Summary

Outcomes of ACL Reconstruction With and Without MCL Injury in Professional Football and Rugby Players are The Same Even With Concomitant MCL Surgery

Abstract

Introduction

Medial collateral ligament (MCL) injuries are commonly sustained in conjunction with anterior cruciate ligament (ACL) ruptures in elite sport.

Aims:

Compare return to play (RTP) rates, time to RTP, and career longevity of professional soccer and rugby players following isolated primary anterior cruciate ligament reconstruction (ACLR), ACLR with non-surgically and surgically managed MCL injuries.

Methods

Retrospective review of all professional football and rugby players undergoing ACLR, or ACLR and non-surgically treated MCL injury, and combined ACL and MCL reconstructions undertaken by two sports knee surgeons was conducted between 2015 to 2022. Athletes aged over 16 years, with a minimum of two-year follow-up and with accessible Magnetic Resonance Imaging (MRI) scans and/or reports were included. MCL surgery was undertaken if there was medial opening on valgus stress with the knee straight, or grade 2 or more MCL laxity at 30 degrees, and a positive dial test for anteromedial rotatory instability. RTP was defined as first match appearance and all RTP and career longevity information was extracted from publicly available databases.

Results

209 professional athletes were included: 118 (56.5%) football players, and 91 (43.5%) rugby players and 197 (94.3%) were males. 84 (40.2%) had isolated ACLR, 88 (42.1%) had ACLR with MRI evidence of MCL injury then treated non-surgically, whilst 37 (17.7%) had combined ACL and MCL reconstructions.
Overall RTP rate was 95.2% (96.2% in soccer, 93.4% in rugby). RTP was highest in the isolated ACLR group compared to those with the MCL treated non-operatively, and those with MCL surgery (98.8% vs 94.3% vs 89.2% respectively (No significant difference.(NS)). All 4 ACL plus MCL surgery patients who failed to RTP were rugby players aged 25, 29, 32 and 33 years at the time of surgery. Overall mean RTP time was 11.8 (+/- 4.5) months post-surgery. Mean RTP time for isolated ACLR patients was 11.6 months compared to 12.1 months in both the non-surgically and surgically treated MCL cohorts (NS). This equals only 12 days difference. Approximately 25-30 athletes had RTP times affected by Covid-19 sporting restrictions.
At 2 years post-surgery 85.3% (174/204) were still playing. 88.1% of isolated ACLR were still playing compared to 84.5% of non-surgical MCL patients and 80.6% of surgically treated MCL patients (NS). Overall 69.0% (98/142) were still playing at 5 years and this was 71.0%, 70.5% and 57.9% respectively (NS). Mean follow up was 6.2 (+/-2.1) years with 83 players (39.7%) still playing at the time of the study.
Six (2.9%) players sustained ACL re-rupture: 2 (2.4%) isolated ACLR, 3 (3.4%) ACLR with MCL non-surgically managed, and 1 (2.7%) following ACL plus MCL surgery (NS).

Conclusion

There were no significant differences in RTP, “still playing” rates and re-ruptures between isolated ACLR and ACLR plus MCL treated with or without surgery. Patients with combined ACL and MCL injuries require careful clinical examination to ascertain whether the MCL injury should be treated surgically or not.

Level of evidence: IV.

Keywords: Return To Play, Career Longevity, Football, Rugby, Anterior Cruciate Ligament, Medial Collateral Ligament