Medial Collateral Ligament Repair, Isolated Suture-Tape-Bracing and No Repair for Grade III Medial Collateral Ligament Tears During Anterior Cruciate Ligament Reconstruction Have Similar Outcome for Combined Anterior Cruciate Ligament With Medial Collateral Ligament Injury: A 3-Arm Randomized Controlled Trial

Abstract

Purpose: To compare various medial collateral ligament (MCL) management strategies (repair vs isolated suture-tape bracing vs no repair) combined with anterior cruciate ligament (ACL) reconstruction and analyze the results of MCL subtypes (femoral-sided, mid-substance, and tibial-sided tears) that occur at distinct levels.

Methods: This study was a double-blind, prospective 3-arm randomized controlled trial. Ninety-six consecutive patients with combined ACL and grade III MCL acute & subacute injuries between 2020 and 2022 with minimum 24-month follow-up were included in the study. Chronic MCL injuries and other ligament injuries were excluded, and computer-generated randomization was performed for allotment into 3 MCL management groups. ACL reconstruction with hamstring autograft was performed and the MCL underwent repair in group 1 (n = 33), isolated suture-tape-bracing in group 2 (n = 32), and no repair in group 3 (n = 31). At follow-up, stress radiographs were used to analyze anterior and medial laxity. The International Knee Documentation Committee score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score, duration of surgery, and cost of surgery were compared. In addition, subgroup analysis was performed to assess outcomes based on location of MCL injury.

Results: Demographic data, duration of injury, mode of injury, and distinct level of MCL injury were similar across groups. Overall, the incidence rates of MCL tears on the femoral side, at the midsubstance, and on the tibial side were 58.3%, 18.7%, and 23.0%, respectively. Postoperatively, significant improvements in range of motion (ROM) and functional scores were observed in all 3 groups (P ≤ .05); however, there were no statistically significant differences among the 3 groups at final follow-up in anterior tibial translation (P = .94), medial opening at 0° of flexion (P = .8) and 30° of flexion (P = .64), ROM (P = .39), International Knee Documentation Committee score (P = .17), Lysholm score (P = .14), and Knee Injury and Osteoarthritis Outcome Score (P = .68). Three patients in group 2 had stiffness at 3 months: 2 were treated with continuous passive motion and physiotherapy, and 1 needed arthrolysis. Medial opening (at 0° and at 30°) was greater in group 3 patients with mid-substance MCL tears (P = .042 and P = .043, respectively). On minimal clinically important difference analysis, more than 80% of patients had improvement in ROM and functional scores, as well as medial opening of less than 5 mm, suggestive of successful outcomes in all 3 groups. The duration of surgery was longer in the repair group (P = .001), whereas cost was higher in the suture-tape bracing group (P = .003).

Conclusions: MCL treatment with repair, isolated suture-tape-bracing, and no repair results in good radiologic outcomes (medial stress laxity) and functional outcomes when combined with ACL reconstruction. MCL repair or isolated suture-tape-bracing more effectively restores medial-sided stability. Mid-substance MCL tears may need an additional procedure (repair or bracing) to restore medial stability.

Level of evidence: Level I, randomized controlled trial.