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Arthroscopic Trans-Portal Deep Medial Collateral Ligament Pie-Crusting Release
Arthroscopic Trans-Portal Deep Medial Collateral Ligament Pie-Crusting Release Ehud Atoun, M.D., Ronen Debbi, M.D., Omri Lubovsky, M.D., Andreas Weiler, M.D., Eytan Debbi, MSc, and Ehud Rath, M.D.
Abstract: Arthroscopic treatments of meniscal injuries of the knee are among the most common orthopaedic procedures performed. Adequate visualization of the posterior horn of the medial meniscus might be challenging, especially in patients with tight medial compartments. In these cases instrument manipulation in an attempt to reach the posterior horn of the meniscus can cause an iatrogenic chondral injury because of the narrow medial joint space. A transcutaneous medial collateral ligament (MCL) pie-crusting release facilitates expansion of the medial joint space in a case of a tight medial compartment. Nevertheless, it might cause injury to the superficial MCL, infection, and pain and injury to the saphenous nerve because of multiple needle punctures of the skin. We describe an inside-out, arthroscopic deep MCL piecrusting release, which allows access to the medial meniscus through the anterior approach to provide good visualization of the footprint and sufficient working space.
M
and the superficial MCL, under direct visualization and control.
From the Orthopaedic Department, Barzilai Medical Center (E.A., R.D., O.L., E.D.), Ashkelon, Ben-Gurion University of the Negev (E.A., R.D., O.L.), Be’er Sheva, and the Orthopaedic Division, Tel Aviv Souraski Medical Center (E.R.), Tel Aviv, Israel; and the Arthroscopy Service, Charité, Campus Virchow-Klinikum, Humboldt-University (A.W.), Berlin, Germany. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 21, 2012; accepted October 23, 2012. Address correspondence to Ehud Atoun, M.D., Orthopaedic Department, Barzilai Medical Center, 2 Hahistadrout St, Ashkelon 78278, Israel. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12338/$36.00 http://dx.doi.org/10.1016/j.eats.2012.10.008
The procedure is performed with the patient under general anesthesia. The patient is positioned supine on the operating table with a pneumatic tourniquet and a side support about the proximal aspect of the thigh. After the induction of anesthesia, he or she is examined to evaluate the stability and range of motion of the joint. A routine inspection of the joint is made through standard anterolateral and anteromedial portals. When pathology of the posterior horn of the medial meniscus is found in patients with a narrow medial joint space in which the meniscus is not fully visualized (Fig 1), an inside-out MCL pie crusting is performed to enable easier access to the posterior horn. The junction of the body and posterior horn of the medial meniscus are visualized with a 30 arthroscope through the anterolateral portal. An 18-gauge needle is inserted through the anteromedial portal, and a gentle valgus force is applied. Multiple needle punctures of the deep MCL are performed under direct visualization, starting at the posterior-most part of the ligament just proximal to the meniscosynovial junction (Fig 2). Puncturing to sever the deep MCL fibers is then extended anteriorly, while the surgeon applies a gentle valgus strain to the knee, until adequate visualization of the entire posterior horn of the medial meniscus is achieved (Fig 3).
eniscal tear is a commonly encountered clinical entity for the practicing orthopaedic surgeon, with an incidence as high as 6 per 1,000 persons in the population.1 Arthroscopic treatments for meniscal injuries are among the most common orthopaedic procedures performed, constituting 10% to 20% of all surgeries at some centers.2,3 Although optimal visualization is crucial for diagnosis and treatment of meniscal pathologies, access to the posterior horn of the medial meniscus might be challenging in patients with tight medial compartments.4,5 We describe our experience with an arthroscopic, inside-out, selective deep medial collateral ligament (MCL) pie-crusting release technique that allows good visualization of the posterior horn of the medial meniscus in patients with tight medial compartments. The procedure is performed without traversing the skin
Technique
Arthroscopy Techniques, Vol 2, No 1 (February), 2013: pp e41-e43
e41
e42
E. ATOUN ET AL.
Fig 1. Typical arthroscopic visualization of medial meniscus in a patient with a narrow medial joint space.
Fig 3. Typical arthroscopic visualization of medial meniscus after arthroscopic pie crusting.
At this stage, dedicated instruments are easily inserted into the joint, and the pathologies of the meniscus can be addressed while minimizing iatrogenic chondral damage to the knee (Fig 4, Video 1).
Optimal visualization and access are crucial for diagnosis and treatment of meniscal pathologies. Access to the posterior horn of the medial meniscus can be challenging in patients with tight medial compartments. In such cases the anterior arthroscopic approach5,6 can cause iatrogenic chondral injury because of the narrow medial joint space.4,7,8 To obtain good visualization of the posterior horn of the medial meniscus and sufficient working space, multiple outside-in needle punctures of the MCL were described by Park et al.9 as a modification of the open pie-crusting release technique that is performed in total knee replacement.9-12 This technique includes multiple transcutaneous needle punctures of the deep MCL.
