1. How I Do MCL Repair M. Razi MD;

2. Anatomy Medial structures MCL POL postero-medial capsular ligament Augmented by dynamic effect of semimembranosus

3. 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

4. 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

5. Physical examination X-Ray MRI

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

7. 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

8. Combined ACL and MCL injuries Current concept Reconstruct ACL and conservative treatment for MCL Reconstruct ACL & repair or reconstruct MCL

10. 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

13. Arthroscopic MCL technique

14. 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 reconstruction Over treatment of MCL in the past & under estimation in recent years.

15. how to reduce post-operative failures in Combined 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

16. 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

17. Perspolis