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Anatomical MCL reconstruction following TKA
THEKNE-02295; No of Pages 4 The Knee xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
The Knee
Case report
Anatomical MCL reconstruction following TKA Guido Wierer a,⁎, Armin Runer b, Christian Hoser b, Peter Gföller b, Christian Fink b,c a b c
Department of Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria 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
a r t i c l e
i n f o
Article history: Received 15 April 2016 Received in revised form 22 May 2016 Accepted 15 June 2016 Available online xxxx Keywords: Total knee arthroplasty TKA Medial collateral ligament reconstruction MCL Valgus instability
a b s t r a c t 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. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Total knee arthroplasty (TKA) is a widely used technique for the relief of disabling pain caused by severe arthritis. To achieve satisfying postoperative results, adequate knee stability is crucial. The incidence of intraoperative medial collateral ligament (MCL) tears is about 0.4% and the revision rates due to instability after fixedbearing, posterior cruciate ligament (PCL)-retaining TKA are reported to be about five percent of all TKA revisions [1,2]. Hereby, symptomatic medial instability is usually treated with a lateral release procedure and inlay exchange. In more severe cases, revision surgery to a more constrained prosthesis might be necessary [3–8]. While anatomical reconstruction of the MCL has become more popular, no anatomical MCL reconstruction following TKA is reported in the literature to our knowledge [9–18]. In contrast to the current management of medial instability following TKA, we present a case of early TKA failure due to secondary valgus laxity, which was successfully treated with an anatomical MCL reconstruction. 2. Case report A 60-year-old female patient presented to our clinic following a cemented, PCL-retaining total knee prosthesis (Attune, DePuy Synthes, Warsaw, IN) on her left knee six months earlier (Figure 1). ⁎ Corresponding author. Tel.: +43 676 749 75 75. E-mail addresses: [email protected] (G. Wierer), [email protected] (A. Runer), [email protected] (C. Hoser), [email protected] (P. Gföller), c.fi[email protected] (C. Fink).
She was complaining of knee instability during daily activities, accompanied by pain, swelling, limping and the inability to squat. In the clinical examination a high-grade medial instability could be observed in extension and mid-flexion. Valgus stress radiographs showed four millimeters of medial compartment opening (Figure 1) in extension and 10 mm in 20° of flexion. On computed tomography (CT) scans the components of the TKA were well aligned, with no signs of loosening. A long leg view radiograph showed neutral limb alignment. The patient had high demands concerning sports activities (dancing, alpine skiing, hiking, ...) and at the time of presentation the patient was unable to participate in any of these. No improvement was obtained throughout extensive physical therapy so the patient was scheduled for revision surgery. Due to the relatively young age and the high activity level a soft tissue procedure was chosen over an exchange to a constrained implant. Intraoperatively, the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) appeared to be insufficient and the sMCL was scarred at the femoro-tibial joint line (Figure 2). Initially, the femoral insertion of the sMCL was identified and an eyelet-passing pin was drilled transversely across the femur. A 30 mm deep tunnel was drilled with a six millimeter reamer over the previously placed pin. The semitendinosus tendon was then harvested and split longitudinally [19], which allowed flattening of the tendon according to the anatomical shape of the MCL. For the reconstruction of the sMCL approximately 16 cm was estimated. The graft was then pulled into the femoral tunnel and secured with a cannulated bioabsorbable screw (Arthrex, Inc., Naples, FL). To reconstruct the sMCL, the longer rein of the graft was passed distally and secured approximately six centimeters distal to the joint
http://dx.doi.org/10.1016/j.knee.2016.06.006 0968-0160/© 2016 Elsevier B.V. All rights reserved.
