1
|
Dayal D, Zalikha AK, El-Othmani MM. Evaluating the optimal management strategy for intraoperative iatrogenic injury to the medial collateral ligament during primary total knee arthroplasty: A systematic review. Knee 2024; 48:138-149. [PMID: 38642540 DOI: 10.1016/j.knee.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/27/2024] [Accepted: 03/18/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Intraoperative iatrogenic MCL injuries during primary TKA are rare complications that lack a gold standard management protocol. This review aims to provide insight into various treatment modalities and evidence-based guidance for improved patient outcomes. METHODS A comprehensive search across five databases identified relevant randomized control trials and retrospective cohort studies with reported outcomes. A total of 17 studies were included, and variables such as patient demographics, injury type, management, and Knee Society Scores (KSS) were assessed. The quality of included studies was evaluated using the Critical Appraisal Skills Programme tool. RESULTS Mean age of included patients ranged from 60.0 to 71.4 years. The mean Body Mass Index ranged from 26.75 to 34.40 kg/m2. Among the included knees, 298 were categorized as MCL avulsion, and 167 as midsubstance/transection injuries. Primary repair with sutures or bone staples emerged as the most common management. Intraoperative MCL injury was correlated with reduced preoperative range of motion (ROM) and postoperative KSS clinical, functional, and pain scores compared to control groups. Postoperative ROM was comparable between MCL injury and control groups, ranging from 100.0° to 130.0° and 107.0° to 130.0°, respectively. CONCLUSION Current evidence supports primary repair as the preferred management for this complication. Factors such as extent of the tear, type of injury, and the surgeon's experience also help to guide treatment. While treatment modalities like allograft or autograft reconstruction show promise, further research with larger sample sizes is needed to enhance future outcomes.
Collapse
Affiliation(s)
- Dev Dayal
- Michigan State University College of Osteopathic Medicine, Detroit, MI, USA
| | - Abdul K Zalikha
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI, USA.
| | - Mouhanad M El-Othmani
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| |
Collapse
|
2
|
Aberman Z, Germano J, Scuderi GR. Intraoperative Medial Instability During Total Knee Arthroplasty. Orthop Clin North Am 2024; 55:61-71. [PMID: 37980104 DOI: 10.1016/j.ocl.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
A review article summarizes the existing literature on intraoperative injury to medial collateral ligament (MCL) during total knee arthroplasty (TKA), methods of fixation, repair, and the outcomes after these injuries. The options for increasing implant constraint and repair of the MCL injury are discussed with the potential indications for each. There is also a review of risk factors for MCL injury during TKA to help anticipate potential issues preoperatively. The proper use of retractors during total knee replacement is also discussed with a focus on careful protection of the MCL during surgery.
Collapse
Affiliation(s)
| | - James Germano
- Long Island Valley Stream Hospital Northwell Health, Valley Stream, NY, USA
| | - Giles R Scuderi
- Department of Orthopaedic Surgery, Lenox Hill, New York, NY, USA.
| |
Collapse
|
3
|
Frisch NB, Keller RA, Mueller JKP, Bandi M, Snethen KG. Treatment of Medial Collateral Ligament Injury During Total Knee Arthroplasty With Internal Suture Brace Augmentation: A Cadaveric and Biomechanical Study. Orthopedics 2022; 45:e269-e275. [PMID: 35485886 DOI: 10.3928/01477447-20220425-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intraoperative medial collateral ligament (MCL) injury during total knee arthroplasty (TKA) is a serious complication. External bracing and/or conversion to a constrained implant has previously been studied. The technique of using an internal high-strength suture brace to augment an MCL repair has been evaluated in the nonarthroplasty patient and could provide an alternate solution. The goal of this study was to determine whether MCL repair with internal suture bracing restores stability of the implanted knee joint. A robotic simulator completed laxity testing on 5 cadaveric knee specimens in 4 sequential phases: (1) intact knee, (2) after implantation with TKA, (3) after sectioning of the MCL, and (4) after MCL repair with suture brace augmentation. Laxity was compared between the different test phases throughout range of motion. Subsequently, the internal brace was tested to failure under valgus load. The MCL repair with internal bracing was effective at restoring laxity in varus-valgus, internal-external, and medial-lateral degrees of freedom through midflexion, with limited support at deeper flexion angles and in anterior-posterior laxity. Rotational laxity was not significantly different than intact knee laxity. Generally, medial-lateral translations were less and anterior-posterior translations were greater and were significantly different at 30° to 45° and 90°, respectively. The mean failure moment was 46.4±9.1 Nm, with the primary mode of failure being MCL repair. Primary MCL repair with internal bracing using a high-strength suture augment showed the potential to provide adequate stability and strength to correct MCL incompetence in TKA without the use of an external knee brace or constrained implants. [Orthopedics. 2022;45(5):e269-e275.].
