Short-term effectiveness of anterior cruciate ligament reconstruction combined with internal brace augmentation for acute anterior cruciate ligament and medial collateral ligament injuries_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YIN Zequn ¹ , ZHANG Yu ² , ZHANG Sheng ² , LIU Xiaohua ² , LI Yan ² ,  SUN Jin ²

1. Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, P. R. China;
2. The First Department of Sports Medicine, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, 100102, P. R. China;

Corresponding?author：

SUN Jin, Email: sunasiasun@163.com

Keywords：

Internal brace augmentation; medial collateral ligament; anterior cruciate ligament; ligament reconstruction; short-term effectiveness

DOI：

10.7507/1002-1892.202603117

Video：

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Objective To evaluate the short-term effectiveness of anterior cruciate ligament (ACL) reconstruction with internal brace augmentation for the treatment of acute ACL and medial collateral ligament (MCL) injuries. Methods A retrospective analysis was conducted on 15 patients with acute ACL and MCL injuries, who underwent ACL reconstruction with internal brace augmentation for MCL repair between January 2020 and December 2024. There were 10 males and 5 females, with a mean age of 37.3 years (range, 16-56 years). The mechanism of injury was sports-related trauma in 14 patients and a traffic accident in 1 patient. The mean interval from injury to operation was 13.5 days (range, 6-20 days). Concomitant meniscal injuries were identified in 11 patients. Clinical outcomes were evaluated pre- and post-operatively using the Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score, and knee range of motion. Knee stability was assessed by measuring the side-to-side difference (SSD) in medial joint space on valgus stress X-ray films and in anterior tibial translation using the KT-2000 arthrometer, respectively. Ligament healing was evaluated by postoperative MRI. Results All incisions healed by first intention, and no surgery-related major complications occurred. All patients were followed up 12-13 months (mean, 12.2 months). At last follow-up, the knee joint activity had been restored in all patients. The Lachman test, anterior drawer test, and valgus laxity were negative in all patients, except for one patient with a positive pivot-shift test. The Lysholm score, IKDC score, Tegner score, and knee range of motion showed progressive improvement after operation (P<0.05). At 12 months after operation, X-ray films demonstrated restoration of the medial joint space; the SSD in anterior tibial translation measured with the KT-2000 arthrometer was (2.5±0.6) mm. The above indicators represented a significant improvement compared with the preoperative measurement (P<0.05). MRI confirmed satisfactory continuity of the repaired MCL and satisfactory graft signal intensity of the reconstructed ACL. Conclusion ACL reconstruction combined with internal brace augmentation for MCL repair provides satisfactory short-term effectiveness in patients with acute ACL and MCL injuries. This technique facilitates early postoperative rehabilitation, restores knee stability, and may reduce the risk of postoperative complications such as knee stiffness.

Citation： YIN Zequn, ZHANG Yu, ZHANG Sheng, LIU Xiaohua, LI Yan, SUN Jin. Short-term effectiveness of anterior cruciate ligament reconstruction combined with internal brace augmentation for acute anterior cruciate ligament and medial collateral ligament injuries. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(8): 1193-1199. doi: 10.7507/1002-1892.202603117 Copy

