Percutaneous Medial Collateral Ligament R
elease in Arthroscopic Medial Menisectomy in
Knees with Tight Medial Compartment
Orthopedic Department, Faculty of Medicine, AL-Azhar University, Egypt
Submission: July 01, 2019;Published: July 24, 2019
*Corresponding author: Mohammed Alnahas, Orthopedic Department, Faculty of Medicine, AL-Azhar University, Nasr City, postal code: 11884 - Cairo - Egypt
How to cite this article: Mohammed Alnahas. Percutaneous Medial Collateral Ligament Release in Arthroscopic Medial Menisectomy in Knees with Tight Medial Compartment. Ortho & Rheum Open Access J. 2019; 14(4): 555891. DOI: 10.19080/OROAJ.2019.14.555891
In tight knee joints with a narrow medial joint space, there is a risk of iatrogenic articular cartilage injury, even by an arthroscopy specialist which may predispose to osteoarthritis of the knee. The aim of the study was to detect if there is any residual knee laxity after the Pie- crusting technique or any other complications. Between February 2018 and April 2019, 30 patients with torn posterior horn of the medial meniscus were found to have tight knees with difficulty in visualization of the tear. The pie-crusting technique was done in those patients, which made the performance of partial menisectomy easy and safe. All the patients complained post-operative from pain over the site of the release (grade I MCL sprain) that has resolved within 1-2 weeks.
The posterior horn of the medial meniscus is a common site of meniscal tears. Unrestricted arthroscopic visualization of the posterior horn of the medial meniscus is crucial to perform adequate menisectomy. In patients with tight knees, the medial femoral condyle makes the visualization of the posterior horn of the medial meniscus and the usage of instruments is very difficult. So, in tight knees, this area is reported to be one of the greatest sources of diagnostic errors in knee arthroscopy [1,2]. Vigorous manipulations with the instruments in cases with tight knees may cause iatrogenic chondral damage which may contribute to degeneration of the articular cartilage and osteoarthritis [3,4]. Also, this inadequate visualization may lead to insufficient menisectomy, with the left meniscal fragment might result in continued symptoms and reoperation [5,6]. Meniscal pathologies may be missed as a result of this inadequate visualization. Moreover, this vigorous manipulation to open the medial compartment, may result in rupture of the MCL or even fracture of the femur [7,8].
Agneskirchner & Lobenhoffer [3,9], Bosch , Park et al.  and later Fakioglu et al.  described a minimally invasive technique to open the medial compartment by puncturing the postero-medial capsulo-ligamentous structures percutaneously with the use of a needle. Although they reported that the injured
structures healed uneventfully, there were no data on the injury localization, healing patterns or complications. In this study, we used the same technique as described by Fakioglu et al.  to enlarge the medial joint space in tight knees, which is, percutaneous puncturing of the postero-medial capsulo-ligamentous structures with the use of needles. Also, we were concerned about studying the possible complications especially residual medial laxity.
From February 2018 and April 2019, a prospective randomized analytical clinical study was done to evaluate the effect of percutaneous release of the superficial medial collateral ligament (pie-crusting technique) in patients with tight medial compartment of the knee undergoing partial menisectomy for torn posterior horn of the medial meniscus. The material of this study includes 30 patients with torn posterior horn of the medial meniscus with tight medial compartment of the knee. All patients were selected according the following criteria: Age: skeletally mature patients, patients with Torn PHMM with tight medial compartment without mal-alignment, no other ligamentous injuries, and no osteoarthritis or any other articular lesions. Twenty-six male patients and 4 female patients were included. Of the thirty patients, 20 patients had torn PHMM of the right knee
and 10 patients had torn PHMM of the left knee. In 16 patients
the cause of the injury was sports practice, while in the other
14 patients the cause was non-sports injury. Table 1 Full clinical
examination of the affected knee and the contra-lateral knee
was done, and the patients scored according to Lysholm score
(Table 2). All patients had poor results preoperative. Standard
standing X- rays of both knee (AP, lateral views): To exclude
osteoarthritis or mal-alignment. MRI of the affected knee was
done to detect the site & type of the meniscal tear and to detect
any other ligamentous injuries or patellar instability.
In this study, timing of surgery from the onset of symptoms
was ranging from 1 month to 4 years. The patient was laid
supine. A tourniquet over soft cotton is applied and elevated
to 300 mmHg after administration of the anaesthesia. A flat
or round, well padded, lateral post is positioned lateral to the
tourniquet halfway up the thigh. Twenty-two patients received
spinal anaesthesia, while the other 8 patients received general
anaesthesia. Standard anterior-lateral and low anterior-medial
portals were used with a 30° viewing scope. A fluid pump was
used for inflow through arthroscopic sheath. Next a quick
diagnostic knee examination was done starting with suprapatellar
pouch, lateral gutter, and patello-femoral joint and
medial gutter. Next, a probe was inserted through the anteriormedial
working portal into the medial compartment. With the
knee in extension to 30o flexion, valgus and external rotation
was applied by the assistant to help better visualization of
the PHMM. When complete visualization was difficult or
instrumentation was difficult, the pie-crusting technique was
done (Figure 1). When visualization or instrumentation of the
posterior-medial meniscus under valgus stress was inadequate,
controlled release of the posterior-medial capsulo-ligamentous
structures with the metal inner shaft of the 16-gauge (G) syringe
needle was performed. The targeted point for release was the
posterior third of the superficial MCL proximal to the medial
meniscus (Figure 2).