Little postoperative instability was reported after arthroscopic MCL release for medial-compartment osteoarthritis,13,14 as well as an approach to the posterior horn of the medial meniscus in a tight knee.9,15 Normal knee function was found, whereas the remaining structures, particularly the anterior cruciate ligament, compensated for the functional deficit of the transected MCL.13 We found achieving visualization and access to the posterior horn of the medial meniscus in patients with tight medial compartments to be very difficult; moreover, attempts to treat these pathologies without release of the MCL can cause iatrogenic chondral damage or uncontrolled damage to the MCL while applying excessive valgus stress to the knee. The outside-in arthroscopic pie-crusting release technique enables the surgeon to access these pathologies, but we have found it to be painful to the patient because of the multiple punctures of the skin; in addition, the release itself can be cumbersome because of the additional maneuvers that are needed to determine the accurate location of the
Fig 2. Trans-portal arthroscopic puncturing of posterior-most part of deep MCL.
Fig 4. Ease of access to posterior horn of medial meniscus after pie crusting.
Discussion
ARTHROSCOPIC PIE-CRUSTING RELEASE Table 1. Comparison of Techniques to Address Medial Meniscal Pathologies in Patients With Tight Knees Risks
No Release
Outside In
Inside Out
Chondral damage Pain Saphenous nerve injury Infection Uncontrolled release Injury to superficial MCL
þþþ þþþ þ þþþ þþ
þ þ þþ þ þþ
þ
, No risk; +, mild risk; ++, moderate risk; +++, high risk.
needle. Moreover, in the outside-in technique, the superficial MCL or saphenous nerve may be severed as the needle courses on its way to the deep MCL (Table 1). We have been using the arthroscopic inside-out piecrusting technique, which is performed under direct visualization through the standard anteromedial portal. In this technique the posterior portion of the deep MCL is released under careful control while the surgeon applies a valgus force to the knee until the entire posterior horn of the medial meniscus is visualized and arthroscopic tools can be inserted without chondral damage. We have used this technique in the past 5 years for patients with tight medial compartments who underwent knee arthroscopy for various meniscal and chondral pathologies. The technique using an inside-out deep MCL piecrusting release could provide good visualization of the posterior horn of the medial meniscus and sufficient working space in patients with tight medial compartments.
References 1. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees. Am J Sports Med 2004;32:675-680. 2. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am 2006;88:660-667. 3. Renstrom P, Johnson RJ. Anatomy and biomechanics of the menisci. Clin Sports Med 1990;9:523-538. 4. Ahn JH, Wang JH, Yoo JC, Noh HK, Park JH. A pull out suture for transection of the posterior horn of the medial
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
e43
meniscus: Using a posterior trans-septal portal. Knee Surg Sports Traumatol Arthrosc 2007;15:1510-1513. Kim YM, Rhee KJ, Lee JK, Hwang DS, Yang JY, Kim SJ. Arthroscopic pullout repair of a complete radial tear of the tibial attachment site of the medial meniscus posterior horn. Arthroscopy 2006;22:795.e1-795.e4. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: Radiographic and clinical results with a 2-year follow-up. Arthroscopy 2009;25:951-958. Choi NH, Son KM, Victoroff BN. Arthroscopic all-inside repair for a tear of posterior root of the medial meniscus: A technical note. Knee Surg Sports Traumatol Arthrosc 2008;16:891-893. Kim JH, Shin DE, Dan JM, Nam KS, Ahn TK, Lee DH. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: Technical note. Arch Orthop Trauma Surg 2009;129:1085-1088. Park YS, Moon HK, Koh YG, et al. Arthroscopic pullout repair of posterior root tear of the medial meniscus: The anterior approach using medial collateral ligament piecrusting release. Knee Surg Sports Traumatol Arthrosc 2011;19:1334-1336. Mihalko WM, Krackow KA. Anatomic and biomechanical aspects of pie crusting posterolateral structures for valgus deformity correction in total knee arthroplasty: A cadaveric study. J Arthroplasty 2000;15:347-353. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am 2005;87(suppl 1): 271-284. Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R, Ranawat AS. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. J Bone Joint Surg Am 2004;86:2671-2676. Leon HO, Blanco CE, Guthrie TB. Arthroscopic decompressive medial release of the varus arthritic knee: Expanding the functional envelope. Arthroscopy 2001;17: 523-526. Lyu SR. Arthroscopic medial release for medial compartment osteoarthritis of the knee: The result of a single surgeon series with a minimum follow-up of four years. J Bone Joint Surg Br 2008;90:1186-1192. Jo CH, Yoon KS, Lee JH, et al. Under-meniscal portal: An alternative portal for an easy access to the medial and lateral menisci. Knee Surg Sports Traumatol Arthrosc 2009;17:1344-1346.