1.	Wright ML, Coladonato C, Ciccotti MG, et al. Combined anterior cruciate ligament and medial collateral ligament reconstruction shows high rates of return to activity and low rates of recurrent valgus instability: an updated systematic review[J]. Arthrosc Sports Med Rehabil, 2023, 5(3): e867-e879.
2.	Ateschrang A, Dobele S, Freude T, et al. Acute MCL and ACL injuries: First results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction[J]. Arch Orthop Trauma Surg, 2016, 136: 1265-1272.
3.	Shultz CL, Poehlein E, Morriss NJ, et al. Nonoperative management, repair, or reconstruction of the medial collateral ligament in combined anterior cruciate and medial collateral ligament injuries-which is best? A systematic review and meta-analysis[J]. Am J Sports Med, 2024, 52(2): 522-534.
4.	Svantesson J, Piussi R, Weissglas E, et al. Shedding light on the non-operative treatment of the forgotten side of the knee: rehabilitation of medial collateral ligament injuries-a systematic review[J/OL]. BMJ Open Sport Exerc Med, 2024, 10(2): e001750. doi: 10.1136/bmjsem-2023-001750.
5.	Denisov D, Chen DS, Motamedi D. Stener-like lesion of the medial collateral ligament of the knee[J]. Radiol Case Rep, 2022, 18(3): 913-916.
6.	Grassi A, D’Ambrosi R, Dal Fabbro G, et al. A systematic review of distal medial collateral ligament Stener-like lesion: Good clinical and functional outcomes of surgical treatment[J]. Knee Surg Sports Traumatol Arthrosc, 2026, 34(3): 881-891.
7.	Ramakanth R, Sundararajan SR, Sujith BSG, et al. 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[J]. Arthroscopy, 2025, 41(6): 2021-2032.
8.	van der List JP, Muscott RK, Parikh N, et al. Early anterior cruciate ligament treatment might be crucial for acute combined anterior cruciate ligament and medial collateral ligament injuries: a systematic review of the various treatment strategies[J]. Arthroscopy, 2024, 40(8): 2322-2336.
9.	Alm L, Krause M, Frosch KH, et al. Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction[J]. Knee Surg Sports Traumatol Arthrosc, 2020, 28(8): 2458-2467.
10.	Noyes FR, Barber-Westin SD. The treatment of acute combined ruptures of the anterior cruciate and medial ligaments of the knee[J]. Am J Sports Med, 1995, 23(4): 380-389.
11.	Holuba K, Vermeijden HD, Yang XA, et al. Treating combined anterior cruciate ligament and medial collateral ligament injuries operatively in the acute setting is potentially advantageous[J]. Arthroscopy, 2023, 39(4): 1099-1107.
12.	Tapasvi S, Shekhar A, Patil S, et al. Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up[J]. Knee Surg Sports Traumatol Arthrosc, 2022, 30(1): 280-287.
13.	DeLong J, Waterman B. Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: a systematic review[J]. Arthroscopy, 2015, 31(11): 2258-2272.
14.	Mackay GM, Blyth MJ, Anthony I, et al. A review of ligament augmentation with the InternalBrace^TM: The surgical principle described for the lateral ankle ligament and ACL repair[J]. Surg Technol Int, 2015, 26: 239-255.
15.	Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19, 457 patients from the Swedish National Knee Ligament Registry[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 1450-1459.
16.	Guenther D, Pfeiffer T, Petersen W, et al. Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG)[J/OL]. Orthop J Sports Med, 2021, 9(11): 23259671211050929. doi: 10.1177/23259671211050929.
17.	Mowers C, Jackson GR, Condon JJ, et al. Medial collateral ligament reconstruction and repair show similar improvement in outcome scores, but repair shows higher rates of knee stiffness and failure: a systematic review[J]. Arthroscopy, 2023, 39(10): 2231-2240.
18.	Shelbourne KD, Porter DA. Anterior cruciate ligament-medial collateral ligament injury: Nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction[J]. Am J Sports Med, 1992, 20(3): 283-286.
19.	Tompkins MA, Williams H, Bechtold JE. An MCL internal brace can withstand cyclic fatigue loading and produce a valgus load to failure similar to that of intact knees[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(9): 3611-3617.
20.	van Eck CF, Nakamura T, Price T, et al. Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee[J]. Knee Surg Sports Traumatol Arthrosc, 2021, 29(8): 2545-2552.
21.	Wierer G, Kittl C, Fink C, et al. Medial collateral ligament reconstruction: a gracilis tenodesis for anteromedial knee instability[J]. Arthrosc Tech, 2022, 11(8): e1409-e1418.
22.	Golden T, Friedman A, Jazayeri R, et al. Primary repair of the medial collateral ligament with a double row suture technique and suture tape augmentation for acute tibial-sided injuries[J]. Arthrosc Tech, 2019, 8(4): e395-e398.
23.	van der List JP, DiFelice GS. Primary repair of the medial collateral ligament with internal bracing[J]. Arthrosc Tech, 2017, 6(4): e933-e937.
24.	Kelly SR, Daniel AV, Smith PA. Open medial meniscotibial ligament repair with concomitant open superficial medial collateral ligament repair with internal brace augmentation [J/OL]. Arthrosc Tech, 2023, 13(1): 102837. doi: 10.1016/j.eats.2023.09.013.
25.	Black AK, Schlepp C, Zapf M, et al. Technique for arthroscopically assisted superficial and deep medial collateral ligament-meniscotibial ligament repair with internal brace augmentation[J]. Arthrosc Tech, 2018, 7(11): e1215-e1219.
26.	Noailles T, Behr J, Bouguennec N, et al. Postoperative weight-bearing, range-of-motion protocols and knee biomechanics after concomitant posterolateral meniscal root repair with ACL reconstruction: a systematic review[J/OL]. J Clin Med, 2026, 15(2): 542. doi: 10.3390/jcm15020542.