Collapse
|
4
|
Kerzner B, Swindell HW, Terhune EB, Ramos P, Fortier LM, Dasari SP, Khan ZA, Gursoy S, Cancienne J, Chahla J. Medial Collateral Ligament and Posterior Oblique Ligament Reconstruction for Valgus Instability After Total Knee Arthroplasty. Arthrosc Tech 2022; 11:e1531-e1539. [PMID: 36185120 PMCID: PMC9519797 DOI: 10.1016/j.eats.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/19/2022] [Indexed: 02/03/2023] Open
Abstract
Medial collateral ligament (MCL) injuries are typically managed non-operatively, with high rates of clinical success. However, patients who present with medial knee laxity with valgus stress testing of a fully extended knee, anteromedial rotatory instability, associated tibial plateau fracture, or multiligament injury or those who continue to be symptomatic after non-operative treatment may benefit from surgical intervention. Patients with a history of total knee arthroplasty who suffer MCL and posterior oblique ligament (POL) injuries represent a challenging patient population and often require surgical attention. In this Technical Note, we describe the preoperative assessment, decision making, and surgical technique for anatomic reconstruction of the superficial MCL and POL with an Achilles allograft in young, active patients with medial-sided knee injuries after total knee arthroplasty.
Collapse
Affiliation(s)
- Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Hasani W. Swindell
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Elizabeth B. Terhune
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Pablo Ramos
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Luc M. Fortier
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Suhas P. Dasari
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Safa Gursoy
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Jourdan Cancienne
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A,Department of Orthopaedic Surgery, Rush University Medical Center, CChicago, Illinois, U.S.A,Address correspondence to Jorge Chahla, M.D., Ph.D., Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St, Suite 300, Chicago, IL 60612, U.S.A.
| |
Collapse
|
5
|
Sun C, Rong W, Du R, Wu S, Liu P, Zhang W, Cai X. Meniscus Graft Augmentation for a Midsubstance Tear of the Medial Collateral Ligament during Total Knee Arthroplasty. J Knee Surg 2022; 35:449-455. [PMID: 32838462 DOI: 10.1055/s-0040-1715115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Multiple surgical techniques exist to repair iatrogenic medial collateral ligament (MCL) injury during total knee arthroplasty (TKA). The objective of the study is to confirm the clinical effectiveness of meniscus transfer for treatment of iatrogenic MCL midsubstance transection in which remaining MCL is of poor quality, and there is a persistent gap between both ligament ends during TKA. From January 2015 to November 2019, we treated 11 patients with MCL injuries of 882 primary TKAs by meniscus transfer. Another 24 primary TKAs were recruited as a control group. The two groups of patients were comparable for age, gender, body mass index (BMI), Knee Society scoring (KSS), knee function score (KFS), and type of prosthesis comparison without significant difference (p > 0.05). We reviewed the patient's stability, as well as objective measures such as KSS and KFS scores, physical examinations, and radiographs. No patient of either group reported impaired wound healing, joint instability on physical examination, pain, radiographic changes, signs of loosening, and other complications. At the final follow-up, there was no significant difference in terms of KSS (p = 0.780) and KFS (p = 0.612) between the injury group and control group at last follow-up. X-ray image review showed no prosthesis loosening or subsidence for both groups. Based on these results, we are cautiously optimistic that midsubstance transections in which the quality of remaining tendon is weak, there is suspicion of stretching, or there is a persistent gap between both ligament ends that can be reconstructed with meniscus autograft transfer augmentation and an unconstrained implant.