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
2
G. Wierer et al. / The Knee xxx (2016) xxx–xxx
Figure 1. (a–c): (a, b) A 60-year-old female patient underwent cemented, PCL-retaining TKA. (c) Valgus stress radiograph shows medial compartment opening.
line at its anatomical insertion site with two 2.9 mm soft anchors (JuggerKnot, Biomet, Warsaw, IN) [17]. The graft was fixed with the tibia in neutral rotation, at 20° of knee flexion, and a slight varus reduction force. Next, the posteromedial capsule was tensioned by capsular plication. To reconstruct the central arm of the POL, the remaining 12 cm of flattened tendon graft were fixed with a 5.5 mm suture anchor (Bio-corkscrew, Arthrex, Inc., Naples, FL) at the dorsomedial tibial plateau, anterior to the direct arm attachment of the semimembranosus tendon [17], and tightened in full extension. Intraoperative examination following MCL reconstruction showed a well-balanced knee, which was confirmed by intraoperative fluoroscopy showing a symmetric join space with no medial gapping during valgus stress neither in extension nor in flexion. Postoperatively, the patient was mobilized with partial weight bearing for three weeks. The range of motion (ROM) was limited to 0° to 30° to 60° for the first six weeks by a hinged knee brace. 2.1. Results The patient's postoperative course was uneventful. At her most recent follow-up 24 months postoperatively all measured scores improved significantly. The pre-operative Lysholm score improved from 27 to 86 postoperatively, the Oxford score from 17 to 47 respectively. The patient reported no more complaints of swelling or limping
and experienced no instability even under strenuous activity. The Tegner Activity Level improved from two to four and the VAS status for pain changed from 10 to one. At clinical and radiological examinations no valgus or varus instability could be observed (Figure 3). Her range of motion was 0° to 130°.
3. Discussion The most important finding of the presented case report is that anatomical MCL reconstruction with a flattened semitendinosus autograft represents a valuable surgical treatment option for valgus knee instability after TKA. Medial collateral ligament tears have been described as an intraoperative complication during TKA. Various treatment options including conservative treatment, primary repair, augmentation, inlay elevation and lateral release procedures as well as, the use of a higher constrained prosthesis, are described by several authors [2–8,20,21]. In the present case, there was no evidence of ligamentous instability during the index procedure. However, an iatrogenic intraoperative injury to the MCL, e.g. by the oscillating saw, may have caused subsequent valgus instability postoperatively. Due to the patient's young age and the early postoperative occurrence of the presented complication, a soft tissue reconstruction appeared favorable over a constraint implant. To the best of our knowledge, no report of an anatomical MCL reconstruction
Figure 2. (a, b): (a) A diagram illustrates the medial aspect of the knee prosthesis (white) and medial femoral epicondyle (M). The POL (I) and sMCL (II) are reconstructed with a flattened semitendinosus graft (black). (b) An intraoperative photograph demonstrates the medial epicondyle (M), the vastus medialis oblique muscle (VMO), the patella (P) and the insufficient POL and sMCL. The flattened semitendinosus graft (ST) is pulled into the femoral tunnel. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
G. Wierer et al. / The Knee xxx (2016) xxx–xxx
3
Several limitations are inherent to a single case report. Most significantly the altered biomechanical situation following TKA limits the comparison to previously published studies on anatomical MCL reconstruction. In summary, the presented case report illustrates an early complication following TKA with valgus instability. For anatomical MCL reconstruction the use of a flattened semitendinosus autograft proved to be a valuable treatment option. Nevertheless, all precautions should be taken in primary TKA to avoid laceration of the MCL in the first place. Conflict of interest statement Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. References
Figure 3. At final follow-up the valgus stress radiograph showed no medial opening.