1. Wright ML, Coladonato C, Ciccotti MG, et al. Combined anterior cruciate ligament and medial collateral ligament reconstruction shows high rates of return to activity and low rates of recurrent valgus instability: an updated systematic review[J]. Arthrosc Sports Med Rehabil, 2023, 5(3): e867-e879.
2. Ateschrang A, Dobele S, Freude T, et al. Acute MCL and ACL injuries: First results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction[J]. Arch Orthop Trauma Surg, 2016, 136: 1265-1272.
3. Shultz CL, Poehlein E, Morriss NJ, et al. Nonoperative management, repair, or reconstruction of the medial collateral ligament in combined anterior cruciate and medial collateral ligament injuries-which is best? A systematic review and meta-analysis[J]. Am J Sports Med, 2024, 52(2): 522-534.
4. Svantesson J, Piussi R, Weissglas E, et al. Shedding light on the non-operative treatment of the forgotten side of the knee: rehabilitation of medial collateral ligament injuries-a systematic review[J/OL]. BMJ Open Sport Exerc Med, 2024, 10(2): e001750. doi: 10.1136/bmjsem-2023-001750.
5. Denisov D, Chen DS, Motamedi D. Stener-like lesion of the medial collateral ligament of the knee[J]. Radiol Case Rep, 2022, 18(3): 913-916.
6. Grassi A, D’Ambrosi R, Dal Fabbro G, et al. A systematic review of distal medial collateral ligament Stener-like lesion: Good clinical and functional outcomes of surgical treatment[J]. Knee Surg Sports Traumatol Arthrosc, 2026, 34(3): 881-891.
7. Ramakanth R, Sundararajan SR, Sujith BSG, et al. 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[J]. Arthroscopy, 2025, 41(6): 2021-2032.
8. van der List JP, Muscott RK, Parikh N, et al. Early anterior cruciate ligament treatment might be crucial for acute combined anterior cruciate ligament and medial collateral ligament injuries: a systematic review of the various treatment strategies[J]. Arthroscopy, 2024, 40(8): 2322-2336.
9. Alm L, Krause M, Frosch KH, et al. Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction[J]. Knee Surg Sports Traumatol Arthrosc, 2020, 28(8): 2458-2467.
10. Noyes FR, Barber-Westin SD. The treatment of acute combined ruptures of the anterior cruciate and medial ligaments of the knee[J]. Am J Sports Med, 1995, 23(4): 380-389.
11. Holuba K, Vermeijden HD, Yang XA, et al. Treating combined anterior cruciate ligament and medial collateral ligament injuries operatively in the acute setting is potentially advantageous[J]. Arthroscopy, 2023, 39(4): 1099-1107.
12. Tapasvi S, Shekhar A, Patil S, et al. Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up[J]. Knee Surg Sports Traumatol Arthrosc, 2022, 30(1): 280-287.
13. DeLong J, Waterman B. Surgical techniques for the reconstruction of medial collateral ligament and posteromedial corner injuries of the knee: a systematic review[J]. Arthroscopy, 2015, 31(11): 2258-2272.
14. Mackay GM, Blyth MJ, Anthony I, et al. A review of ligament augmentation with the InternalBrace^TM: The surgical principle described for the lateral ankle ligament and ACL repair[J]. Surg Technol Int, 2015, 26: 239-255.
15. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19, 457 patients from the Swedish National Knee Ligament Registry[J]. Knee Surg Sports Traumatol Arthrosc, 2019, 27(8): 1450-1459.
16. Guenther D, Pfeiffer T, Petersen W, et al. Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG)[J/OL]. Orthop J Sports Med, 2021, 9(11): 23259671211050929. doi: 10.1177/23259671211050929.
17. Mowers C, Jackson GR, Condon JJ, et al. Medial collateral ligament reconstruction and repair show similar improvement in outcome scores, but repair shows higher rates of knee stiffness and failure: a systematic review[J]. Arthroscopy, 2023, 39(10): 2231-2240.
18. Shelbourne KD, Porter DA. Anterior cruciate ligament-medial collateral ligament injury: Nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction[J]. Am J Sports Med, 1992, 20(3): 283-286.
19. Tompkins MA, Williams H, Bechtold JE. An MCL internal brace can withstand cyclic fatigue loading and produce a valgus load to failure similar to that of intact knees[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(9): 3611-3617.
20. van Eck CF, Nakamura T, Price T, et al. Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee[J]. Knee Surg Sports Traumatol Arthrosc, 2021, 29(8): 2545-2552.
21. Wierer G, Kittl C, Fink C, et al. Medial collateral ligament reconstruction: a gracilis tenodesis for anteromedial knee instability[J]. Arthrosc Tech, 2022, 11(8): e1409-e1418.
22. Golden T, Friedman A, Jazayeri R, et al. Primary repair of the medial collateral ligament with a double row suture technique and suture tape augmentation for acute tibial-sided injuries[J]. Arthrosc Tech, 2019, 8(4): e395-e398.
23. van der List JP, DiFelice GS. Primary repair of the medial collateral ligament with internal bracing[J]. Arthrosc Tech, 2017, 6(4): e933-e937.
24. Kelly SR, Daniel AV, Smith PA. Open medial meniscotibial ligament repair with concomitant open superficial medial collateral ligament repair with internal brace augmentation [J/OL]. Arthrosc Tech, 2023, 13(1): 102837. doi: 10.1016/j.eats.2023.09.013.
25. Black AK, Schlepp C, Zapf M, et al. Technique for arthroscopically assisted superficial and deep medial collateral ligament-meniscotibial ligament repair with internal brace augmentation[J]. Arthrosc Tech, 2018, 7(11): e1215-e1219.
26. Noailles T, Behr J, Bouguennec N, et al. Postoperative weight-bearing, range-of-motion protocols and knee biomechanics after concomitant posterolateral meniscal root repair with ACL reconstruction: a systematic review[J/OL]. J Clin Med, 2026, 15(2): 542. doi: 10.3390/jcm15020542.

Chinese Journal of Reparative and Reconstructive Surgery

Short-term effectiveness of anterior cruciate ligament reconstruction combined with internal brace augmentation for acute anterior cruciate ligament and medial collateral ligament injuries

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