What is the MCL?
The MCL is a ligament on the medial or inner side of the knee, that attaches between the femur (thigh bone) and the tibia (shin bone). It helps to stabilise the knee and prevent excessive side to side movement.
How is it injured?
An MCL injury typically occurs from direct contact to the outside of the knee that pushes the knee inwards. It can also occur as part of a larger multi-ligament knee injury.
What problems does an MCL injury cause?
An injured MCL is called a sprain, which are graded on a scale. An XRay and MRI (Magnetic Resonance Imaging) are performed to help investigate the degree of the MCL injury.
Grade 1 sprains are associated with pain and swelling only, with nearly all the fibres of the ligament intact. Instability is rarely a problem.
Grade 2 sprains represent a partial injury to the ligament, and patients may feel some instability as they walk or run.
Grade 3 sprains represent a complete injury to the ligament, with almost all fibres disrupted. The knee is felt to be very unstable, with difficulty walking and running without the knee giving way.
How is an MCL injury treated?
The majority of MCL sprains are treated non-operatively. Initial management of the injury consists of RICE (Rest, ice, compression and elevation). This will help decrease the swelling and pain associated with the injury. Ones the pain settles down, you can weight bear as tolerated. A rehabilitation and strengthening protocol is then instituted with a physiotherapist to improve the range of motion and stability of the knee.
A special brace, called a hinged-knee brace, is used for the non-operative treatment of more severe sprains (Grade 2 and Grade 3). It is a brace that offers external side to side support for the knee while allowing the ligament to heal. The brace can also be set to restrict certain degrees of bending to again help the ligament heal.
Physiotherapy and the use of a hinged knee brace is also required in the event Medial Collateral Ligament Surgery is required.
What MCL sprains require surgery?
MCL injuries rarely need surgery immediately. Severe Grade 3 sprains, where the ligament is torn off the tibial side, have a low chance of healing with non-operative management and surgery is indicated. A failure of non-operative management, or the presence of multiple injuries in the knee are also possible indications for surgery.
What is the difference between MCL repair and reconstruction?
Ligament repair is suturing the ends of your injured MCL back together. MCL Reconstruction is using a graft to replace your injured MCL.
In addition to the MCL repair, a special surgical anchor or augmentation with suture material is sometimes added to help the healing process and protect your own MCL while it heals.
Reconstruction surgery is chosen when your surgeon at Melbourne Hip and Knee feels that your own MCL will not be able to repair itself even with the ends sutured together. This may be because of the severity of the injury, or the long period of time since the original injury leaving too much scar tissue present. Your MCL is reconstructed using a tendon graft, often your own hamstring tendons. A donor graft or specialised surgical material is sometimes used instead to reconstruct the MCL.
A decision will be made if the MCL injury is for repair or reconstruction. The surgery requires one night in hospital postoperatively. A Knee Arthroscopy is performed first, followed by the repair or reconstruction.
Under a general or spinal anaesthetic, two small incisions are made in the front of the knee to gain access into the joint. A full assessment is performed within the knee to rule out other conditions such as meniscal tears, which are managed if found.
An incision is then made on the medial side of the knee and the pathway of the MCL is exposed from the end of the femur to the top of the tibia.
The torn ends are sutured together. Surgical suture anchors are added to hold the repair. Specialised suture material is sometimes added as a band that runs the length of your own MCL to help protect the repair while it heals.
The graft choice is made prior to the operation. If a hamstring autograft is required, then your own semitendinosus tendon is freed and re-routed to replicate the pathway of the MCL. The graft may instead be from a donor or a thick band of specialised surgical material. The graft is held in place with anchors and screws.
What happens after surgery?
You will go home the day after surgery. Before you leave hospital, your surgeon from Melbourne Hip and Knee will talk to you about the findings of the arthroscopy and the management performed. They will go through this with you again at your two week review.
You will be given instructions about how to care for your knee and the dressings in the first two weeks. You will be able to walk on your knee, but may need to use crutches to help protect the ligament for a short period of time. A hinged knee brace will be placed on your knee which will allow bending, but prevent side to side movement. It is common to have some mild pain and swelling for a few weeks after your surgery, and your surgeon will ensure that you have adequate pain relief to go home with.
Post operative recovery
Your surgeon will see you at two weeks in our rooms at MHK to ensure you have recovered well, and to explain the findings and management of the surgery again. Typically a second appointment is organised at 6 weeks to progress your rehabilitation. You should be able to return to a desk job after a week and be able to spend a few hours on your feet after 2 weeks. After 6 weeks, weightbearing is increased and the use of the brace is decreased. In conjunction with your physiotherapist, we will guide you through a rehabilitation program that will help return range of motion, strength and function to your knee.