in case of early secondary valgus instability following TKA is presented in literature. Lind et al. [12] published the first study presenting clinical results after isolated MCL reconstruction. They used the term anatomical reconstruction because both the sMCL and POL were augmented with a semitendinosus autograft. In comparison to earlier reports [12,13, 18], we did not retain the tendon's insertion at the pes anserinus, but fixed it with two soft anchors at the anatomic tibial insertion of the sMCL [17]. Suture anchors proved to be a reliable method allowing a large-area fixation [10], which was of major interest because we split the semitendinosus tendon longitudinally in order to flatten the tendon. Converting round tendons to flat tendon constructs showed to have no influence on the structural properties and seems to be a biomechanical stable graft option for anatomic reconstruction of natively flat and wide shaped structures like a MCL [19]. The technique has been utilized in all patients with chronic MCL deficiency without TKA by the senior author (Figure 2). According to LaPrade et al. [17] the femoral attachment sites of the sMCL and POL differ from each other and should be reconstructed separately. In our case this aspect was outweighed by the more demanding technique and modified setting of prior TKA. With this in mind, the term of anatomical MCL reconstruction in patients with knee prosthesis might be discussible. Nonetheless, due to the combined valgus knee laxity at extension and mid-flexion, repair of the sMCL alone without reconstruction of the POL was proven to be insufficient [11–14,22,23]. A recent technical note on isolated sMCL reconstruction in case of valgus laxity during TKA reports neither range of instability nor clinical results, which makes it invalid to compare the two techniques [21]. In case of MCL and POL reconstruction the appropriate rank order and angles for tightening the two grafts are controversial [11–14,22]. Furthermore the postoperative rehabilitation protocols are based on a low level of evidence [12,13,24]. However, the intraoperatively determined “safe zone” for early ROM seems reasonable [25], especially in such extraordinary cases. The presented case is a challenging complication following TKA. Rather than performing salvage procedures towards a more constraint prosthesis, the choice of anatomical ligament reconstruction is of major value especially in relatively young and active patients.
[1] Scott RD. The evolving incidence and reasons for re-operation after fixed-bearing PCL retaining total knee arthroplasty. J Bone Joint Surg Br 2012;94:134–6. [2] Shahi A, Tan TL, Tarabichi S, Maher A, Della Valle C, Saleh UH. Primary repair of iatrogenic medial collateral ligament injury during TKA: a modified technique. J Arthroplasty 2015;30:854–7. [3] 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:86–91. [4] Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res 2011;469:64–8. [5] 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;16:479–83. [6] Stephens S, Politi J, Backes J, Czaplicki T. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics 2012;35:e154–9. [7] 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;24:1249–53. [8] Naudie DD, Rorabeck CH. Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 2004;53:207–15. [9] Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther 2012;42:221–33. [10] Wijdicks CA, Michalski MP, Rasmussen MT, Goldsmith MT, Kennedy NI, Lind M, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med 2013;41: 2858–66. [11] Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, et al. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 2010;38:339–47. [12] Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med 2009;37:1116–22. [13] Kim SJ, Lee DH, Kim TE, Choi NH. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br 2008;90:1323–7. [14] Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L. Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. Am J Sports Med 2009;37: 140–8. [15] Wijdicks CA, Griffith CJ, LaPrade RF, Spiridonov SI, Johansen S, Armitage BM, et al. Medial knee injury: part 2, load sharing between the posterior oblique ligament and superficial medial collateral ligament. Am J Sports Med 2009;37:1771–6. [16] Griffith CJ, LaPrade RF, Johansen S, Armitage B, Wijdicks C, Engebretsen L. Medial knee injury: part 1, static function of the individual components of the main medial knee structures. Am J Sports Med 2009;37:1762–70. [17] LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007;89:2000–10. [18] Madonna V, Screpis D, Condello V, Piovan G, Russo A, Guerriero M, et al. A novel technique for combined medial collateral ligament and posterior oblique ligament reconstruction: technical note. Knee Surg Sports Traumatol Arthrosc 2015;23: 2814–9. [19] Domnick C, Herbort M, Raschke MJ, Schliemann B, Siebold R, Smigielski R, et al. Converting round tendons to flat tendon constructs: does the preparation process have an influence on the structural properties? Knee Surg Sports Traumatol Arthrosc 2015. [20] Siqueira MB, Haller K, Mulder A, Goldblum AS, Klika AK, Barsoum WK. Outcomes of medial collateral ligament injuries during total knee arthroplasty. J Knee Surg 2016; 29:68–73. [21] Adravanti P, Dini F, Calafiore G, Rosa MA. Medial collateral ligament reconstruction during TKA: a new approach and surgical technique. Joints 2015;3:215–7.
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
4
G. Wierer et al. / The Knee xxx (2016) xxx–xxx
[22] Robinson JR, Bull AM, Thomas RR, Amis AA. The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med 2006;34:1815–23. [23] Hughston JC. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Joint Surg Am 1994;76:1328–44.
