Abstract
Background:
Distal medial collateral ligament (MCL) injuries are less common and have worse healing potential than proximal MCL injuries. The purpose of this video is to demonstrate the surgical technique of distal MCL repair with suture augmentation.
Indications:
The patient is a 17-year-old man who sustained a distal MCL injury and medial meniscocapsular junction tear while playing soccer. He was indicated for surgical management due to a complete distal MCL tear with symptomatic instability and concomitant medial meniscocapsular injury.
Technique Description:
The patient was placed in a supine position, and the bilateral knee was examined. Arthroscopic evaluation demonstrated a medial meniscocapsular junction tear, which was treated with a series of all-inside, horizontal mattress sutures. The proximal attachment of the MCL was identified proximally and posteriorly to the medial epicondyle under fluoroscopic imaging. The deep and superficial MCL attachments on the tibia were marked 1 and 6 cm distal to the medial joint line, respectively. After dissection of the pes anserine and distal MCL, a 1.8-mm knotless, all-suture anchor was inserted into the proximal attachment site of the MCL, and a fiber tape was passed through the anchor and folded to create 2 limbs. Two 1.8-mm knotless, all-suture anchors were inserted anterior and posterior to the native deep MCL, creating a mattress construct. The 2 limbs of the fiber tape were passed under the pes anserine and secured to the tibia with a 4.75-mm biocomposite knotless anchor with the knee positioned in neutral rotation, 30° of knee flexion, and varus stress.
Results:
The patient presented had full range of motion and stability compared with the contralateral extremity at 3 months postoperatively. Strength testing at 6 months demonstrated >95% strength in his proximal thigh musculature compared with the contralateral extremity. He was returned to sports without limitations at 6 months postoperatively.
Discussion/Conclusion:
Complete distal MCL injuries with instability and concomitant meniscal tears may be indicated for surgery, and arthroscopic medial meniscal repair with distal MCL repair with suture augmentation is a viable and replicable surgical treatment for this condition.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
Background
The patient is a 17-year-old man who sustained a knee injury while playing soccer. He was able to continue playing, but he experienced pain on the medial side of his knee. A few games later, his knee gave out again, and he was unable to continue playing. On presentation, he endorses medial knee pain and instability.
He is in the 12th grade and competes in multiple sports—including basketball, soccer, and track.
On physical examination, he has a trace effusion. He is tender at the medial joint line and the proximal and distal attachments of the medial collateral ligament (MCL). He has around 5° of hyperextension and 135° of flexion, which is symmetric to the contralateral side.
He is stable to varus and valgus stress at 0°, but he has a grade 2 valgus laxity at 30°. The remainder of his ligamentous examination is normal, with a negative Lachman, anterior and posterior drawer, pivot-shift, and dial tests at 30° and 90°.
He has a positive McMurray's and Apley's test medially.
Radiographic evaluation demonstrates closed physes, and there are well-maintained medial, lateral, and patellofemoral joint spaces. Of note, there is an incidental finding of a nonossifying fibroma at the medial supracondylar femur.
A magnetic resonance imaging (MRI) of the knee was performed, and it demonstrates a medial meniscocapsular separation and a complete tear of the distal MCL with surrounding swelling.
Indications
Based on the clinical and radiographic findings of a medial meniscocapsular tear and a complete distal MCL tear with persistent instability, this patient was indicated for surgery.
Other surgical indications are as follows:
Failure of nonoperative treatment with recalcitrant valgus laxity
Multiligamentous knee injury
MCL Anatomy
The anatomy of the medial knee is complex.