Collapse
Affiliation(s)
- Changjiao Sun
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Wei Rong
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Ruiyong Du
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Sha Wu
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Pu Liu
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Wei Zhang
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| | - Xu Cai
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Dongxiaokou Town, Changping District, Beijing, People's Republic of China
| |
Collapse
|
6
|
Li J, Yan Z, Lv Y, Li Y, Ye P, Deng P, Zhang H, Chen J, Li J, Qi X, Zeng J, Zeng Y, Feng W. Impact of intraoperative medial collateral ligament injury on outcomes after total knee arthroplasty: a meta-analysis and systematic review. J Orthop Surg Res 2021; 16:686. [PMID: 34801058 PMCID: PMC8605566 DOI: 10.1186/s13018-021-02824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND As an uncommon but severe complication, medial collateral ligament (MCL) injury in total knee arthroplasty (TKA) may be significantly under-recognized. We aimed to determine whether MCL injury influences postoperative outcomes of patients undergoing TKA. METHODS Two independent reviewers searched PubMed, Cochrane Library, and EMBASE from their inception to July 1, 2021. The main outcomes were postoperative function, and secondary outcomes included the incidences of revision and complications. RESULTS A total of 403 articles yielded 15 studies eligible for inclusion with 10 studies used for meta-analysis. This study found that there was a statistically significant difference in postoperative functional scores, range of motion (ROM), complications, and revision rates, with adverse outcomes occurring more commonly in patients with MCL injury. CONCLUSIONS This meta-analysis highlights the complexity of MCL injury during TKA and shows the impact on postoperative function, joint mobility, complications, and revision. Surgeons need to prevent and put more emphasis on MCL injury during TKA.
Collapse
Affiliation(s)
- Jiahao Li
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Zijian Yan
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Yan Lv
- The First Affiliated Hospital of Nanchang University, 17 Yongwai Street, Nanchang, 330006, China
| | - Yijin Li
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Pengcheng Ye
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Peng Deng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Haitao Zhang
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Jinlun Chen
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Xinyu Qi
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
| |
Collapse
|
7
|
Motififard M, Sheikhbahaei E, Piri Ardakani M, Cheraghsahar H, Shahzamani A. Intraoperative repair for iatrogenic MCL tear due to medial pie-crusting in TKA yields satisfactory mid-term outcomes. Knee Surg Sports Traumatol Arthrosc 2021; 29:3246-3253. [PMID: 32613338 DOI: 10.1007/s00167-020-06126-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/24/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE This study aimed to assess the rate of iatrogenic mid-substance superficial medial collateral ligament (sMCL) tear due to the medial pie-crusting technique during varus deformity total knee arthroplasty and compare the knee society score (KSS), range of motion (ROM), and instability rate of the repaired group to the control group with intact sMCL. METHODS For this retrospective series of prospectively collected data, the multiple needle puncturing technique was performed for 653 out of the 1768 knees during algorithmic medial soft-tissue release. Iatrogenic tear was observed in 35 knees (5%); hence, repair with running locking nonabsorbable braided suture was performed. Patients were visited and reviewed both clinically and radiographically at 6 weeks, 3 months, 6 months, 12 months, and annually thereafter. Chi-square, ANOVA, Mann-Whitney, independent and paired t test were used to analyze the variables. P value < 0.05 was considered statistically significant. RESULTS 85% of the repaired sMCL had stable joints with a mean KSS of 88 ± 3 and a mean ROM of 103 ± 11 degrees (°). The other five patients (15%) with mean KSS of 40 ± 8 and mean ROM of 81° ± 5° had an instability and needed to undergo a revision surgery. The control group had a mean KSS of 86 ± 15 and mean ROM of 107° ± 8°; however, 7 knees had an instability and needed a revision surgery. No significant difference was observed in terms of KSS (P = 0.86) and ROM (P = 0.64) between the control and repaired groups. CONCLUSION The mid-substance sMCL tear is an important intraoperative complication of medial pie-crusting. Repairing this iatrogenic tear with nonabsorbable suture had satisfying clinical outcomes regarding the postoperative knee ROM and KSS in comparison to the control group. However, there is a chance of failure, which should be perceived by the surgeons. LEVEL OF EVIDENCE Therapeutic studies, investigating the results of treatment, Level III.