[24] Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 2010;92:1266–80. [25] Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res 2012;470:806–14.
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
Contents lists available at ScienceDirect
The Knee
Case report
Anatomical MCL reconstruction following TKA Guido Wierer a,⁎, Armin Runer b, Christian Hoser b, Peter Gföller b, Christian Fink b,c a b c
Department of Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria 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
a r t i c l e
i n f o
Article history: Received 15 April 2016 Received in revised form 22 May 2016 Accepted 15 June 2016 Available online xxxx Keywords: Total knee arthroplasty TKA Medial collateral ligament reconstruction MCL Valgus instability
a b s t r a c t 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. © 2016 Elsevier B.V. All rights reserved.
1. Introduction Total knee arthroplasty (TKA) is a widely used technique for the relief of disabling pain caused by severe arthritis. To achieve satisfying postoperative results, adequate knee stability is crucial. The incidence of intraoperative medial collateral ligament (MCL) tears is about 0.4% and the revision rates due to instability after fixedbearing, posterior cruciate ligament (PCL)-retaining TKA are reported to be about five percent of all TKA revisions [1,2]. Hereby, symptomatic medial instability is usually treated with a lateral release procedure and inlay exchange. In more severe cases, revision surgery to a more constrained prosthesis might be necessary [3–8]. While anatomical reconstruction of the MCL has become more popular, no anatomical MCL reconstruction following TKA is reported in the literature to our knowledge [9–18]. In contrast to the current management of medial instability following TKA, we present a case of early TKA failure due to secondary valgus laxity, which was successfully treated with an anatomical MCL reconstruction. 2. Case report A 60-year-old female patient presented to our clinic following a cemented, PCL-retaining total knee prosthesis (Attune, DePuy Synthes, Warsaw, IN) on her left knee six months earlier (Figure 1). ⁎ Corresponding author. Tel.: +43 676 749 75 75. E-mail addresses: [email protected] (G. Wierer), [email protected] (A. Runer), [email protected] (C. Hoser), [email protected] (P. Gföller), c.fi[email protected] (C. Fink).
She was complaining of knee instability during daily activities, accompanied by pain, swelling, limping and the inability to squat. In the clinical examination a high-grade medial instability could be observed in extension and mid-flexion. Valgus stress radiographs showed four millimeters of medial compartment opening (Figure 1) in extension and 10 mm in 20° of flexion. On computed tomography (CT) scans the components of the TKA were well aligned, with no signs of loosening. A long leg view radiograph showed neutral limb alignment. The patient had high demands concerning sports activities (dancing, alpine skiing, hiking, ...) and at the time of presentation the patient was unable to participate in any of these. No improvement was obtained throughout extensive physical therapy so the patient was scheduled for revision surgery. Due to the relatively young age and the high activity level a soft tissue procedure was chosen over an exchange to a constrained implant. Intraoperatively, the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) appeared to be insufficient and the sMCL was scarred at the femoro-tibial joint line (Figure 2). Initially, the femoral insertion of the sMCL was identified and an eyelet-passing pin was drilled transversely across the femur. A 30 mm deep tunnel was drilled with a six millimeter reamer over the previously placed pin. The semitendinosus tendon was then harvested and split longitudinally [19], which allowed flattening of the tendon according to the anatomical shape of the MCL. For the reconstruction of the sMCL approximately 16 cm was estimated. The graft was then pulled into the femoral tunnel and secured with a cannulated bioabsorbable screw (Arthrex, Inc., Naples, FL). To reconstruct the sMCL, the longer rein of the graft was passed distally and secured approximately six centimeters distal to the joint
http://dx.doi.org/10.1016/j.knee.2016.06.006 0968-0160/© 2016 Elsevier B.V. All rights reserved.
