity, functional tests, strength, one-legged hop and return to sport.

3.5

3.5 Surgical (repair or reconstruction) management of both ACL and MCL (S)

Within this review 21 studies reported solely on surgical management of both ACL and MCL (S). Of these, 13 involved MCLR, 7 involved MCL repair, and 1 involved both. There has been a noticeable increase in the number of studies focusing exclusively on reconstruction of both ligaments. Out of 13 such studies, 12 have been published since 2010. Using a percutaneous cadaveric graft approach for the MCL, Batista et al. evaluated 30 patients who underwent concurrent reconstruction in the same surgical procedure. At an average follow-up of 43 months, average Lysholm score was 91, with 63.3% of patients returning to pre-injury sporting level.20 Lind et al. retrospectively analysed outcomes in 495 combined ACL-MCL injury patients from the Danish knee ligament reconstruction registry. At 1-year follow-up, there were statistically significant improvements in KOOS-4, Tegner scores, valgus laxity and AP laxity amongst patients with ACL and MCL reconstructions.21

Fewer studies within this review focused on MCL repair in combined surgical management. Osti et al. reported on 22 patients with chronic grade II valgus laxity and ACL insufficiency, in whom both ligaments were addressed at the same surgical setting. Clinical and functional outcomes improved at an average of 36 months (minimum 12 months) follow-up, with 91% of patients returning to sport at pre-injury level.22 The only RCT falling in this category was by Shi et al. However, this study did not compare surgical with conservative approaches. Instead, the authors sought to compare ipsilateral peroneus longus tendon (PLT) autograft against autologous hamstring tendon (HT) for acute ACL rupture with grade III MCL injury. No significant differences were found between approaches.23

Unique within this review, Alm et al. retrospectively evaluated patients with revision ACLR and chronic grade II medial instability to compare MCL repair against reconstruction. At a mean follow-up of 28.8 months, MCLR generated lower failure rates than repair. MCLR was also associated with lower AP instability, less medial instability and greater Lysholm score.24

3.6

3.6 Surgical (repair or reconstruction) management of ACL + conservative management of MCL (A)

13 studies within this systematic review solely included surgical ACL intervention alongside conservative MCL management. A case series of 68 patients by Shelbourne et al. reported a mean AP laxity side-side difference of 2 mm with maximum KT arthrometer assessment. 13% of patients required manipulation under anaesthesia (MUA) for limitations in flexion, whilst 7% needed arthroscopic release for full extension range of motion (ROM).25 In their prospective cohort study, Hara et al. assessed clinical outcomes for 53 patients with chronic ACL injury and grade II valgus laxity who received medial hamstring ACLR alone. The authors compared this group with 289 patients with isolated chronic ACL injury without valgus laxity, reporting no significant difference in AP laxity, ROM, pivot shift test, Lysholm scores, knee extensor muscle strength, return to sporting activities and IKDC scores.26 Chen et al. compared double-bundle and single-bundle ACLR on patients with accompanying grade II MCL injury. This study found no dissimilarity between groups other than rotational instability, for which double-bundle ACLR proved superior. For both groups there was significant improvement in AP laxity, medial stability, rotational stability, and both IKDC (90.1) and Lysholm (92.1) scores.27

3.7

3.7 Conservative management of ACL + surgical (repair or reconstruction) management of MCL (M)

One study included within this review reported solely on conservative management of ACL with surgical management of MCL. In their case series, Frölke et al. used IKDC guidelines to rate outcomes at 2.5 years. Subjective assessment was ‘normal/near normal’ in 55% of patients, with 7% scoring ‘severely abnormal’ for symptoms. 100% of participants scored ‘normal’ for ROM.28

3.8

3.8 Conservative management of both ACL and MCL (C)

Three studies included only conservatively managed ACL-MCL injuries, dated 1984, 1989 and 1993. This systematic review revealed no such studies since. Jokl et al. studied 28 patients with grade III MCL injuries, followed-up at a range of 8 months–11 years.29 68% of patients returned to pre-injury levels of activity, with 71% attaining ‘good’ to ‘excellent’ outcomes on the Hospital for Special Surgery knee assessment (HSS). However, objective outcomes like laxity and ROM were not evaluated. Mok et al. performed a prospective study on 25 patients with acute complete rupture of the MCL with associated ACL injury managed by cast bracing and physiotherapy.30 The authors reported 100% return to pre-level injury of sporting activities by 1 year, with ‘good’ to ‘excellent’ Marshall's scores amongst all participants.

