Arthroscopic decompressive medial release of the varus arthritic knee: Expanding the functional envelope

doi:10.1053/jars.2001.24066

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 17, Issue 5, May–June 2001, Pages 523-526

https://doi.org/10.1053/jars.2001.24066 Get rights and content

Abstract

We present the rationale and technique for treating medial knee osteoarthritis by dynamically unloading the medial compartment of the knee. Recent advances in kinematic studies indicate a dynamic linkage between differing degrees of freedom in the knee joint. Both the adduction moment and the foot progression angle are important determinants of medial compartment loading. The medially osteoarthritic knee has progressive compromise of free motion in more than 1 plane. Arthroscopic decompressive medial release unloads the medial compartment by release of the medial capsule and medial collateral ligament in the presence of intact cruciate ligaments, which may allow a decreased adduction moment and decrease of the external rotation restraint in extension found in more severely osteoarthritic knees. A case series of 38 patients with medial gonarthrosis was treated by this technique at the Hermanos Ameijeiras Hospital in Havana, Cuba. All patients had good results without postoperative valgus instability or significant complications. We feel that this technique warrants further clinical and biomechanical study for its use in isolation or in combination with high tibial osteotomy or minimally invasive selective osteotomy for the treatment of medial gonarthrosis of the knee. A minimally invasive, selective approach to biomechanical factors in osteoarthritis may be combined with other modulating techniques in efforts to forestall or prevent the need for total joint replacement.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 523–526

Section snippets

Preoperative selection

Patients best suited for this procedure are those with Ahlback grade III or higher changes and medial collateral/capsular tightness, regardless of the degree of varus. It is our opinion that the procedure may be combined with HTO if desired in patients with higher degrees of varus, although our series did not include HTO patients. A functional anterior cruciate ligament (ACL) is required to prevent excessive laxity.

Operative procedure

After induction of adequate anesthesia, the patient is positioned supine with a

Discussion

Thirty-eight patients with medial gonarthrosis have been treated with the above protocol. No high tibial osteotomies were used. There were no significant complications. All patients had more than 1 year of follow-up and 23 patients were seen for a 2-year follow-up. All patients had good to excellent results with full knee motion and no or occasional mild discomfort. All were satisfied with the procedure. No symptomatic postoperative instability was encountered.

As biomechanical and kinematic

References (21)

DL Kowalk et al.
Abduction-adduction moments at the knee during stair ascent and descent
J Biomech
(1996)
DK Ramsey et al.
Biomechanics of the knee: Methodological considerations in the in vivo kinematic analysis of the tibiofemoral and patellofemoral joint
Clin Biomech (Bristol, Avon)
(1999)
NM Fisher et al.
Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation
Disabil Rehabil
(1997)
M Fransen et al.
A revised group exercise program for osteoarthritis of the knee
Physiother Res Int
(1997)
BE Baker et al.
A biomechanical study of the static stabilizing effect of knee braces on medial stability
Am J Sports Med
(1987)
TN Lindenfeld et al.
Joint loading with valgus bracing in patients with varus gonarthrosis
Clin Orthop
(1997)
M Andrews et al.
Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: A critical analysis of the reliability of gait analysis data
J Orthop Res
(1996)
L Sharma et al.
Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis
Arthritis Rheum
(1998)
CC Prodromos et al.
A relationship between gait and clinical changes following high tibial osteotomy
J Bone Joint Surg Am
(1985)
M Wada et al.
Relationship between gait and clinical results after high tibial osteotomy
Clin Orthop
(1998)

There are more references available in the full text version of this article.

Cited by (22)

