How I Do MCL RepairM. Razi MD;

Anatomy Medial structures

MCL POL postero-medial

capsular ligament Augmented by

dynamic effect of

semimembranosus

BIOMECHANICS LaPrade et al. in a cadaveric study Am J Sports Med 2010

Increase in knee inst.. After sectioning of knee medial ligaments in all flexion angles.

Significant increase in external and internal rotation after sectioning of medial structure.

Small increase in anterior and posterior translation after cutting the medial knee structures

BIOMECHANICS

Tibial rotation better controlled by collateral ligaments & capsular structures. Noyes FR

MCL provides resistance to anterior drawer test only after ACL is gone shoemaker SC

Combined ACL & MCL injury further comprise anterior stability. Sullivan D

Physical examination X-Ray MRI

Natural history

Instability Stiffness Functional valgus deformity Valgus thrust Failiure of ACL or PCL reconsruction Partial healing and non symptomatic

Combined ACL and MCL injuries Factors to be considered

Limb alignment ? Is there gross anteromedial instability ? Is there gross medial instability near full

extension ? Patients demand ? Arthroscopic evaluation

Combined ACL and MCL injuries Current concept

Reconstruct ACL

and conservative treatment

for MCL

Reconstruct ACL & repair or reconstruct MCL

Combined ACL and MCL injuries what I am doing

Conservative treatment for 6

to 12 weeks to obtain full ROM and enough time for evaluation

BTB ACL reconstruction

Secondary Repair of MCL & posterior oblique ligament or reconstruction by Semi T from normal side. Or allograft

Arthroscopic MCL technique

how to reduce post-operative failures in Combined ACL and MCL injuries:

Conservative treatment for 6 to 12 weeks to obtain full ROM and enough time for evaluation

BTB ACL reconstruction In subtle MCL tears also consider limb alignment Combined BTB ACL & MCL & posterior oblique ligament

reconstruction by semi T from normal side in grade II &

III tears. or arthroscopic MCL reconstructionOver treatment of MCL in the past & under Over treatment of MCL in the past & under

estimation in recent years.estimation in recent years.

how to reduce post-operative failures inCombined ACL and MCL injuries:

Do not perform HTO in the presence of MCL injuries

Do not use ipsilateral hamstring graft in MCL deficient knee

Be ware of stiffness in early surgery of multiple ligament injuries

Arthroscopic MCL reconsrruction

Since 2009 to 2011 35 In 23 cases acl and mcl In 6 cases pcl and mcl In 5 cases acl mcl and pls In one case mcl and medial meniscus From 2010 to 2011 8 cases of MCL

reefing combined with ACL reconstruction

Perspolis