Abstract: Arthroscopic treatments of meniscal injuries of the knee are among the most common orthopaedic procedures performed. Adequate visualization of the posterior horn of the medial meniscus might be challenging, especially in patients with tight medial compartments. In these cases instrument manipulation in an attempt to reach the posterior horn of the meniscus can cause an iatrogenic chondral injury because of the narrow medial joint space. A transcutaneous medial collateral ligament (MCL) pie-crusting release facilitates expansion of the medial joint space in a case of a tight medial compartment. Nevertheless, it might cause injury to the superficial MCL, infection, and pain and injury to the saphenous nerve because of multiple needle punctures of the skin. We describe an inside-out, arthroscopic deep MCL piecrusting release, which allows access to the medial meniscus through the anterior approach to provide good visualization of the footprint and sufficient working space.
M
and the superficial MCL, under direct visualization and control.
From the Orthopaedic Department, Barzilai Medical Center (E.A., R.D., O.L., E.D.), Ashkelon, Ben-Gurion University of the Negev (E.A., R.D., O.L.), Be’er Sheva, and the Orthopaedic Division, Tel Aviv Souraski Medical Center (E.R.), Tel Aviv, Israel; and the Arthroscopy Service, Charité, Campus Virchow-Klinikum, Humboldt-University (A.W.), Berlin, Germany. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 21, 2012; accepted October 23, 2012. Address correspondence to Ehud Atoun, M.D., Orthopaedic Department, Barzilai Medical Center, 2 Hahistadrout St, Ashkelon 78278, Israel. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12338/$36.00 http://dx.doi.org/10.1016/j.eats.2012.10.008
The procedure is performed with the patient under general anesthesia. The patient is positioned supine on the operating table with a pneumatic tourniquet and a side support about the proximal aspect of the thigh. After the induction of anesthesia, he or she is examined to evaluate the stability and range of motion of the joint. A routine inspection of the joint is made through standard anterolateral and anteromedial portals. When pathology of the posterior horn of the medial meniscus is found in patients with a narrow medial joint space in which the meniscus is not fully visualized (Fig 1), an inside-out MCL pie crusting is performed to enable easier access to the posterior horn. The junction of the body and posterior horn of the medial meniscus are visualized with a 30 arthroscope through the anterolateral portal. An 18-gauge needle is inserted through the anteromedial portal, and a gentle valgus force is applied. Multiple needle punctures of the deep MCL are performed under direct visualization, starting at the posterior-most part of the ligament just proximal to the meniscosynovial junction (Fig 2). Puncturing to sever the deep MCL fibers is then extended anteriorly, while the surgeon applies a gentle valgus strain to the knee, until adequate visualization of the entire posterior horn of the medial meniscus is achieved (Fig 3).
eniscal tear is a commonly encountered clinical entity for the practicing orthopaedic surgeon, with an incidence as high as 6 per 1,000 persons in the population.1 Arthroscopic treatments for meniscal injuries are among the most common orthopaedic procedures performed, constituting 10% to 20% of all surgeries at some centers.2,3 Although optimal visualization is crucial for diagnosis and treatment of meniscal pathologies, access to the posterior horn of the medial meniscus might be challenging in patients with tight medial compartments.4,5 We describe our experience with an arthroscopic, inside-out, selective deep medial collateral ligament (MCL) pie-crusting release technique that allows good visualization of the posterior horn of the medial meniscus in patients with tight medial compartments. The procedure is performed without traversing the skin
Technique
Arthroscopy Techniques, Vol 2, No 1 (February), 2013: pp e41-e43
e41
e42
E. ATOUN ET AL.
Fig 1. Typical arthroscopic visualization of medial meniscus in a patient with a narrow medial joint space.
Fig 3. Typical arthroscopic visualization of medial meniscus after arthroscopic pie crusting.
At this stage, dedicated instruments are easily inserted into the joint, and the pathologies of the meniscus can be addressed while minimizing iatrogenic chondral damage to the knee (Fig 4, Video 1).
Optimal visualization and access are crucial for diagnosis and treatment of meniscal pathologies. Access to the posterior horn of the medial meniscus can be challenging in patients with tight medial compartments. In such cases the anterior arthroscopic approach5,6 can cause iatrogenic chondral injury because of the narrow medial joint space.4,7,8 To obtain good visualization of the posterior horn of the medial meniscus and sufficient working space, multiple outside-in needle punctures of the MCL were described by Park et al.9 as a modification of the open pie-crusting release technique that is performed in total knee replacement.9-12 This technique includes multiple transcutaneous needle punctures of the deep MCL.
