Prevention and treatment of iatrogenic medial collateral ligament injuries in total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Bohan ^1,2 , DU Yinqiao ¹ , SUN Jingyang ¹ , SHEN Junmin ¹ , LI Tiejian ¹ ,  ZHOU Yonggang ¹

1. Department of Orthopedics, the First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, P.R.China;
2. Medical School of Chinese PLA, Beijing, 100853, P.R.China;

Corresponding author：

ZHOU Yonggang, Email: zhouyg@263.net

Keywords：

Total knee arthroplasty; medial collateral ligament; iatrogenic injury; prevention and treatment

DOI：

10.7507/1002-1892.202004126

Video：

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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.

Citation： ZHANG Bohan, DU Yinqiao, SUN Jingyang, SHEN Junmin, LI Tiejian, ZHOU Yonggang. Prevention and treatment of iatrogenic medial collateral ligament injuries in total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(1): 14-19. doi: 10.7507/1002-1892.202004126 Copy

1.	Stephens S, Politi J, Backes J, et al. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics, 2012, 35(2): e154-159.
2.	Torre DP, Stephens A, Oh LH, et al. Management of medial collateral ligament injury during primary total knee arthroplasty: a systematic review. Reconstructive Review, 2014, 4(2): 17-23.
3.	Wang XM, Liu HX, Cao PK, et al. Clinical outcomes of medial collateral ligament injury in total knee arthroplasty. Medicine (Baltimore), 2017, 96(30): e7617.
4.	Choi YJ, Lee KW, Seo DK, et al. Conservative management after intraoperative over-release of the medial collateral ligament from its tibial insertion site in patients undergoing total knee arthroplasty. J Knee Surg, 2018, 31(8): 786-791.
5.	Jin C, Zhao JY, Santoso A, et al. Primary repair for injury of medial collateral ligament during total-knee arthroplasty. Medicine (Baltimore), 2019, 98(39): e17134.
6.	Shahi A, Tan TL, Tarabichi S, et al. Primary repair of iatrogenic medial collateral ligament injury during TKA: A modified technique. J Arthroplasty, 2015, 30(5): 854-857.
7.	Leopold SS, McStay C, Klafeta K, et al. Primary repair of intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J Bone Joint Surg (Am), 2001, 83(1): 86-91.
8.	Bohl DD, Wetters NG, Del Gaizo DJ, et al. Repair of intraoperative injury to the medial collateral ligament during primary total knee arthroplasty. J Bone Joint Surg (Am), 2016, 98(1): 35-39.
9.	Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg (Am), 1998, 80(12): 1770-1774.
10.	Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res, 2011, 469(1): 64-68.
11.	Elmasry SS, Sculco PK, Kia M, et al. A geometric ratio to predict the flexion gap in total knee arthroplasty. J Orthop Res, 2020, 38(7): 1637-1645.
12.	Wada K, Hamada D, Tamaki S, et al. Influence of medial collateral ligament release for internal rotation of tibia in posterior-stabilized total knee arthroplasty: A cadaveric study. J Arthroplasty, 2017, 32(1): 270-273.
13.	Lee HJ, Kim SH, Park YB. Selective medial release using multiple needle puncturing with a spacer block in situ for correcting severe varus deformity during total knee arthroplasty. Arch Orthop Trauma Surg, 2020. doi: 10.1007/s00402-020-03510-7.
14.	Liu F, Yue B, Gadikota HR, et al. Morphology of the medial collateral ligament of the knee. J Orthop Surg Res, 2010, 5(1): 69. doi: 10.1186/1749-799X-5-69.
15.	马路遥, 郭万首. 初次全膝关节置换术中内侧副韧带损伤的诊治研究现状. 中华关节外科杂志 (电子版), 2015, 9(5): 659-662.
16.	王俏杰, 沈灏, 王琦, 等. 全膝关节置换术中膝关节内侧副韧带损伤的处理. 中华解剖与临床杂志, 2014, 19(6): 452-455.
17.	蒋勇, 梁海燕, 熊咏民, 等. TKA 术中原位修复医源性内侧副韧带损伤效果观察. 中国骨与关节损伤杂志, 2018, 33(4): 420-421.
18.	周捍东. 膝内侧副韧带损伤治疗现状及进展. 中国骨与关节损伤杂志, 2010, 25(6): 572-574.
19.	Liu F, Gadikota HR, Kozánek M, et al. In vivo length patterns of the medial collateral ligament during the stance phase of gait. Knee Surg Sports Traumatol Arthrosc, 2011, 19(5): 719-727.
20.	Cheng XW, Wang ZB, Zhang Y, et al. Tightening medial collateral ligament during total knee arthroplasty for patients with fixed valgus deformity: A novel technique. J Orthop Surg (Hong Kong), 2019, 27(1): 1-5.