The superficial MCL has both femoral and tibial attachments. The femoral attachment occurs proximal and posterior to the medial epicondyle. The tibial attachment occurs approximately 6 cm distal to the medial joint line. 8 The superficial MCL is in the second layer of the medial knee structures. 14
The deep MCL has distinct meniscofemoral and meniscotibial attachments, representing a thickening of the medial capsule. 8 The deep MCL resides in the third layer of the medial knee. 14
While the path of the saphenous nerve is highly variable, there are safe corridors for dissection, and the saphenous vein and branches of the saphenous nerve should be protected during the anteromedial approach to the knee. 7 The saphenous nerve emerges from the adductor canal between the gracilis and sartorius before branching into the infrapatellar and sartorial branches. Distal dissection can be performed between these 2 branches, as the infrapatellar branch runs anteriorly, while the sartorial branch runs posteromedially with the saphenous vein distally. 5
Clinical Examination
Patients should be assessed for valgus stability at both 0° and 30°. This can be graded as stable, grade 1 (<5 mm), grade 2 (>5 mm but <10 mm), or grade 3 (>10 mm), and the endpoint should be assessed.1,11
Laxity at 0° indicates injury to the MCL and posterior oblique ligament, and is likely to involve injury to either one or both of the cruciate ligaments, most commonly the anterior cruciate ligament.1,3
If there is laxity at 30° only, this indicates isolated ligamentous injury to the MCL.1,3
Patients should also be assessed clinically for a valgus thrust with ambulation.
Observe here how the joint space opens during valgus stress at 30° compared to the contralateral side. There is no clear endpoint on the affected knee.
Considerations for Treatment
MCL injury represents approximately 8% of all sports-related knee injuries. 9
Most MCL injuries can be treated conservatively. Surgical treatment is often reserved for patients with multiligamentous knee injury or those with recalcitrant valgus laxity. 2
Approximately 90% of MCL injuries occur at the femoral attachment. 12 Proximal injuries tend to heal well.
Distal MCL injuries can result in entrapment by the pes anserine tendons, also known as a “Stener lesion.” This has poor healing potential; therefore, patients with distal MCL injuries may be indicated for surgical treatment.2,11
Technique Description
Meniscal Repair
Arthroscopic inspection of the knee demonstrated no cartilage damage to the medial compartment.
There was a grade 2 opening with valgus stress and a tear posteromedially at the meniscocapsular junction with erythematous posterior capsule indicative of injury.
Using a Gillquist maneuver, the posteromedial portion of the knee was visualized, demonstrating no meniscal ramp lesions.
A probe was used to test the posterior horn of the medial meniscus, and it had more anterior excursion than usual, which is another indication for repair of the meniscocapsular junction tear.
A meniscal rasp and the shaver were used to prepare the area of the tear and ensure a bleeding surface to stimulate healing.
A series of all-inside suture devices was used to repair the tear.
A probe was used to test the meniscus and the repair, and it was stable at this time.
MCL Repair
Attention was then turned toward MCL repair.
Anatomic landmarks were outlined, and fluoroscopic images were used to identify the medial epicondyle for the proximal attachment of the MCL.
On the tibia, the deep MCL attachment site was marked approximately 1 cm distal to the joint line, and the superficial MCL attachment site was marked approximately 6 cm distal to the joint line.
A 3-cm incision was made longitudinally at the distal tibial attachment of the MCL.
Dissection was carried down, and the pes anserine was identified. The MCL was identified underneath.
A 1-cm incision was made over the medial epicondyle. Dissection was carried down to the bone.
The medial epicondyle was identified, and a 1.8-mm knotless all-suture anchor was inserted slightly posterior and proximal to the medial epicondyle.
A fiber tape was passed through the loop of the femoral attachment anchor and folded onto itself, creating 2 limbs of the fiber tape.
Two 1.8-mm knotless, all-suture anchors were inserted approximately 1 cm distal to the joint line. The first anchor was placed just anterior to the deep MCL attachment, and the second was placed just posterior to the deep MCL attachment, creating a mattress construct to secure the deep MCL.
The blue repair suture from the anterior anchor was shuttled through the posterior anchor.
Then, the blue repair suture from the posterior anchor was shuttled through the anterior anchor.
Both blue repair sutures were then cinched down to establish a mattress repair of the deep portion of the MCL.
Both limbs of the femoral-sided fiber tape were shuttled underneath the fascia toward the tibial attachment site.
We carefully inspected to ensure that the tape was under the hamstring tendons.
The 2 limbs of the fiber tape were then loaded onto a 4.75-mm biocomposite knotless anchor.
A drill hole was made at the anatomic distal tibial attachment site of the MCL.
The hole was tapped, and the anchor was inserted.