Puncture at this site produces a cracking sensation with
a resultant opening in the medial compartment of the knee
seen on the arthroscopy screen. If the opening in the medial
compartment was enough on the monitor, then the release was
stopped. Otherwise, without removing the needle from the
skin, the posterior-medial capsulo-ligamentous structures were
punctured again. In a more horizontal plane, while endeavoring
to limit the punctures to the posterior part of the MCL, and the
process was continued until the desired amount of opening of the
medial compartment of the knee was reached (Figure 3). Better
visualization of the footprint was obtained and subsequent
partial medial menisectomy was done. Postoperative the patient
was advised to use ice. No brace was used. Analgesics: ethidine
50-100 mg ampoule intramuscular was given when required
for 2-3 days, Diclofenac sodium 50 mg. tablets twice daily for
one week starting from the second day. Prophylactic antibiotics:
Ceftriaxone IV. Weight bearing was encouraged from the second
day post- operative whether with or without crutches as
tolerated by the patient. Discharging the patient was after 24
Active range of motion as tolerated. Weight bearing was
allowed as tolerated. Isometric quadriceps contraction exercises.
No squatting. No pivoting. Squatting is allowed gradually. Pivoting
is allowed gradually. All patients were evaluated after surgery
every two weeks up to the second postoperative month, then
after one month. In this study the follow up period was 3 months.
After assessment of the patients clinically and radiographically,
the postoperative rating scales were recorded, and all data were
documented 3 months post-operatively. Postoperative clinical
evaluation was like the preoperative evaluation. In addition,
the site of pie-crusting was examined for tenderness, swelling
or ecchymosis. Stress valgus x-rays were done in full extension
and 30° flexion after 3 months and the difference with the
contralateral normal limb were documented. Medial joint space
opening: The joint space width was measured as follows: A
horizontal line (distal femoral line) was drawn tangent to the
most distal portions of the femoral condyles. From this line, a
perpendicular line was drawn to the most medial point of the
medial plateau (Figure 4).
Between February 2018 and April 2019, 30 patients were
admitted to the department of Orthopedics and Traumatology
in Al-Azhar University Hospital with torn posterior horn of
the medial meniscus and intra-operatively they were found to
have tight medial compartment. Considerable intra-operative
chondral damage was expected on attempting to reach the
posterior horn of the medial meniscus to perform partial
menisectomy. In all the patients a partial menisectomy was
performed with adequate visualization of the posterior horn of the medial meniscus and avoiding iatrogenic chondral injury.
The duration of follow-up was 3 months. The results of the study
at the end of the follow-up period were assessed both clinically
and radiologically. Patients were evaluated using Lysholm score.
In our study the median Lysholm score preoperatively was 49
(35-65). The median Lysholm score had increased at the end of
the follow up period to 93 (86-98) with P value < 0.05 which was
statistically significant (Tables 3-7).
The posterior horn of the medial meniscus is still the single
greatest source of errors in knee arthroscopy, despite the great
advancement in arthroscopic techniques and instruments.
Most errors occur in tight knees that have hidden lesions at the
periphery of the posterior horn of the medial meniscus [1,2,13].
The posterior root attachment of the medial meniscus is critical
for preserving important functions of the meniscus. Tears of the
posterior root of the meniscus are clearly associated with major
extrusion (>3 mm) of the medial meniscus, and meniscal extrusion
appears to be associated with progression of osteoarthritis .
Resection of irreparable tears or repair of meniscal tears is
associated with high success rate and minimal complications. In
knee joints with a narrow medial joint space, there is a risk that
cartilage may be damaged by the resection instruments, even by
an arthroscopy specialist. Even superficial cartilaginous lesions
due to hits or scratches caused by instruments and affecting the
cartilage of the posterior femoral condyle and the tibial plateau
do not heal with normal hyaline cartilage. They may predispose
to osteoarthritis of the knee joint, especially if extensive partial
menisectomy is performed simultaneously . The superficial
MCL is the primary stabilizer of the medial side of the knee.
Biomechanical studies have shown that the highest strains
in the MCL have been recorded in the posterior region of the
ligament proximal to the joint line with the knee in extension
during valgus loading [14,15]. Therefore, this area is thought to
be the primary restraint to medial knee opening during valgus
force in arthroscopy. In our study the targeted point for release
was the posterior third of the superficial MCL proximal to the
medial meniscus. This was done using a 16-gauge needle which
was moved out-in.
Adequate visualization of the posterior horn of the medial
meniscus is crucial for the performance of proper menisectomy.
In cases with tight knees, the Pie-crusting technique is safe and
efficient for visualization of the posterior horn of the medial
meniscus. It allows the avoidance of causing iatrogenic chondral
damage or fracture of the medial femoral condyle. The medial
collateral ligament heals eventually in all patients after the Piecrusting
technique without causing any subjective instability.