21.	Rossi R, Cottino U, Bruzzone M, et al. Total knee arthroplasty in the varus knee: tips and tricks. Int Orthop, 2019, 43(1): 151-158.
22.	Koo MH, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty, 2009, 24(8): 1249-1253.
23.	Dragosloveanu S, Cristea S, Stoica C, et al. Outcome of iatrogenic collateral ligaments injuries during total knee arthroplasty. Eur J Orthop Surg Traumatol, 2014, 24(8): 1499-1503.
24.	Jung KA, Lee SC, Hwang SH, et al. Quadriceps tendon free graft augmentation for a midsubstance tear of the medial collateral ligament during total knee arthroplasty. Knee, 2009, 16(6): 479-483.
25.	Siqueira MB, Haller K, Mulder A, et al. Outcomes of medial collateral ligament injuries during total knee arthroplasty. J Knee Surg, 2016, 29(1): 68-73.
26.	Cao JG, Wang L, Zhao HW, et al. Semitendinosus and gracilis transfer for treatment of medial collateral ligament injury of total knee arthroplasty. Eur Rev Med Pharmacol Sci, 2016, 20(18): 3738-3742.
27.	史哲, 张晓岗, 张坤, 等. 非可吸收编织线修复医源性内侧副韧带损伤的短期效果评估. 中华骨与关节外科杂志, 2019, 12(2): 126-130.
28.	Wierer G, Runer A, Hoser C, et al. Anatomical MCL reconstruction following TKA. Knee, 2016, 23(5): 911-914.
29.	Dimitris K, Taylor BC, Steensen RN. Excursion of oscillating saw blades in total knee arthroplasty. J Arthroplasty, 2010, 25(1): 158-160.
30.	安帅, 曹光磊, 沈惠良, 等. 全膝关节置换术中膝关节内侧副韧带损伤原位修复的疗效分析. 中国骨与关节损伤杂志, 2019, 34(8): 867-869.
31.	Cho WS, Byun SE, Lee SJ, et al. Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2015, 23(6): 1816-1823.
32.	Ohmori T, Kabata T, Kajino Y, et al. Effectiveness and safety of needle medial collateral ligament pie-crusting in total knee arthroplasty: A cadaveric study. J Knee Surg, 2018, 31(8): 705-709.
33.	Meneghini RM, Daluga AT, Sturgis LA, et al. Is the pie-crusting technique safe for MCL release in varus deformity correction in total knee arthroplasty? J Arthroplasty, 2013, 28(8): 1306-1309.
34.	Kwak DS, In Y, Kim TK, et al. The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 188-194.
35.	Ha CW, Park YB, Lee CH, et al. Selective medial release technique using the pie-crusting method for medial tightness during primary total knee arthroplasty. J Arthroplasty, 2016, 31(5): 1005-1010.
36.	Herschmiller T, Grosso MJ, Cunn GJ, et al. Step-wise medial collateral ligament needle puncturing in extension leads to a safe and predictable reduction in medial compartment pressure during TKA. Knee Surg Sports Traumatol Arthrosc, 2018, 26(6): 1759-1766.
37.	Amundsen SH, Meyers KN, Wright TM, et al. Variability in elongation and failure of the medial collateral ligament after pie-crusting with 16- and 18-gauge needles. J Arthroplasty, 2018, 33(8): 2636-2639.
38.	Kayani B, Konan S, Pietrzak JRT, et al. Iatrogenic bone and soft tissue trauma in robotic-arm assisted total knee arthroplasty compared with conventional jig-based total knee arthroplasty: a prospective cohort study and validation of a new classification system. J Arthroplasty, 2018, 33(8): 2496-2501.
39.	Hampp EL, Sodhi N, Scholl L, et al. Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach: a blinded assessment. Bone Joint Res, 2019, 8(10): 495-501.
40.	Hampp EL, Chughtai M, Scholl LY, et al. Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared with manual techniques. J Knee Surg, 2019, 32(3): 239-250.
41.	Sultan AA, Piuzzi N, Khlopas A, et al. Utilization of robotic-arm assisted total knee arthroplasty for soft tissue protection. Expert Rev Med Devices, 2017, 14(12): 925-927.
42.	White KT, Fleischman A, Ackerman CT, et al. Managing superficial distal medial collateral ligament insufficiency in primary total knee arthroplasty using bone staples. J Knee Surg, 2019, 32(9): 900-905.
43.	Adravanti P, Dini F, Calafiore G, et al. Medial collateral ligament reconstruction during TKA: a new approach and surgical technique. Joints, 2016, 3(4): 215-217.
44.	Donaldson WF, Sculco TP, Insall JN, et al. Total condylar Ⅲ knee prosthesis. Long-term follow-up study. Clin Orthop Relat Res, 1988, (226): 21-28.