4

4 Discussion

Involvement of both the ACL and MCL represents the most common presenting pattern for multiligament knee injuries (MLKIs). MLKIs of the ACL and LCL represent the second most common presenting pattern, however are far less prevalent.31,32

The optimal management of combined ACL-MCL injuries lacks a global consensus. Several approaches exist, which can be broadly divided based on surgical intervention for one, both or neither of the ligaments. Further uncertainty surrounds the best interval between injury and surgery, as well as the choice of surgical technique. To our knowledge, this is the first systematic review on combined ACL-MCL management to include both study outcomes and methodology assessment. This also represents the first systematic review in over a decade to report on this topic.33,34

At present, it is agreed that management of combined injuries should include surgical intervention for the ACL in patients wishing to return to sports. For grade I and II MCL injuries, ACLR alone is often chosen. It is typically thought that spontaneous healing of complete ACL tears is not possible. However conservative treatment of both ligaments has been described, largely in older literature. Jokl et al.29 advocated for an initial non-surgical approach, with subsequent surgical intervention only if postoperative and follow-up assessments are clinically unsatisfactory. In their retrospective cohort analysis of 350 patients, Razi et al. reported 15 patients in whom spontaneous healing occurred when managed conservatively.35 In this population the mean healing time using MRI imaging was 8.6 months. The authors found that of 27 patients referred with combined injuries from skiing, five (18.5%) exhibited spontaneous healing. They hypothesised that patients with valgus and external rotation noncontact injuries may therefore benefit from a ‘watch-and-wait’ approach. Whilst limited, this evidence may prove useful to patients who either refuse surgical intervention or for whom operative management is contraindicated by comorbidities.

The evidence for surgical management of only the MCL is limited, and less favoured amongst orthopaedic surgeons in practice. The case series by Frölke et al. generated amongst the lowest IKDC outcomes within this review.28 In their prospective study of 45 patients, Andersson and Gillquist compared this approach against patients with concomitant augmented repair of the ACL, reporting superior stability, better subjective results, and more frequent return to strenuous activity in the latter.16 In comparison to conservative approaches for both ligaments, Shirakura et al. reported superior Lysholm score outcomes for repaired grade III MCLs, however no significant differences in girth, stability and activity levels.18

Perhaps the greatest controversy centres on whether surgical MCL management together with ACLR provides clinical benefit for patients with combined injuries. Whilst favourable results have been reported for isolated ACLRs, some studies have advocated for surgical MCL intervention to avoid chronic valgus and residual anteromedial instability. Surgical treatment of the MCL is not without its risk – for example, Noyes and Barber-Westin reported increased rates of patellofemoral pain and flexion loss in patients with combined operative management.36 A RCT performed by Halinen et al. represents one of few level I evidence studies to address this question.11 They reported no significant difference in results (n = 47) with surgical and nonsurgical MCL management. The only noticeable difference between the groups was a longer time required to recover both strength and ROM with MCL repair. Recently, a RCT by Funchal et al. (2019) compared the outcomes of patients with an arthroscopic ‘floating meniscus’, with and without medial compartment reconstruction surgery.12 Of 112 patients with combined ACL-MCL grade II injuries to be treated with ACLR, 58 were treated with surgical MCL intervention and 54 with a conservative MCL approach. The authors found that in the presence of this sign, reconstruction of both ligaments generated lower frequency of ACLR failure and residual MCL laxity. These patients also exhibited superior Tegner and Lysholm scores.

The findings of Funchal et al. highlight the potential benefit of further categorising medial knee morphology beyond the standard MCL injury grading system. Identification of arthroscopic and imaging-based findings associated with inferior rates of non-surgical MCL healing may assist in intervention choice for combined ACL-MCL injuries. Guidance from MCL morphology has previously been suggested by Robins et al., who retrospectively analysed 20 patients with ACLR and conservatively managed grade III MCL injuries.37 The authors compared ROM in patients with proximal MCL tears (off the femoral attachment) and distal MCL tears (off the tibial attachment). At a mean follow-up of 12 months, patients with distal MCL tears experienced fewer additional surgeries, earlier return of ROM (flexion and extension) and greater maximum knee flexion. Nakamura et al. also investigated the effects of grade II-III MCL injury location in combined ACL-MCL lesions.10 The authors assessed 17 patients as part of their prospective study, which also evaluated surgical versus conservative management of the MCL. Injury location was categorised by MRI into proximal (femoral insertion), distal (tibial insertion) and complete (throughout the length of the MCL). They showed that most femoral-sided injuries could heal with conservative therapy, whilst complete injuries did not recover valgus stability with nonsurgical management. These findings further support the need for studies discovering and utilising prognostic indicators in combined injuries. This could help to guide decisions between surgical and nonsurgical approaches for grade II-III MCL lesions.