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
2
G. Wierer et al. / The Knee xxx (2016) xxx–xxx
Figure 1. (a–c): (a, b) A 60-year-old female patient underwent cemented, PCL-retaining TKA. (c) Valgus stress radiograph shows medial compartment opening.
line at its anatomical insertion site with two 2.9 mm soft anchors (JuggerKnot, Biomet, Warsaw, IN) [17]. The graft was fixed with the tibia in neutral rotation, at 20° of knee flexion, and a slight varus reduction force. Next, the posteromedial capsule was tensioned by capsular plication. To reconstruct the central arm of the POL, the remaining 12 cm of flattened tendon graft were fixed with a 5.5 mm suture anchor (Bio-corkscrew, Arthrex, Inc., Naples, FL) at the dorsomedial tibial plateau, anterior to the direct arm attachment of the semimembranosus tendon [17], and tightened in full extension. Intraoperative examination following MCL reconstruction showed a well-balanced knee, which was confirmed by intraoperative fluoroscopy showing a symmetric join space with no medial gapping during valgus stress neither in extension nor in flexion. Postoperatively, the patient was mobilized with partial weight bearing for three weeks. The range of motion (ROM) was limited to 0° to 30° to 60° for the first six weeks by a hinged knee brace. 2.1. Results The patient's postoperative course was uneventful. At her most recent follow-up 24 months postoperatively all measured scores improved significantly. The pre-operative Lysholm score improved from 27 to 86 postoperatively, the Oxford score from 17 to 47 respectively. The patient reported no more complaints of swelling or limping
and experienced no instability even under strenuous activity. The Tegner Activity Level improved from two to four and the VAS status for pain changed from 10 to one. At clinical and radiological examinations no valgus or varus instability could be observed (Figure 3). Her range of motion was 0° to 130°.
3. Discussion The most important finding of the presented case report is that anatomical MCL reconstruction with a flattened semitendinosus autograft represents a valuable surgical treatment option for valgus knee instability after TKA. Medial collateral ligament tears have been described as an intraoperative complication during TKA. Various treatment options including conservative treatment, primary repair, augmentation, inlay elevation and lateral release procedures as well as, the use of a higher constrained prosthesis, are described by several authors [2–8,20,21]. In the present case, there was no evidence of ligamentous instability during the index procedure. However, an iatrogenic intraoperative injury to the MCL, e.g. by the oscillating saw, may have caused subsequent valgus instability postoperatively. Due to the patient's young age and the early postoperative occurrence of the presented complication, a soft tissue reconstruction appeared favorable over a constraint implant. To the best of our knowledge, no report of an anatomical MCL reconstruction
Figure 2. (a, b): (a) A diagram illustrates the medial aspect of the knee prosthesis (white) and medial femoral epicondyle (M). The POL (I) and sMCL (II) are reconstructed with a flattened semitendinosus graft (black). (b) An intraoperative photograph demonstrates the medial epicondyle (M), the vastus medialis oblique muscle (VMO), the patella (P) and the insufficient POL and sMCL. The flattened semitendinosus graft (ST) is pulled into the femoral tunnel. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
G. Wierer et al. / The Knee xxx (2016) xxx–xxx
3
Several limitations are inherent to a single case report. Most significantly the altered biomechanical situation following TKA limits the comparison to previously published studies on anatomical MCL reconstruction. In summary, the presented case report illustrates an early complication following TKA with valgus instability. For anatomical MCL reconstruction the use of a flattened semitendinosus autograft proved to be a valuable treatment option. Nevertheless, all precautions should be taken in primary TKA to avoid laceration of the MCL in the first place. Conflict of interest statement Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. References
Figure 3. At final follow-up the valgus stress radiograph showed no medial opening.