1. Stephens S, Politi J, Backes J, et al. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics, 2012, 35(2): e154-159.
2. Torre DP, Stephens A, Oh LH, et al. Management of medial collateral ligament injury during primary total knee arthroplasty: a systematic review. Reconstructive Review, 2014, 4(2): 17-23.
3. Wang XM, Liu HX, Cao PK, et al. Clinical outcomes of medial collateral ligament injury in total knee arthroplasty. Medicine (Baltimore), 2017, 96(30): e7617.
4. Choi YJ, Lee KW, Seo DK, et al. Conservative management after intraoperative over-release of the medial collateral ligament from its tibial insertion site in patients undergoing total knee arthroplasty. J Knee Surg, 2018, 31(8): 786-791.
5. Jin C, Zhao JY, Santoso A, et al. Primary repair for injury of medial collateral ligament during total-knee arthroplasty. Medicine (Baltimore), 2019, 98(39): e17134.
6. Shahi A, Tan TL, Tarabichi S, et al. Primary repair of iatrogenic medial collateral ligament injury during TKA: A modified technique. J Arthroplasty, 2015, 30(5): 854-857.
7. Leopold SS, McStay C, Klafeta K, et al. Primary repair of intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J Bone Joint Surg (Am), 2001, 83(1): 86-91.
8. Bohl DD, Wetters NG, Del Gaizo DJ, et al. Repair of intraoperative injury to the medial collateral ligament during primary total knee arthroplasty. J Bone Joint Surg (Am), 2016, 98(1): 35-39.
9. Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg (Am), 1998, 80(12): 1770-1774.
10. Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res, 2011, 469(1): 64-68.
11. Elmasry SS, Sculco PK, Kia M, et al. A geometric ratio to predict the flexion gap in total knee arthroplasty. J Orthop Res, 2020, 38(7): 1637-1645.
12. Wada K, Hamada D, Tamaki S, et al. Influence of medial collateral ligament release for internal rotation of tibia in posterior-stabilized total knee arthroplasty: A cadaveric study. J Arthroplasty, 2017, 32(1): 270-273.
13. Lee HJ, Kim SH, Park YB. Selective medial release using multiple needle puncturing with a spacer block in situ for correcting severe varus deformity during total knee arthroplasty. Arch Orthop Trauma Surg, 2020. doi: 10.1007/s00402-020-03510-7.
14. Liu F, Yue B, Gadikota HR, et al. Morphology of the medial collateral ligament of the knee. J Orthop Surg Res, 2010, 5(1): 69. doi: 10.1186/1749-799X-5-69.
15. 马路遥, 郭万首. 初次全膝关节置换术中内侧副韧带损伤的诊治研究现状. 中华关节外科杂志 (电子版), 2015, 9(5): 659-662.
16. 王俏杰, 沈灏, 王琦, 等. 全膝关节置换术中膝关节内侧副韧带损伤的处理. 中华解剖与临床杂志, 2014, 19(6): 452-455.
17. 蒋勇, 梁海燕, 熊咏民, 等. TKA 术中原位修复医源性内侧副韧带损伤效果观察. 中国骨与关节损伤杂志, 2018, 33(4): 420-421.
18. 周捍东. 膝内侧副韧带损伤治疗现状及进展. 中国骨与关节损伤杂志, 2010, 25(6): 572-574.
19. Liu F, Gadikota HR, Kozánek M, et al. In vivo length patterns of the medial collateral ligament during the stance phase of gait. Knee Surg Sports Traumatol Arthrosc, 2011, 19(5): 719-727.
20. Cheng XW, Wang ZB, Zhang Y, et al. Tightening medial collateral ligament during total knee arthroplasty for patients with fixed valgus deformity: A novel technique. J Orthop Surg (Hong Kong), 2019, 27(1): 1-5.
21. Rossi R, Cottino U, Bruzzone M, et al. Total knee arthroplasty in the varus knee: tips and tricks. Int Orthop, 2019, 43(1): 151-158.
22. Koo MH, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty, 2009, 24(8): 1249-1253.
23. Dragosloveanu S, Cristea S, Stoica C, et al. Outcome of iatrogenic collateral ligaments injuries during total knee arthroplasty. Eur J Orthop Surg Traumatol, 2014, 24(8): 1499-1503.
24. Jung KA, Lee SC, Hwang SH, et al. Quadriceps tendon free graft augmentation for a midsubstance tear of the medial collateral ligament during total knee arthroplasty. Knee, 2009, 16(6): 479-483.