Little postoperative instability was reported after arthroscopic MCL release for medial-compartment osteoarthritis,13,14 as well as an approach to the posterior horn of the medial meniscus in a tight knee.9,15 Normal knee function was found, whereas the remaining structures, particularly the anterior cruciate ligament, compensated for the functional deficit of the transected MCL.13 We found achieving visualization and access to the posterior horn of the medial meniscus in patients with tight medial compartments to be very difficult; moreover, attempts to treat these pathologies without release of the MCL can cause iatrogenic chondral damage or uncontrolled damage to the MCL while applying excessive valgus stress to the knee. The outside-in arthroscopic pie-crusting release technique enables the surgeon to access these pathologies, but we have found it to be painful to the patient because of the multiple punctures of the skin; in addition, the release itself can be cumbersome because of the additional maneuvers that are needed to determine the accurate location of the
Fig 2. Trans-portal arthroscopic puncturing of posterior-most part of deep MCL.
Fig 4. Ease of access to posterior horn of medial meniscus after pie crusting.
Discussion
ARTHROSCOPIC PIE-CRUSTING RELEASE Table 1. Comparison of Techniques to Address Medial Meniscal Pathologies in Patients With Tight Knees Risks
No Release
Outside In
Inside Out
Chondral damage Pain Saphenous nerve injury Infection Uncontrolled release Injury to superficial MCL
þþþ þþþ þ þþþ þþ
þ þ þþ þ þþ
þ
, No risk; +, mild risk; ++, moderate risk; +++, high risk.
needle. Moreover, in the outside-in technique, the superficial MCL or saphenous nerve may be severed as the needle courses on its way to the deep MCL (Table 1). We have been using the arthroscopic inside-out piecrusting technique, which is performed under direct visualization through the standard anteromedial portal. In this technique the posterior portion of the deep MCL is released under careful control while the surgeon applies a valgus force to the knee until the entire posterior horn of the medial meniscus is visualized and arthroscopic tools can be inserted without chondral damage. We have used this technique in the past 5 years for patients with tight medial compartments who underwent knee arthroscopy for various meniscal and chondral pathologies. The technique using an inside-out deep MCL piecrusting release could provide good visualization of the posterior horn of the medial meniscus and sufficient working space in patients with tight medial compartments.
References 1. Metcalf MH, Barrett GR. Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees. Am J Sports Med 2004;32:675-680. 2. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am 2006;88:660-667. 3. Renstrom P, Johnson RJ. Anatomy and biomechanics of the menisci. Clin Sports Med 1990;9:523-538. 4. Ahn JH, Wang JH, Yoo JC, Noh HK, Park JH. A pull out suture for transection of the posterior horn of the medial
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
e43
meniscus: Using a posterior trans-septal portal. Knee Surg Sports Traumatol Arthrosc 2007;15:1510-1513. Kim YM, Rhee KJ, Lee JK, Hwang DS, Yang JY, Kim SJ. Arthroscopic pullout repair of a complete radial tear of the tibial attachment site of the medial meniscus posterior horn. Arthroscopy 2006;22:795.e1-795.e4. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: Radiographic and clinical results with a 2-year follow-up. Arthroscopy 2009;25:951-958. Choi NH, Son KM, Victoroff BN. Arthroscopic all-inside repair for a tear of posterior root of the medial meniscus: A technical note. Knee Surg Sports Traumatol Arthrosc 2008;16:891-893. Kim JH, Shin DE, Dan JM, Nam KS, Ahn TK, Lee DH. Arthroscopic suture anchor repair of posterior root attachment injury in medial meniscus: Technical note. Arch Orthop Trauma Surg 2009;129:1085-1088. Park YS, Moon HK, Koh YG, et al. Arthroscopic pullout repair of posterior root tear of the medial meniscus: The anterior approach using medial collateral ligament piecrusting release. Knee Surg Sports Traumatol Arthrosc 2011;19:1334-1336. Mihalko WM, Krackow KA. Anatomic and biomechanical aspects of pie crusting posterolateral structures for valgus deformity correction in total knee arthroplasty: A cadaveric study. J Arthroplasty 2000;15:347-353. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am 2005;87(suppl 1): 271-284. Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R, Ranawat AS. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. J Bone Joint Surg Am 2004;86:2671-2676. Leon HO, Blanco CE, Guthrie TB. Arthroscopic decompressive medial release of the varus arthritic knee: Expanding the functional envelope. Arthroscopy 2001;17: 523-526. Lyu SR. Arthroscopic medial release for medial compartment osteoarthritis of the knee: The result of a single surgeon series with a minimum follow-up of four years. J Bone Joint Surg Br 2008;90:1186-1192. Jo CH, Yoon KS, Lee JH, et al. Under-meniscal portal: An alternative portal for an easy access to the medial and lateral menisci. Knee Surg Sports Traumatol Arthrosc 2009;17:1344-1346.