Medial Collateral Ligament (MCL) Reconstruction
What Is MCL Reconstruction?
The medial collateral ligament (MCL) runs from the femur to the inner side of the tibia and stabilises the knee against opening inwards (valgus). MCL reconstruction is surgery that restores the function of this ligament with a graft in injuries that exceed its healing capacity or leave lasting valgus instability.
Most MCL injuries heal with non-surgical treatment because the ligament has a good capacity to heal, so reconstruction is reserved for selected patients. For detail on the injury itself and its non-surgical treatment you can review the MCL injury page, and for the ligament structures of the knee the knee ligament tear page.
Who Is a Candidate, and Who Is Not?
The decision for surgery rests not on the MRI alone but on ongoing instability, the location of the injury and any accompanying ligament damage. Surgery is generally considered in the following situations:
- Valgus instability that persists despite non-surgical treatment and affects daily life and sport.
- Severe (high-grade) tears and certain injury patterns, such as the MCL avulsing from bone, that are unfavourable for healing.
- Multiligament injuries in which the ACL or PCL is also injured.
In isolated MCL injuries that are favourable for healing, non-surgical treatment is the first option. Planning is different in multiligament injuries; for detail you can review the multiple ligament knee reconstruction page.
Preparing for Surgery
Before surgery, the swelling in the knee is reduced and range of motion and muscle strength are restored as far as possible; this lowers the risk of stiffness afterwards. A detailed examination, X-rays and MRI clarify the location and grade of the injury and any accompanying damage.
The graft options, the risks and the rehabilitation process are discussed beforehand. Blood-thinning medication, smoking and general health are reviewed so the plan can be individualised.
Repair or Reconstruction?
There are two main approaches in MCL surgery, and the choice depends on the type and timing of the injury.
- Repair (and augmentation): in suitable, usually acute injuries where the ligament has avulsed from bone, the torn ligament is reattached with sutures and anchors; the repair may be supported with a graft or suture tape when needed.
- Reconstruction: in chronic instability, or when the tissue quality is not suitable for repair, the ligament is rebuilt with a graft (usually the patient's own tendon) and fixed at the anatomical attachment points with screws or anchors.
The graft can come from the patient's own tissue (autograft) or from a tissue bank (allograft). The choice is individualised to age, activity level, accompanying ligament injuries and any previous surgery. The aim is to reproduce the anatomical attachment points and tension of the MCL as closely as possible.
Anaesthesia and the Operation
The operation is performed under general or regional anaesthesia; nerve blocks may be added for pain control. Through an incision on the inner side of the knee the attachment points of the ligament are reached, the graft or repair is prepared, and the knee is fixed with the tension set at an appropriate angle.
Because an MCL injury is often accompanied by an ACL, PCL or meniscus injury, procedures for these structures may be addressed in the same session. In that case the operating time and rehabilitation plan are shaped accordingly.
The First Period After Surgery
In the early period the knee is usually protected in a hinged brace; weight-bearing and range of motion progress gradually according to the procedure performed and any accompanying repairs. Controlling swelling and pain and early, controlled movement are the priorities of this period.
The angle allowed by the brace and the amount of weight-bearing are increased over time. Protection against clots related to immobility is also managed according to the doctor's plan.
Rehabilitation and Return to Sport
Physiotherapy begins early after surgery and the programme is individualised. It proceeds roughly in three phases:
- Early phase: controlling swelling and pain, regaining range of motion and activating the thigh muscles.
- Middle phase: gradually opening the brace, increasing weight-bearing and balanced strengthening.
- Advanced phase: a controlled return to activity with running, change of direction and sport-specific work.
Return to sport is guided by criteria rather than a fixed date: pain-free full range of motion, muscle strength close to the other leg, stability against valgus stress and controlled hop-and-landing quality. Reaching these criteria takes longer after multiligament surgery, and no fixed timeframe is promised.
Risks and Factors That Affect the Outcome
MCL surgery is generally safe; nevertheless, as with any surgery, certain risks are kept in mind: infection, bleeding, joint stiffness, an inadequate graft or repair, ongoing instability and, rarely, nerve or blood-vessel problems.
The outcome is shaped by the type and chronicity of the injury, accompanying ligament and meniscus damage, leg alignment, the graft choice and, above all, the patient's adherence to rehabilitation. Expectations and limitations are therefore discussed openly before surgery.
When Should You See a Doctor?
Some symptoms after a knee injury call for surgical assessment, and some symptoms after surgery are urgent.
- Pain on the inner side of the knee and a sense of it opening or giving way persist despite non-surgical treatment.
- The knee locks, swells markedly or feels unreliable.
- After surgery, increasing pain, fever, drainage from the wound or one-sided calf swelling should be assessed without delay.
For the assessment and treatment of knee ligament injuries you can contact Assoc. Prof. Serkan Sürücü, and you can also review the other conditions covered within knee surgery.