25. Siqueira MB, Haller K, Mulder A, et al. Outcomes of medial collateral ligament injuries during total knee arthroplasty. J Knee Surg, 2016, 29(1): 68-73.
26. Cao JG, Wang L, Zhao HW, et al. Semitendinosus and gracilis transfer for treatment of medial collateral ligament injury of total knee arthroplasty. Eur Rev Med Pharmacol Sci, 2016, 20(18): 3738-3742.
27. 史哲, 张晓岗, 张坤, 等. 非可吸收编织线修复医源性内侧副韧带损伤的短期效果评估. 中华骨与关节外科杂志, 2019, 12(2): 126-130.
28. Wierer G, Runer A, Hoser C, et al. Anatomical MCL reconstruction following TKA. Knee, 2016, 23(5): 911-914.
29. Dimitris K, Taylor BC, Steensen RN. Excursion of oscillating saw blades in total knee arthroplasty. J Arthroplasty, 2010, 25(1): 158-160.
30. 安帅, 曹光磊, 沈惠良, 等. 全膝关节置换术中膝关节内侧副韧带损伤原位修复的疗效分析. 中国骨与关节损伤杂志, 2019, 34(8): 867-869.
31. Cho WS, Byun SE, Lee SJ, et al. Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2015, 23(6): 1816-1823.
32. Ohmori T, Kabata T, Kajino Y, et al. Effectiveness and safety of needle medial collateral ligament pie-crusting in total knee arthroplasty: A cadaveric study. J Knee Surg, 2018, 31(8): 705-709.
33. Meneghini RM, Daluga AT, Sturgis LA, et al. Is the pie-crusting technique safe for MCL release in varus deformity correction in total knee arthroplasty? J Arthroplasty, 2013, 28(8): 1306-1309.
34. Kwak DS, In Y, Kim TK, et al. The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 188-194.
35. Ha CW, Park YB, Lee CH, et al. Selective medial release technique using the pie-crusting method for medial tightness during primary total knee arthroplasty. J Arthroplasty, 2016, 31(5): 1005-1010.
36. Herschmiller T, Grosso MJ, Cunn GJ, et al. Step-wise medial collateral ligament needle puncturing in extension leads to a safe and predictable reduction in medial compartment pressure during TKA. Knee Surg Sports Traumatol Arthrosc, 2018, 26(6): 1759-1766.
37. Amundsen SH, Meyers KN, Wright TM, et al. Variability in elongation and failure of the medial collateral ligament after pie-crusting with 16- and 18-gauge needles. J Arthroplasty, 2018, 33(8): 2636-2639.
38. Kayani B, Konan S, Pietrzak JRT, et al. Iatrogenic bone and soft tissue trauma in robotic-arm assisted total knee arthroplasty compared with conventional jig-based total knee arthroplasty: a prospective cohort study and validation of a new classification system. J Arthroplasty, 2018, 33(8): 2496-2501.
39. Hampp EL, Sodhi N, Scholl L, et al. Less iatrogenic soft-tissue damage utilizing robotic-assisted total knee arthroplasty when compared with a manual approach: a blinded assessment. Bone Joint Res, 2019, 8(10): 495-501.
40. Hampp EL, Chughtai M, Scholl LY, et al. Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared with manual techniques. J Knee Surg, 2019, 32(3): 239-250.
41. Sultan AA, Piuzzi N, Khlopas A, et al. Utilization of robotic-arm assisted total knee arthroplasty for soft tissue protection. Expert Rev Med Devices, 2017, 14(12): 925-927.
42. White KT, Fleischman A, Ackerman CT, et al. Managing superficial distal medial collateral ligament insufficiency in primary total knee arthroplasty using bone staples. J Knee Surg, 2019, 32(9): 900-905.
43. Adravanti P, Dini F, Calafiore G, et al. Medial collateral ligament reconstruction during TKA: a new approach and surgical technique. Joints, 2016, 3(4): 215-217.
44. Donaldson WF, Sculco TP, Insall JN, et al. Total condylar Ⅲ knee prosthesis. Long-term follow-up study. Clin Orthop Relat Res, 1988, (226): 21-28.

Chinese Journal of Reparative and Reconstructive Surgery

Prevention and treatment of iatrogenic medial collateral ligament injuries in total knee arthroplasty

Abstract Full text Figures/Tables Video References Cited by

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