The current review reveals a significant lack of prospective comparative data, particularly randomised controlled trials (RCT) evaluating management options. Our search found only 3 RCTs which satisfied the inclusion criteria. Of these, two studies provided comparative data for surgical and non-surgical options,11,12 whilst one sought to compare tendon graft choices for ACLR.23 There was marked heterogeneity amongst outcome measures – only three were included in over 50% of studies (AP laxity, Lysholm score and medial/valgus laxity). Furthermore, comparison and collation of outcome measure data was challenging, as both follow-up time and methods of reporting were inconsistent. Outcome measures could be reported as group mean, proportion within a certain category, side-side comparison, absolute outcome values, and absolute or proportional differences between pre- and postoperative states. Assessment methods for the same outcome measures also varied; for example, AP laxity can be tested through several techniques including the Lachman test, KT-1000 knee arthrometer, planar stress radiography and roentgen stereophotogrammetry analysis (RSA). MCL grades of injury were also heterogeneous, with variability in definition and diagnosis. 12 studies did not report on the grade, whilst many others did not mention the diagnostic criteria used.

Based on the current evidence, our treatment algorithm for complete ACL and MCL tears remains largely unchanged from that of Grant et al. (Fig. 2).38 There is scope for modification of this algorithm when further data from anatomical studies of the MCL in combined injuries are available.

Algorithm for management of combined complete ACL-MCL tears, adapted from Grant et al.33 The value of stress X-rays is discussed by LaPrade et al.40 ACL: Anterior cruciate ligament, ACLR: Anterior cruciate ligament reconstruction, AP: Anteroposterior, MCL: Medial collateral ligament, MCLR: Medial collateral ligament reconstruction, ROM: Range of motion.
Fig. 2 Algorithm for management of combined complete ACL-MCL tears, adapted from Grant et al.33 The value of stress X-rays is discussed by LaPrade et al.40 ACL: Anterior cruciate ligament, ACLR: Anterior cruciate ligament reconstruction, AP: Anteroposterior, MCL: Medial collateral ligament, MCLR: Medial collateral ligament reconstruction, ROM: Range of motion.

The mean CMS of 55 suggests a moderate quality of methodology. In their 2010 systematic review, Papalia et al.32 found that CMS correlated positively with year of publication, indicating an improvement in methodological quality of studies over time. Our analysis generated lower CMS scores in comparison, which could partially be explained by more stringent assignments of evidence levels and differentiation between cohort studies and case series.39 We found no significant correlation between CMS and year of publication, suggesting no overall improvement in methodological quality of studies between 1984 and now.

4.1

4.1 Limitations

The authors recognise the limitations of the current systematic review. The CMS range of included studies limits the value of extrapolated findings, as well as the subsequent interpretation. The literature search revealed mostly level III and IV studies, which were not subject to randomisation or blinding, and often comprised low case numbers. There are also limitations from using the CMS, including the fact that this system rates quality of reporting rather than study quality itself, as previously described by Papalia et al.34 Given our restricted inclusion criteria for English articles only, it is possible that relevant data was missed within our qualitative analysis. 14 studies allowed for comparison between surgical and conservative treatment options – out of these, only two were RCTs. Aggregation of data was not possible secondary to study design inconsistency and heterogeneity in factors such as: outcome measures, injury to surgery interval times, follow-up times, outcome measure assessment method, MCL grades of injury and definition/diagnosis of injury grades. As such we could not generate a valid meta-analysis. Greater homogeneity amongst studies would allow consideration of different medial instabilities in a stratified analysis, to assess the influence on clinical outcomes.

5

5 Conclusion

At present the limited quality and consistency of data prevents approval of one particular treatment strategy for combined ACL-MCL injuries. Knee surgeons have been required to corroborate study outcomes with expert opinion in guiding management approach. This review has identified good outcomes for ACLR patients with either MCLR, MCL repair or conservative MCL therapy. Based on the current evidence, the authors follow the management algorithm illustrated in Fig. 2 for complete ACL and MCL tears. There is a clear need for prospective comparative data to assess the optimal MCL approach, including evaluation of nonsurgical prognostic indicators such as injury location and arthroscopic appearance. Future studies should utilise this review to select commonly reported outcome measures, ideally with consistency in assessment methods and reporting. Healthcare providers must tailor current management toward MCL injury grade, comorbidities, patient preference and long-term postoperative activity targets.

Funding/sponsorship

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Approved the final version to be published.

Informed consent

N/A.

Ethical approval

N/A.

Contributorship

RR, RB, BA, RV, and AC have all made substantial contributions to the concept and design of the work. RR and RB were responsible for data collection, analysis and interpretation. RR drafted the article. RR, RB, BA, RV and AC revised it critically for intellectual content.

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