Collapse
Affiliation(s)
- Mehdi Motififard
- Orthopedic Surgery Department, School of Medicine, Kashani University Hospital, Isfahan University of Medical Sciences, Kashani St. Felezi Br., Isfahan, Iran
| | - Erfan Sheikhbahaei
- Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Piri Ardakani
- Orthopedic Surgery Department, School of Medicine, Kashani University Hospital, Isfahan University of Medical Sciences, Kashani St. Felezi Br., Isfahan, Iran.
| | - Hojat Cheraghsahar
- Orthopedic Surgery Department, School of Medicine, Kashani University Hospital, Isfahan University of Medical Sciences, Kashani St. Felezi Br., Isfahan, Iran
| | - Arvin Shahzamani
- Student Research Committee, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
8
|
Rajkumar N, Soundarrajan D, Dhanasekararaja P, Rajasekaran S. Influence of Intraoperative Medial Collateral Ligament Bony Avulsion Injury on the Outcome of Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:1284-1294. [PMID: 33229070 DOI: 10.1016/j.arth.2020.10.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/17/2020] [Accepted: 10/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is (1) to find the clinical and radiological outcome of intraoperative bony avulsion of medial collateral ligament (MCL) treated with screw and washer construct and (2) to predict the preoperative factors which may contribute to the avulsion-type MCL injury during primary total knee arthroplasty (TKA). METHODS Intraoperative MCL avulsion injury occurred in 46 (0.8%) of the 4916 consecutive primary TKA from January 2011 to December 2015. After exclusion, the 41 knees were matched 1:2 with controls without MCL injury and compared for the various clinical, radiological, and functional parameters. The clinical parameters analyzed were age, gender, body mass index, preoperative diagnosis like osteoarthritis or rheumatoid arthritis, range of motion, sagittal deformity, and vitamin D levels. The radiological parameters calculated were coronal deformity, proximal tibial varus angle, distal femur valgus angle, joint line congruence angle, posterior tibial slope, "cup and saucer" morphology, presence or absence of knee subluxation, tibia vara, and femoral bowing. The preoperative and postoperative Knee Society Score and Knee Society Functional Score were analyzed. Complications or revisions, if any, were noted during the follow-up. Multivariate logistic regression analysis was used to predict the preoperative risk factors for MCL avulsion injury. RESULTS At a mean follow-up of 58.4 ± 19.3 months, there were no radiological or physical examination findings of instability. Compared to the preoperative disability, there was a statistically significant improvement in clinical scores (Knee Society Score and Knee Society Functional Score) in the final follow-up (P < .001) in both cases and the control group. The mean preoperative coronal deformity was 170.6 ± 6.96 in the study group and 167.7 ± 4.3 in the control group (P = .021). The mean preoperative tibial slope was 10.5 ± 4.9 in the study group and 7.91 ± 4.15 in the control group (P = .003). The preoperative knee subluxation was present in 48.8% knees (P < .001) and "cup and saucer" morphology in 68.3 knees (P < .001) in the study group. The adjusted odds of MCL avulsion injury were greater for severe varus deformity (odds ratio [OR] 1.462, 95% confidence interval [CI] 1.15-1.86), knee subluxation (OR 39.78, 95% CI 3.78-418.86), and "cup and saucer" morphology (OR 33.11, 95% CI 5.69-192.66). CONCLUSION Intraoperative MCL bony avulsion injury can be managed successfully with screw and washer construct without the need for increased prosthetic constraint in primary TKA. The presence of severe varus deformity, knee subluxation, and "cup and saucer" morphology tend to have an increased chance of MCL avulsion injury.
Collapse
|
9
|
Zhang B, Du Y, Sun J, Shen J, Li T, Zhou Y. [Prevention and treatment of iatrogenic medial collateral ligament injuries in total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:14-19. [PMID: 33448193 DOI: 10.7507/1002-1892.202004126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the prevention and treatment of iatrogenic medial collateral ligament (MCL) injuries in total knee arthroplasty (TKA). Methods The relevant literature about iatrogenic MCL injuries in TKA was summarized, and the symptoms, causes, preventions, and treatments were analyzed. Results Preventions on the iatrogenic MCL injuries in TKA is significantly promoted. With the occurrence of MCL injuries, the femoral avulsion can be fixed with the screw and washer or the suture anchors; the tibial avulsion can be treated with the suture anchors fixation, bone staples fixation, or conservative treatment; the mid-substance laceration can be repaired directly; the autologous quadriceps tendon, semitendinosus tendon, or artificial ligament can be used for the patients with poor tissue conditions or obvious residual gap between the ligament ends; the use of implant with greater constraint can be the last alternative method. Conclusion No consensus has been reached to the management of iatrogenic MCL injuries in TKA. Different solutions and strategies can be integrated and adopted flexibly by surgeons according to the specific situation.
