Conservative Management after Intraoperative Over-Release of the Medial Collateral Ligament from its Tibial Insertion Site in Patients Undergoing Total Knee Arthroplasty

Young Joon Choi; Ki Won Lee; Dong Kyo Seo; Suk Kyu Lee; Sang Bum Kim; Hyun Il Lee

doi:10.1055/s-0037-1608848

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2018; 31(08): 786-791
DOI: 10.1055/s-0037-1608848

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Conservative Management after Intraoperative Over-Release of the Medial Collateral Ligament from its Tibial Insertion Site in Patients Undergoing Total Knee Arthroplasty

Young Joon Choi

¹Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan Collage of Medicine, Gangneung, Republic of Korea

,

Ki Won Lee

¹Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan Collage of Medicine, Gangneung, Republic of Korea

,

Dong Kyo Seo

¹Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan Collage of Medicine, Gangneung, Republic of Korea

,

Suk Kyu Lee

¹Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan Collage of Medicine, Gangneung, Republic of Korea

,

Sang Bum Kim

¹Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan Collage of Medicine, Gangneung, Republic of Korea

,

Hyun Il Lee

²Department of Orthopedic Surgery, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Republic of Korea

› Author Affiliations

Abstract

During varus deformity correction in a patient undergoing total knee arthroplasty (TKA), the medial collateral ligament (MCL) could get completely detached from its distal insertion site. Our aim was to evaluate the (1) mid-term clinical outcome and implant survival after conservative treatment in patients with intraoperatively over-released MCL and (2) preoperative risk factors for MCL over-release. A retrospective study was conducted on patients who had undergone a primary TKA between 2001 and 2006. The number of knees with intraoperative MCL over-release (over-released group) was 47 (40 patients); we compared these with the knees that had intact MCL (intact group, 502 knees). Simple anchoring of MCL was performed with no additional protection. The postoperative clinical outcome and implant survival were compared. Risk factors for MCL over-release were identified using multivariate analysis. The average follow-up period was 7.5 years. The mean Knee Society score of the over-released group improved from 23.3 to 92.7 and it was not significantly different from the intact group. Three cases of aseptic loosening occurred in the over-released group and 19 in the intact group (p = 0.423). The survival rates of the implant were 94.4% and 96.1%, respectively, at 13 years postoperatively. Multivariate analysis showed preoperative femoral–tibial angle as the only risk factor for over-release. This study showed that even MCL was over-released inadvertently, but it did not affect the clinical outcome. Preoperative femoral–tibial angle was the only predictable risk factor for MCL over-release.

