AOSSM/AANA Specialty Day 2020-MCL Injuries_ Surgical Indications and Timing

MCL Injuries_ Surgical Indications and Timing

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This presentation by Dr. Darren L. Johnson provides an in-depth overview of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries, focusing on when and how to fix medial-sided knee injuries. Key points include:<br /><br />- MCL injuries increase strain and loading on the ACL, particularly partial and complete tears, raising the risk of ACL injury.<br />- Medial knee stability is provided by the superficial MCL (sMCL), deep MCL, and the posterior oblique ligament (POL). The POL is especially important in controlling internal rotation and valgus stability.<br />- Grade III MCL injuries, especially distal avulsion injuries with a "Stener-like" lesion, often do not heal well nonoperatively and may lead to chronic valgus instability.<br />- Clinical decision-making for treatment considers athlete demands, tear location, involvement of the POL, office examination, arthroscopic evaluation, and shared decision making.<br />- Most isolated MCL injuries are managed nonoperatively with bracing, protected weight-bearing, and motion protocols before ACL reconstruction is performed electively.<br />- Operative repair or reconstruction of the MCL is reserved for chronic deficiencies, grade III MCL/POL injuries that open under stress at surgery, cases with positive arthroscopic drive-through signs, and distal avulsion injuries.<br />- A multicenter prospective study showed both operative and nonoperative MCL management during ACL reconstruction improve outcomes at 2 years, though surgical MCL repair was associated with worse baseline symptoms and higher rates of arthrofibrosis.<br />- Reconstruction techniques involve anatomic repair of sMCL and POL using semitendinosus grafts with tensioning to restore knee stability, particularly important in high-level athletes.<br />- Failure to treat significant MCL injuries can result in persistent medial knee laxity and instability despite intact ACL function.<br />  <br />In summary, proper diagnosis and appropriate treatment of medial-sided injuries in combination with ACL tears are crucial to restore knee stability and function. Surgical intervention is reserved for specific indications such as severe, chronic, or distal avulsion MCL tears, while most cases are treated conservatively with timely ACL reconstruction.

Keywords

anterior cruciate ligament

medial collateral ligament

MCL injuries

ACL reconstruction

medial knee stability

posterior oblique ligament

grade III MCL tear

operative repair

nonoperative management

knee instability