When securing the fiber tape suture augmentation, the knee was positioned in neutral rotation, approximately 30° of knee flexion, and slight varus to reestablish the tension of the construct.
The knee was taken through the full range of motion. Valgus stress at 0° and 30° had a good endpoint.
Incisions were closed in a layered fashion, and a hinged knee brace was applied with the brace locked in extension.
Results
Postoperative
Postoperatively, the patient was made weightbearing as tolerated with a hinged knee brace locked in extension. He was given Aspirin, 81 mg daily, for 28 days for deep vein thrombosis prophylaxis.
Physical therapy was started at 2 weeks.
From 2 to 6 weeks, the patient was encouraged to advance his range of motion, and he was allowed to unlock his brace for ambulation at 6 weeks.
At 3 months postoperatively:
He had a symmetric range of motion compared to the contralateral side at 5° of hyperextension and 135° of flexion.
Clinically, he had symmetric quadricep and hip flexor strength compared to the contralateral extremity, but he had not yet undergone formal strength testing.
He was stable to valgus stress at 0° and 30°.
At 6 months postoperatively:
He had no tenderness at the proximal, mid, or distal MCL, and there was no tenderness at the medial or lateral joint line.
He remained stable to valgus stress at 0° and 30°.
Lachman, anterior drawer, and posterior drawer tests remained stable.
His McMurray's test was negative.
He underwent formal strength testing at physical therapy, and his quadriceps, hamstrings, hip extensors, hip abductors, and hip flexors were all within 95% to 110% of his contralateral side.
Hop testing was >94% symmetry for all tests.
Based on the patient's clinical progress, he was cleared to return to all sporting activities at this time.
Discussion/Conclusion
Technique: Implants and Location
The Fibertape is brought down to the attachment site of the proximal MCL at the medial epicondyle through a 1.8-mm knotless anchor.
The deep MCL is secured at its attachment with mattress sutures from the 1.8-mm knotless anchors.
The FiberTape is shuttled on top of the repair and secured with the sutures from the superficial MCL into a distal 4.75-mm knotless anchor.
Technique Considerations
There are multiple considerations for the surgical technique presented.
According to Gilmer et al, 4 MCL repair with suture augmentation provides greater strength than repair alone and is comparable in strength to reconstruction with allograft under biomechanical testing.
MCL repair should be tensioned at 30° of knee flexion under slight varus stress.
Suture augmentation theoretically protects the repair and provides stability while the repair heals. This may allow for accelerated rehabilitation,13,6,12,11 although this is speculative. While the biomechanical data demonstrate improved time-zero stability with suture augmentation,13,4 there have been no dedicated trials examining whether this translates to accelerated rehabilitation in isolated MCL repair with suture augmentation. More research on accelerated rehabilitation in isolated MCL injuries is warranted.
The suture augmentation must not be overtightened, as this has the potential to overconstrain the medial knee. We recommend placement of a hemostat under the suture augmentation at the time of fixation of the distal anchor to avoid overconstraint.
MCL repair with suture augmentation is indicated for acute injuries. In the chronic setting, the MCL tissue may not be amenable to direct repair.
MCL Repair Versus MCL Reconstruction
MCL repair with suture augmentation offers the advantage of no donor site morbidity while maintaining native anatomy and proprioceptive capacity. There is superior biomechanical strength compared to repair alone, with comparable strength compared to reconstruction. There are likely to be smaller implants and drill tunnels than those used in reconstruction.
Disadvantages and limitations of MCL repair with suture augmentation include the possibility of overconstraining the medial knee and the unknown long-term impact of suture augmentation on outcomes. MCL repair is not indicated in the chronic setting and may have a higher rate of stiffness and failure than reconstruction at 2 years. 10
MCL reconstruction, however, can be performed in either the acute or chronic setting, but requires the use of an allograft or an autograft. However, there is substantial variability in technique.
Footnotes
Submitted April 4, 2025; accepted July 28, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: N.S. is on the editorial or governing body of Arthroscopy; E.M. engages in other professional activities for Arthrex, Arthroscopy Association of North America, and is on the editorial or governing body of Arthroscopy; G.M. is a paid consultant for Vericel and Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
