Common treatments for Medial collateral ligament (MCL) injuries include bracing to surgical repair, augmentation and reconstruction. However, reports of residual valgus instability particularly in high-grade injuries are reported. The MCL provides valgus and anterior stability to the tibia with deep MCL fibres closely related to the medial meniscus. Therefore, meniscal anomalies such as “lift-off” and extrusion have been described in MCL injuries. We report the results of using a minimally invasive arthroscopic assisted technique to suture the deep MCL to the medial joint capsule improving MCL healing and preventing valgus instability and meniscal extrusion.

The repair is indicated in grade III clinical MCL injuries and classified according to a newer MRI based classification proposed by Makhmalbaf and Shahpari which is based on the site of injury. After a standard diagnostic arthroscopy and management of any other ligament injury, if present, the MCL tear location was arthroscopically confirmed by performing a valgus stress test with the knee in 30 degrees of flexion to elicit meniscal “lift-off”. In a femoral side tear, the meniscus moves inferiorly with the tibia and a tibial side injury the meniscus moves superiorly with the femur. For femoral tears No.2-0 FiberWire sutures are passed inside out above the medial meniscus at the meniscocapsular junction using a meniscal stitcher double lumen cannula. The sutures are directed into the proximal end of the distal MCL stump inside out and then through the medial joint capsule and held taut outside the knee. Site-specific reduction and restoration of normal meniscal movements and lift off is arthroscopically confirmed. Retrieving the fibre wire percutaneously through an incision over the medial femoral epicondyle, it is anchored using a 4.75-mm SwiveLock in 30 degrees of knee flexion. For tibial side tears, a 2.4mm suture anchor was anchored through the capsule, 1 cm subarticular near the tibial insertion of the DMCL. Using a 1.8mm SutureLasso, sutures are taken through the torn tibial MCL fibres and with a mini-incision tied outside the joint capsule with the knee in 30 degrees of flexion and meniscal reduction confirmed arthroscopically. The patient is braced and non-weight bearing for 6 weeks with weekly increasing range of motion, static quadriceps contractions, ankle pumps and straight leg raising exercises.

9 patients underwent the procedure 2 with tibial side tears and 7 with femoral side tears. 12 months postop Lysholm scores were assessed and pre and post-operative valgus stress x-rays were compared. Additionally, the operated limb was radiologically compared against the uninjured knee for valgus opening in extension. The average preoperative x-ray valgus stress opening was 10.15 mm, postoperatively reduced to 5.9 mm which indicated a significant reduction in valgus opening (p= <0.05) and average Lysholm score was 92.2. The average postoperative x-ray valgus opening did not vary significantly (p=>0.05) when compared to the valgus stress x-ray of the uninjured limb.
This technique was a simple, effective minimally invasive treatment for MCL tears with good predictable postoperative results but does require a larger sample size and further follow up.