Collapse
Affiliation(s)
- Bohan Zhang
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China;Medical School of Chinese PLA, Beijing, 100853, P.R.China
| | - Yinqiao Du
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Jingyang Sun
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Junmin Shen
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Tiejian Li
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| | - Yonggang Zhou
- Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China
| |
Collapse
|
10
|
Ni M, Sun JY, Fu J, Du YQ, Shen JM, Yang XX, Zhou YG, Zhang GQ, Chen JY. Management of Medial Collateral Ligament Insufficiency During Total Knee Arthroplasty with a Screw and Rectangular Spiked Washer: A Case Series of 14 Patients. Orthop Surg 2020; 12:1784-1791. [PMID: 33063440 PMCID: PMC7767681 DOI: 10.1111/os.12818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 08/23/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To describe the technique of primary repair of medial collateral ligament (MCL) insufficiency using a screw and rectangular spiked washer in a case series of 14 patients. Methods Fourteen patients undergoing MCL repair by a screw and rectangular spiked washer during TKA between March 2018 and March 2019 were retrospectively reviewed. Among them, half injuries were avulsion of the femoral origin, and the other half were MCL laxity. There were 12 women and two men included in the study, with an average age of 63.6 years (range, 49–79 years) at the time of surgery. This series were followed up with a focus on range of motion (ROM), coronal alignment, Hospital for Special Surgery (HSS) knee scores, their subjective sense of joint instability, and related complications. At the last follow‐up, function of the MCL was assessed by manually applying a valgus stress to the knee at both 0° and 30° of knee flexion. Results The mean follow‐up time for all patients was 15.6 months (range, 13–20 months). Repair of the MCL was successful in all patients. ROM improved from a mean of 70.7° ± 35.1° before surgery to 103.9° ± 6.8° at latest follow‐up (P = 0.001). All patients were able to perform a half squat easily, but none were able to do full squatting. The mean preoperative HSS score was 43.6 ± 13.4 and increased to a mean of 85.6 ± 3.8 postoperatively (P < 0.001). The femorotibial angle improved from a mean of −3.22° ± 9.47° before surgery to a mean of 5.16° ± 3.14° at the final follow‐up (P = 0.006). At the time of final follow‐up, no patient required revision and manipulation under anesthesia following the index arthroplasty. No radiolucencies or migration were observed in association with the knee prostheses. No displacement of the screw and rectangular spiked washer was found. There were no clinical complications. No patient reported subjective instability of the knee. Upon physical examination, no patient was found to have laxity in the coronal plane in either 30° of flexion or full extension. Conclusions The screw and rectangular spiked washer is a simple and effective method for treating MCL sufficiency in TKA, and a study with a larger cohort and extended follow‐up is requisite to claim its role in preventing coronal instability and component failure.
Collapse
Affiliation(s)
- Ming Ni
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing-Yang Sun
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yin-Qiao Du
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun-Min Shen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,Medical School of Nankai University, Tianjin, China
| | - Xiao-Xi Yang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China.,Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Yong-Gang Zhou
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guo-Qiang Zhang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ji-Ying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
11
|
The Medial Collateral Ligament in Primary Total Knee Arthroplasty: Anatomy, Biomechanics, and Injury. J Am Acad Orthop Surg 2020; 28:e510-e516. [PMID: 32097134 DOI: 10.5435/jaaos-d-19-00355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Understanding the anatomy and biomechanics of the medial collateral ligament (MCL) is crucial in producing good outcomes after total knee arthroplasty. A solid grasp of the surgical techniques that address the MCL are necessary to ensure good coronal plane ligament balance. Furthermore, intraoperative injury to the MCL in total knee arthroplasty is an uncommon yet serious complication which often goes unrecognized. Loss of the integrity of the MCL can lead to instability, loosening, and accelerated polyethylene wear. There is still controversy regarding the ideal method of treatment of intraoperative MCL injuries with suggested treatment modalities ranging from conservative management to use of varus-valgus constrained implants.
