Dataset Information

The Outside-In, Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy.

ABSTRACT: The outside-in, percutaneous release of the medial collateral ligament (MCL) is a technique used to increase the medial tibiofemoral joint space during arthroscopy to facilitate the use of instrumentation and improve visualization without causing iatrogenic cartilage damage. A recent systematic review of the literature has shown this technique to be efficacious and safe, with no evidence of associated short- or long-term complications. This technique has been used for this indication by the senior author without requiring any deviation from our institution's standard protocol for knee arthroscopy. In an attempt to standardize this technique's utilization and allow for further evaluation in the literature, the senior author's method for this percutaneous, outside-in approach of "pie crusting" the MCL is described.

SUBMITTER: Moran TE

PROVIDER: S-EPMC7093731 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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The Outside-In, Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy.

Moran Thomas E TE Demers Alex A Awowale John T JT Werner Brian C BC Miller Mark D MD

Arthroscopy techniques 20200225 3

The outside-in, percutaneous release of the medial collateral ligament (MCL) is a technique used to increase the medial tibiofemoral joint space during arthroscopy to facilitate the use of instrumentation and improve visualization without causing iatrogenic cartilage damage. A recent systematic review of the literature has shown this technique to be efficacious and safe, with no evidence of associated short- or long-term complications. This technique has been used for this indication by the seni ...[more]

PMID: 32226748

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Project description:PurposeTo quantify intraoperative joint space widening afforded by the outside-in, percutaneous release of the medial collateral ligament (MCL) and to evaluate its impact on medial compartment width and functional outcomes at 6-week follow-up for patients undergoing a partial medial meniscectomy without postoperative bracing.MethodsPatients with posteromedial meniscus tears and no evidence of ipsilateral knee pathology, undergoing partial medial meniscectomy, were enrolled. Intraoperatively, medial compartment width was quantified with fluoroscopy before and after the percutaneous MCL release with an 18-gauge spinal needle proximal to the joint line. At 6-week follow-up, valgus stress radiographs re-evaluated medial compartment width. International Knee Documentation Committee (IKDC) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores were completed preoperatively and at 6-week follow-up to evaluate functional outcomes. A paired sample t test performed at a 95% confidence interval (CI) was used to compare these variables.ResultsForty-two patients, mean (± standard deviation) age 55.3 ± 10.7 years, were available for analysis of intraoperative medial compartment widening. Medial compartment width increased from 5.95 ± 1.32 to 11.09 ± 1.74 mm intraoperatively after MCL release. At 6-week follow-up, radiographic assessment demonstrated a mean medial compartment width of 5.85 ± .99 mm, which represented an insignificant change compared with the preoperative value (CI -0.68 to .33, P = .474). PROMIS and IKDC scores significantly improved from baseline, with increases of 6.9 ± 12.4 (CI 2.0 to 11.8, P = .008) and 11.7 ± 17.8 (CI 4.7 to 18.8, P = .002), respectively.ConclusionsPercutaneous MCL release during knee arthroscopy improves visualization and facilitates instrumentation by providing an almost 2× wider working space within the medial tibiofemoral joint. In this study, the performance of percutaneous MCL release did not result in any complications. Radiographic and clinical resolution of iatrogenic laxity was demonstrated by 6-weeks postoperatively, without the use of postoperative bracing.Level of evidenceIV, therapeutic case series.

Project description:The posterior horn of the medial meniscus can be challenging to view during arthroscopy because the medial femoral condyle obstructs vision, especially in tight medial compartments. Previous studies have described techniques for improving access, one being a percutaneous medial collateral ligament (MCL) release. This technique allows for increased medial compartment space, which offloads a tight medial compartment, minimizes iatrogenic chondral injury, incomplete meniscal resection, uncontrolled MCL rupture, and allows for accurate diagnosis and management. Studies have proven the safety of the controlled percutaneous MCL release, with no significant postoperative MCL laxity on stress views, no subjective patient instability, fewer iatrogenic cartilage lesions, and no saphenous neurovascular injury. Furthermore, retrospective studies have shown improved postoperative patient-reported outcomes with a controlled percutaneous MCL release in comparison to standard of care without a release. We hypothesize that a controlled percutaneous release of the MCL effectively alleviates some of the pressure within the medial compartment, which could potentially explain the improved postoperative clinical outcomes. This technique also facilitates improved visualization, a decreased risk of iatrogenic chondral injury, and a more complete meniscal resection. The purpose of this Technical Note is to describe our surgical technique and provide surgical pearls for a controlled percutaneous MCL release during knee arthroscopy. Technique Video Video 1 We outline some of the surgical tips and techniques for a controlled percutaneous medial collateral ligament (MCL) release during knee arthroscopy through a case-based approach. First, we outline the relevant surface anatomy and the location of our adjuvant percutaneous MCL release. Next, we display our starting point on a sectioned anatomic model, showing the nearby saphenous nerve and saphenous vein, which must be avoided. In addition, we present our patient positioning and setup for the procedure, as well as our preference for portal placement. Following this, recorded arthroscopic footage of our procedure is presented. We confirm our starting point both arthroscopically and through the use of the relevant surface anatomy as described. We then perform our adjuvant percutaneous MCL release through sequential pie crusting and display the increased medial-compartment space arthroscopically. Finally, we review our group’s experience with this procedure and describe our postoperative protocol. We do not routinely use postoperative bracing.

Dataset Information

The Outside-In, Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy.

Publications

The Outside-In, Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy.

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