in case of early secondary valgus instability following TKA is presented in literature. Lind et al. [12] published the first study presenting clinical results after isolated MCL reconstruction. They used the term anatomical reconstruction because both the sMCL and POL were augmented with a semitendinosus autograft. In comparison to earlier reports [12,13, 18], we did not retain the tendon's insertion at the pes anserinus, but fixed it with two soft anchors at the anatomic tibial insertion of the sMCL [17]. Suture anchors proved to be a reliable method allowing a large-area fixation [10], which was of major interest because we split the semitendinosus tendon longitudinally in order to flatten the tendon. Converting round tendons to flat tendon constructs showed to have no influence on the structural properties and seems to be a biomechanical stable graft option for anatomic reconstruction of natively flat and wide shaped structures like a MCL [19]. The technique has been utilized in all patients with chronic MCL deficiency without TKA by the senior author (Figure 2). According to LaPrade et al. [17] the femoral attachment sites of the sMCL and POL differ from each other and should be reconstructed separately. In our case this aspect was outweighed by the more demanding technique and modified setting of prior TKA. With this in mind, the term of anatomical MCL reconstruction in patients with knee prosthesis might be discussible. Nonetheless, due to the combined valgus knee laxity at extension and mid-flexion, repair of the sMCL alone without reconstruction of the POL was proven to be insufficient [11–14,22,23]. A recent technical note on isolated sMCL reconstruction in case of valgus laxity during TKA reports neither range of instability nor clinical results, which makes it invalid to compare the two techniques [21]. In case of MCL and POL reconstruction the appropriate rank order and angles for tightening the two grafts are controversial [11–14,22]. Furthermore the postoperative rehabilitation protocols are based on a low level of evidence [12,13,24]. However, the intraoperatively determined “safe zone” for early ROM seems reasonable [25], especially in such extraordinary cases. The presented case is a challenging complication following TKA. Rather than performing salvage procedures towards a more constraint prosthesis, the choice of anatomical ligament reconstruction is of major value especially in relatively young and active patients.
[1] Scott RD. The evolving incidence and reasons for re-operation after fixed-bearing PCL retaining total knee arthroplasty. J Bone Joint Surg Br 2012;94:134–6. [2] Shahi A, Tan TL, Tarabichi S, Maher A, Della Valle C, Saleh UH. Primary repair of iatrogenic medial collateral ligament injury during TKA: a modified technique. J Arthroplasty 2015;30:854–7. [3] 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:86–91. [4] Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res 2011;469:64–8. [5] 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;16:479–83. [6] Stephens S, Politi J, Backes J, Czaplicki T. Repair of medial collateral ligament injury during total knee arthoplasty. Orthopedics 2012;35:e154–9. [7] 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;24:1249–53. [8] Naudie DD, Rorabeck CH. Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 2004;53:207–15. [9] Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther 2012;42:221–33. [10] Wijdicks CA, Michalski MP, Rasmussen MT, Goldsmith MT, Kennedy NI, Lind M, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med 2013;41: 2858–66. [11] Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, et al. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 2010;38:339–47. [12] Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med 2009;37:1116–22. [13] Kim SJ, Lee DH, Kim TE, Choi NH. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br 2008;90:1323–7. [14] Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L. Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. Am J Sports Med 2009;37: 140–8. [15] Wijdicks CA, Griffith CJ, LaPrade RF, Spiridonov SI, Johansen S, Armitage BM, et al. Medial knee injury: part 2, load sharing between the posterior oblique ligament and superficial medial collateral ligament. Am J Sports Med 2009;37:1771–6. [16] Griffith CJ, LaPrade RF, Johansen S, Armitage B, Wijdicks C, Engebretsen L. Medial knee injury: part 1, static function of the individual components of the main medial knee structures. Am J Sports Med 2009;37:1762–70. [17] LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007;89:2000–10. [18] Madonna V, Screpis D, Condello V, Piovan G, Russo A, Guerriero M, et al. A novel technique for combined medial collateral ligament and posterior oblique ligament reconstruction: technical note. Knee Surg Sports Traumatol Arthrosc 2015;23: 2814–9. [19] Domnick C, Herbort M, Raschke MJ, Schliemann B, Siebold R, Smigielski R, et al. Converting round tendons to flat tendon constructs: does the preparation process have an influence on the structural properties? Knee Surg Sports Traumatol Arthrosc 2015. [20] Siqueira MB, Haller K, Mulder A, Goldblum AS, Klika AK, Barsoum WK. Outcomes of medial collateral ligament injuries during total knee arthroplasty. J Knee Surg 2016; 29:68–73. [21] Adravanti P, Dini F, Calafiore G, Rosa MA. Medial collateral ligament reconstruction during TKA: a new approach and surgical technique. Joints 2015;3:215–7.
Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006
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Please cite this article as: Wierer G, et al, Anatomical MCL reconstruction following TKA, Knee (2016), http://dx.doi.org/10.1016/ j.knee.2016.06.006