Keywords

knee - varus deformity - soft tissue balancing - medial collateral ligament

Full Text

References

References
1 Yasgur DJ, Scuderi GR, Insall JN. Surgical techniques in total knee arthroplasty. In: Scuderi GR, Tria Jr. AJ. , eds. New York: Springer-Verlag; 2002: 186-196
2 Krackow KA, Mihalko WM. The effect of medial release on flexion and extension gaps in cadaveric knees: implications for soft-tissue balancing in total knee arthroplasty. Am J Knee Surg 1999; 12 (04) 222-228
3 Whiteside LA, Saeki K, Mihalko WM. Functional medical ligament balancing in total knee arthroplasty. Clin Orthop Relat Res 2000; (380) 45-57
4 Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA. Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 2009; 17 (12) 766-774
5 Cho WS, Byun SE, Lee SJ, Yoon J. Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1816-1823
6 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 (08) 1249-1253
7 Cameron HU, Hunter GA. Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthop Relat Res 1982; (170) 141-146
8 Donaldson III WF, Sculco TP, Insall JN, Ranawat CS. Total condylar III knee prosthesis. Long-term follow-up study. Clin Orthop Relat Res 1988; (226) 21-28
9 Hartford JM, Goodman SB, Schurman DJ, Knoblick G. Complex primary and revision total knee arthroplasty using the condylar constrained prosthesis: an average 5-year follow-up. J Arthroplasty 1998; 13 (04) 380-387
10 Healy WL, Della Valle CJ, Iorio R. , et al. Complications of total knee arthroplasty: standardized list and definitions of the Knee Society. Clin Orthop Relat Res 2013; 471 (01) 215-220
11 Lachiewicz PF, Falatyn SP. Clinical and radiographic results of the Total Condylar III and Constrained Condylar total knee arthroplasty. J Arthroplasty 1996; 11 (08) 916-922
12 Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res 2011; 469 (01) 64-68
13 Bohl DD, Wetters NG, Del Gaizo DJ, Jacobs JJ, Rosenberg AG, Della Valle CJ. Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty. J Bone Joint Surg Am 2016; 98 (01) 35-39
14 Leopold SS, McStay C, Klafeta K, Jacobs JJ, Berger RA, Rosenberg AG. Primary repair of intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J Bone Joint Surg Am 2001; 83-A (01) 86-91
15 Ballmer PM, Jakob RP. The non operative treatment of isolated complete tears of the medial collateral ligament of the knee. A prospective study. Arch Orthop Trauma Surg 1988; 107 (05) 273-276
16 Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Relat Res 1990; (256) 174-177
17 Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; (248) 13-14
18 Verdonk PC, Pernin J, Pinaroli A, Ait Si Selmi T, Neyret P. Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach. Knee Surg Sports Traumatol Arthrosc 2009; 17 (06) 660-666
19 Engh GA, Ammeen D. Results of total knee arthroplasty with medial epicondylar osteotomy to correct varus deformity. Clin Orthop Relat Res 1999; (367) 141-148
20 Laskin RS. The Insall Award. Total knee replacement with posterior cruciate ligament retention in patients with a fixed varus deformity. Clin Orthop Relat Res 1996; (331) 29-34
21 Whiteside LA. Soft tissue balancing: the knee. J Arthroplasty 2002; 17 (04) (Suppl. 01) 23-27
22 Wymenga AB, Kats JJ, Kooloos J, Hillen B. Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee. Knee Surg Sports Traumatol Arthrosc 2006; 14 (03) 229-234
23 Matsueda M, Gengerke TR, Murphy M, Lew WD, Gustilo RB. Soft tissue release in total knee arthroplasty. Cadaver study using knees without deformities. Clin Orthop Relat Res 1999; (366) 264-273
24 Rosenberg AG, Verner JJ, Galante JO. Clinical results of total knee revision using the Total Condylar III prosthesis. Clin Orthop Relat Res 1991; (273) 83-90
25 Sculco TP. Total condylar III prosthesis in ligament instability. Orthop Clin North Am 1989; 20 (02) 221-226
26 Stephens S, Politi J, Backes J, Czaplicki T. Repair of medial collateral ligament injury during total knee arthroplasty. Orthopedics 2012; 35 (02) e154-e159
27 Jung KA, Lee SC, Hwang SH, Jung SH. Quadriceps tendon free graft augmentation for a midsubstance tear of the medial collateral ligament during total knee arthroplasty. Knee 2009; 16 (06) 479-483
28 Laskin RS. Alignment of total knee components. Orthopedics 1984; 7 (01) 62-72
29 Laskin RS, Schob CJ. Medial capsular recession for severe varus deformities. J Arthroplasty 1987; 2 (04) 313-316
30 Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 1994; (299) 153-156
31 Hood RW, Vanni M, Insall JN. The correction of knee alignment in 225 consecutive total condylar knee replacements. Clin Orthop Relat Res 1981; (160) 94-105
32 Cameron HU. Tibial component wear in total knee replacement. Clin Orthop Relat Res 1994; (309) 29-32
33 Hsu HP, Garg A, Walker PS, Spector M, Ewald FC. Effect of knee component alignment on tibial load distribution with clinical correlation. Clin Orthop Relat Res 1989; (248) 135-144
34 Insall JN, Lachiewicz PF, Burstein AH. The posterior stabilized condylar prosthesis: a modification of the total condylar design. Two to four-year clinical experience. J Bone Joint Surg Am 1982; 64 (09) 1317-1323
35 Moreland JR. Mechanisms of failure in total knee arthroplasty. Clin Orthop Relat Res 1988; (226) 49-64
36 Windsor RE, Scuderi GR, Moran MC, Insall JN. Mechanisms of failure of the femoral and tibial components in total knee arthroplasty. Clin Orthop Relat Res 1989; (248) 15-19
37 Heesterbeek PJ, Keijsers NL, Wymenga AB. Ligament releases do not lead to increased postoperative varus-valgus laxity in flexion and extension: a prospective clinical study in 49 TKR patients. Knee Surg Sports Traumatol Arthrosc 2010; 18 (02) 187-193
38 Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am 1998; 80 (12) 1770-1774
39 Teeny SM, Krackow KA, Hungerford DS, Jones M. Primary total knee arthroplasty in patients with severe varus deformity. A comparative study. Clin Orthop Relat Res 1991; (273) 19-31