Collapse
|
12
|
Wang X, Liu H, Cao P, Liu C, Dong Z, Qi J, Wang F. Clinical outcomes of medial collateral ligament injury in total knee arthroplasty. Medicine (Baltimore) 2017; 96:e7617. [PMID: 28746219 PMCID: PMC5627845 DOI: 10.1097/md.0000000000007617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED Intraoperative injury to the medial collateral ligament (MCL) during total knee arthroplasty (TKA) is a rare but severe complication. The main treatment methods are primary repair and revision with a more constrained implant; however, the clinical outcomes of primary reconstruction without a constrained implant have rarely been reported.A retrospective study was performed to evaluate the prevalence of iatrogenic injury to the MCL during primary TKA, and to report the clinical outcomes of MCL reconstruction without the use of a constrained device.A total of 1749 patients (2054 knees) underwent primary TKA between 2007 and 2013 and were retrospectively evaluated. Seventeen patients (0.83%) experienced an MCL injury intraoperatively, and the remaining 1732 patients (2037 knees) were considered as the controls. We attempted to reconstruct the MCL with an unconstrained prosthesis in all patients. The Knee Society Score (KSS) was used to evaluate knee function after an average 51-month follow-up (range, 36-72 months).No patients were lost during the follow-up period. In the MCL injury group, the mean KSS was 84.7 for function and 87.7 for pain, while the scores were 87.9 and 90.6, respectively, in the control group. No patient treated with MCL reconstruction without increased prosthetic constraint experienced knee instability requiring revision.MCL reconstruction without a constrained implant achieved excellent results for MCL injury during TKA. LEVEL OF EVIDENCE Level IV, therapeutic study.
Collapse
|
13
|
Tsubosaka M, Matsumoto T, Takayama K, Nakano N, Kuroda R. Two cases of late medial instability of the knee due to hip disease after total knee arthroplasty. Int J Surg Case Rep 2017; 37:200-204. [PMID: 28704747 PMCID: PMC5508621 DOI: 10.1016/j.ijscr.2017.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There are few specific reports of late medial instability after total knee arthroplasty (TKA). We described two cases of late medial instability of the knee due to hip disease with osteoarthritis or rheumatoid arthritis after TKA, which required revision TKA. PRESENTATION OF CASES An 82-year-old woman experienced right femoral neck fracture due to a fall that required conservative treatment at age 77 years and underwent left TKA at age 80 years. A 68-year-old woman underwent left TKA at age 54 years, right TKA at age 64 years, and left THA at age 67 years. Both cases required revision TKA with constrained knee prostheses due to the severe medial instability. Hip-knee-ankle (HKA) angle, range of motion (ROM), Knee Society score (KSS) and functional score (FS) were evaluated pre- and postoperatively. Their respective HKA angle improved from 134° and 155° preoperatively to 184° and 179° postoperatively. KSS improved from -4 and 53 points to 59 and 100 points, respectively. FS improved from -10 and 58 points to 25 and 90 points, respectively. In the 82-year-old woman, ROM did not improve from -10-90° to -20-90°. On the other hand, in the 68-year-old woman, ROM improved from 0-110° to 0-125°. The late medial instability in the current case report was partly due to a similar mechanism underlying the long leg arthropathy and coxitis knee caused by hip joint degeneration. CONCLUSIONS Constrained prostheses were applied for both patients, providing moderately good short-term results.
Collapse
Affiliation(s)
- Masanori Tsubosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Koji Takayama
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Naoki Nakano
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| |
Collapse
|
14
|
Wierer G, Runer A, Hoser C, Gföller P, Fink C. Anatomical MCL reconstruction following TKA. Knee 2016; 23:911-4. [PMID: 27396812 DOI: 10.1016/j.knee.2016.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/22/2016] [Accepted: 06/15/2016] [Indexed: 02/02/2023]
Abstract
Adequate ligament balancing has a tremendous impact on successful total knee arthroplasty. In case of instability, severely disabling symptoms require revision surgery. Here we present a case of early total knee arthroplasty failure due to secondary valgus laxity, which was successfully treated with medial collateral ligament (MCL) reconstruction. For anatomical MCL reconstruction, a flattened semitendinosus autograft was used to reconstruct the superficial medial collateral and the posterior oblique ligament.
Collapse
Affiliation(s)
- Guido Wierer
- Department of Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Armin Runer
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Christian Hoser
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Peter Gföller
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Christian Fink
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria; Research Unit for OSMI, UMIT/ISAG, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
| |
Collapse
|
15
|
Primary Repair of Iatrogenic Medial Collateral Ligament Injury During TKA: A Modified Technique. J Arthroplasty 2015; 30:854-7. [PMID: 25618812 DOI: 10.1016/j.arth.2014.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/04/2014] [Accepted: 12/30/2014] [Indexed: 02/01/2023] Open
Abstract
Intraoperative injury to the medial collateral ligament (MCL) is a rare but important complication of total knee arthroplasty (TKA). While described treatment methods are mainly primary repair and revision with a more constrained implant, a few studies have investigated the outcomes of primary repair without constrained implants. A retrospective study was performed to evaluate the prevalence of iatrogenic injury to the MCL during primary TKA and determine the clinical outcomes of MCL repair augmented with synthetic material without the use of a constrained device. The incidence of intraoperative tear of the MCL was 0.43% (15/3432). No patient demonstrated instability during the follow-up period. Primary repair of iatrogenic MCL injury without the use of constrained implants appears to be a potential alternative that warrants further investigation.
