MCL surgery has always been a challenge and during my training we used a lot of autograft or donor graft and although we got reasonable results with this, it often involved large incisions, bracing patients for a prolonged period of time, and was a very painful, prolonged process to recover from MCL surgery, there was often a lot of muscle waste associated with it, it was a challenge operation that surgeons tended to avoid, and if you could get away without treating an MCL you would do.

My thinking evolved from some of my mentors, who were gradually switching over to various forms of synthetics, but still, the recovery was slow with the large incisions and the impact on the nerves on the medial side of the knee, and I've always been very anti-bracing. If we can get patients moving sooner, the results are always better.

That's where my evolution to develop less traumatic ways of reconstructing the MCL came about, and I was in the process of doing this when, about 5-6 years ago, I came across the Infinity-Lock range, and I thought this is perfect for what I am thinking about doing. And so I did work with Xiros, we did some basic mechanical testing to see if the concept of what I was looking at worked, and then we put that into clinical practice, and I've been doing it ever since, for the last 6 years, and we've modified the technique and evolved it. Now we're at the stage where most MCL operations are 15/20-minute operations, and the patients are not braced, so we can get them moving immediately. What I've found as a result of that is that there are much lower rates of stiffness, you barely have to do any manipulations, and the return to sport has become much more predictable for patients.

I have been very pleased with the evolution.

I think the benefits for the patient of using synthetics are that you're not taking your own tissue, and that lowers your morbidity immediately. It is a strong, solid fixation to start with, so you can commence the early mobilisation and particularly in relation to MCL, it is really important in terms of maintaining muscle control and keeping function.

We've been recording all our results ever since we started, we've got very good data on how patients have been doing, and hopefully that will be published over the next 6-months or so. 

What I have found is that the return to sport is a lot more predictable, the failure rates have been exceptionally low, and the complication rate on the whole have been exceptionally low compared to more traditional open techniques and using autografts, where there is a higher rate of the grafts loosening.

Surgery is all about being accurate and knowing your anatomy, so my advice is always make sure your positioning of any synthetic or autograft you use is very precise, understand the anatomy that you're dealing with and ensure you get as close to isometry as possible with the ligaments that are isometric. That would be my big tip.

There is always a concern with synthetics about over-constraining, that has not really been an issue in my practice with MCL surgery, but is something you should be conscious of when you start using it.

In my view, synthetics are very safe for extra-articular reconstructions; they've been used for a long time for PCL reconstruction, posterolateral reconstructions and MCL surgery.

I really have no concerns at all about using it for those reconstructions. 

There is growing data on the use of synthetics for ACL reconstruction as well, but that is something that will be down to the individual surgeon to feel if it is appropriate for their practice.

I think synthetics have had a bad name in the UK, some for very good reasons, and some for not very good reasons.

What we're seeing from the new generation of synthetics and how we're applying them and how we're using them, is that the results are very good in general