Collapse
|
16
|
Ligament reconstruction/advancement for management of instability due to ligament insufficiency during total knee arthroplasty: a viable alternative to constrained implant. J Orthop Sci 2014; 19:564-70. [PMID: 24771137 DOI: 10.1007/s00776-014-0564-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/26/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND We aimed to assess the results of ligament reconstruction/advancement for the management of ligament insufficiency during total knee arthroplasty. METHOD We retrospectively reviewed the results of ligament reconstruction/advancement for management of instability due to ligament insufficiency during total knee arthroplasty (TKA). Between January 2001 and January 2008 collateral ligament reconstruction/advancement was done in 15 patients. Wherever ligament advancement was not possible (mid-substance tear) ligament reconstruction was done using the hamstring tendon. Knee society scores were calculated and Kaplan-Meier survival analysis was done. RESULTS Average follow-up was 6.2 years. No patient developed instability until the last follow-up, except one patient who required revision due to instability at six years after primary surgery. CONCLUSION We concluded from this study that ligament reconstruction/advancement during TKA is a viable option to address instability due to ligament insufficiency.
Collapse
|
17
|
Stephens S, Politi J, Backes J, Czaplicki T. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics 2012; 35:e154-9. [PMID: 22310399 DOI: 10.3928/01477447-20120123-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intraoperative midsubstance lacerations of the medial collateral ligament (MCL) must be addressed during surgery, and failure to obtain coronal plane stability could affect patient outcomes and satisfaction. This article reports our results of a series of patients who sustained an intraoperative MCL injury during a primary total knee arthroplasty and were treated by direct primary repair and no change in implant constraint or postoperative protocol. Over a 5-year period, 9 patients sustained this complication. We reviewed their subjective satisfaction and stability, as well as objective measures such as functional scores, physical examinations, and radiographs. Average patient age was 58 years, and mean patient body mass index was 43.3. All patients were satisfied with the procedure and demonstrated no instability on physical examination. Average Knee Society pain score was 91.5 and functional score was 73.3. No radiographic changes or signs of loosening were noted. This novel approach for intraoperative midsubstance lacerations of the MCL does not involve altering implants or postoperative protocols and has encouraging results.
Collapse
|
18
|
Abstract
BACKGROUND Intraoperative injuries to the medial collateral ligament are often unrecognized and failure to appropriately manage ligament loss may result in knee instability and loosening. QUESTIONS/PURPOSES We compared the functional scores in patients with iatrogenic injury to the medial collateral ligament (MCL) treated with additional constraint to those without. METHODS We retrospectively reviewed the records of all 1478 patients (1650 knees) who underwent primary TKA between 1998 and 2004. Thirty-seven patients (2.2%) had recognized intraoperative injury to the MCL; the remaining 1441 patients (1613 knees) served as controls. We attempted to repair the ligament in 14 patients; increased prosthetic constraint over that planned was used in 30 of the 37 patients. We determined Knee Society scores (KSS) in all patients. Three patients were lost to followup. The minimum followup was 36 months (average, 54 months; range, 36-120 months). RESULTS The mean KSS for all MCL injury knees for pain and function averaged 81 and 74 points, respectively, compared with 91 and 87 for the control group. However, in the 30 knees in which the MCL insufficiency was treated with increased constraint, the mean scores for pain and function increased to 88 and 83 points, respectively. Four of the seven patients treated without increased prosthetic constraint were revised for instability; no revisions for instability were performed in the 37 patients treated with additional constraint. CONCLUSIONS Recognition of MCL injury during TKA is crucial, since using nonstabilizing inserts was associated with residual instability requiring revision. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104 USA
| | - Paul A. Lotke
- Department of Orthopaedic Surgery, University of Pennsylvania, 1 Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104 USA
| |
Collapse
|