Percutaneous Partial Outside-In Release of Medial Collateral Ligament for Arthroscopic Medial Meniscus Surgery With Tight Medial Compartment by Finding a “Magic Point”
2020, Arthroscopy Techniques
Citation Excerpt :
Although Park et al.3 used a similar posteromedial release technique and reported that the released structure was the deep MCL, many techniques have been described in the literature to increase the medial joint space and to prevent the aforementioned complications. Spahn14 applied intra-articular medial capsule and medial collateral ligament release as suggested by Leon et al.15 to treat varus arthritic knee, whereas others have suggested using the posteromedial portal for direct inspection of lesions of the posterior horn of the medial meniscus2,16-18 and accessing the inframeniscal portal for instrument assessment. The aforementioned methods are technically difficult and may have follow-up morbidities; hence, they are not popular among arthroscopy surgeons.
The medial meniscus is one of the more commonly injured structures as compared with the lateral meniscus. In patients with tight medial joint space, it is difficult to visualize the posterior horn and posterior root of medial meniscus and even more difficult to use instrumentation for surgical procedures. Normally, the mean medial joint space (4.74 ± 0.75 mm) is less than the mean lateral joint space width (5.63 ± 0.86). Forceful instrumentation in a tight and a narrow medial joint compartment may cause damage to the articular cartilage, which may increase chances of arthritis in future. To increase the opening of the medial compartment after valgus extension stress position of the knee, different techniques of medial collateral ligament release have been described in the literature. However, the majority of articles describe a multiple-puncture method to the medial collateral ligament called the “pie-crusting” method, not explaining the exact point or precise location of release. Here, we describe a simple and reliable method of medial collateral ligament release by finding the exact release point, a “magic point” to increase the medial joint compartment width to facilitate better visualization and instrumentation for surgical procedures.
Does Release of the Superficial Medial Collateral Ligament Result in Clinically Harmful Effects After the Fixation of Medial Meniscus Posterior Root Tears?
2017, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
In a biomechanical study, the complete release of the distal fibers of the MCL resulted in effective decompression of medial compartment pressure after a medial opening wedge HTO.17 Arthroscopic medial compartment release could result in reduced pain and favorable outcomes without instability in a varus arthritic knee.7,8 Fakioglu et al.4 reported that the percutaneous release of the sMCL proximal to the medial meniscus in tight knees during arthroscopic meniscectomy made it easier to handle in posterior medial meniscus tears and allowed for a better understanding of tear configurations, thus helping to avoid iatrogenic chondral lesions.
To investigate pain and tenderness, stress testing, clinical outcome scores, complications, and operation time at 24 months and magnetic resonance imaging (MRI) analysis at 12 months after the release of the distal attachment of the superficial medial collateral ligament (sMCL) during medial meniscus posterior root tear (MMPRT) fixation.
Patients who received MMPRT fixation with a follow-up of at least 2 years were included. During fixation, the release of the distal attachment of the sMCL on the proximal tibia was performed to improve visualization and provide sufficient working space. Pain and tenderness at the released area, manual valgus stress tests of 30° and 0° flexion (grade 0/1/2/3), and subjective instability during weight bearing were evaluated serially at postoperative 3, 6, 12, and 24+ months. The contour of detachment area was assessed using MRI 12 months postoperatively. As a subgroup analysis, tourniquet time (minutes) and final clinical scores were compared between release and nonrelease groups.
The numbers of participants in the release and nonrelease groups were 118 and 20 patients, and their mean follow-up durations were 42.4 ± 19.3 (24-95) and 37.2 ± 7.8 (30-55) months, respectively. In the release group, percentages of patients with pain and tenderness at 3 months were 15% and 18%, respectively; however, no patients had symptoms at 12 months. In valgus stress tests (30°, 0°), 12% and 2% of patients showed grade 1 laxity at 3 months, and 7% had grade 1 laxity in only 30° flexion at the final follow-up. However, no patients had subjective valgus laxity. An intact contour was confirmed in all cases among 94 patients checked by performing follow-up MRI. Tourniquet time was significantly shorter in the release group (42.4 ± 19.3) than in the nonrelease group (58.5 ± 9.5; P < .001). Between release and nonrelease groups, Lysholm (84.4 ± 12.1, 88.1 ± 12.8; P = .117) and International Knee Documentation Committee scores (73.6 ± 11.2, 77.5 ± 11.9; P = .112) did not differ.
The release of the distal attachment of the sMCL during fixation of MMPRT did not result in pain and tenderness, residual instability, and complication. An intact contour of the sMCL was confirmed in all cases with MRI. This procedure reduced operation time and showed similar clinical results when compared between the release and nonrelease groups. However, this study had low power to detect the difference for clinical scores between the 2 groups.
Level IV, therapeutic case series.
Complications in posteromedial arthroscopic suture of the medial meniscus
2016, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
There are biomechanical explanations [18–20] for this high rate of failure, but also a technical explanation in terms of the narrowness of access to the posterior horn on an anterior portal, compromising diagnosis, freshening and suturing. Alternatives (use of distractors, or medial collateral ligament “pie-crusting” using a needle [21–23]) have been proposed, improving visibility in the posterior horn but not in the most peripheral area, which is the site of a capsulomeniscal or ramp lesion in 16.6–40% of cases of ACL repair [10,12,24]. Posterior visualization of the posterior spaces through the intercondylar notch is therefore recommended as routine practice [25–28].
All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing.
The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates.
Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire.
The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31 months (range, 28–35 months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of “postage-stamp” effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45 cm²).
Some retears, or “partial failures”, may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal.
The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal.
IV.
Complications in posteromedial arthroscopic suture of the medial meniscus
2016, Revue de Chirurgie Orthopedique et Traumatologique
Les sutures tout en dedans par abord postéromédial des lésions du segment postérieur du ménisque médial lors de la reconstruction du LCA permettent un avivement efficace et montrent de bons résultats sur le taux de cicatrisation.
Nous faisons l’hypothèse que la réalisation de l’abord postéromédial permet d’obtenir un taux de cicatrisation satisfaisant sans augmenter la morbidité et le taux de complications.
La survenue de complications peropératoires et postopératoires a été colligée dans une série consécutive monocentrique de 132 patients ayant bénéficié d’une suture du ménisque médial au crochet par abord postéromédial conjointement à une reconstruction du LCA. La cicatrisation méniscale a été évaluée par le taux de récidive d’une lésion symptomatique du ménisque médial (critère de Barett) et lors de la reprise chirurgicale lorsqu’elle était réalisée (aspect et étendue de la lésion itérative). Les troubles de la sensibilité et leurs étendues ont été évalués à l’aide d’un questionnaire.
Le taux de complications peropératoires est de 1,5 % (2 ponctions de la veine saphène interne). Au recul moyen de 31 mois (28–35 mois), aucun patient n’était perdu de vue. Douze patients ont présenté une récidive symptomatique de la lésion du ménisque médial (9 %) ayant conduit à 10 réopérations. Dans 6 cas, les lésions récurrentes survenaient dans une portion plus petite et plus centrale du ménisque en avant des fils décrivant un « timbre-poste » et potentiellement induite par le crochet de suture et/ou le fil non résorbable (4,5 %). Aucun cas d’infection, de fistule n’a été rapporté. Sept pour cent des patients ont présenté un hématome dans les suites. Deux patients (1,8 %) estiment présenter des zones de dysesthésies supérieures ou égales à la surface d’une carte bancaire, soit 45 cm².
La récidive de certaines lésions appelée échec partiel peut s’expliquer par la survenue de nouvelles lésions induites par le crochet et possiblement maintenu par le fil non résorbable utilisé pour la suture. Les hématomes et la survenue de troubles sensitifs sont comparables aux séries de reconstruction isolée du ligament croisé antérieur sans abord postéromédial.
Nos résultats montrent que la suture arthroscopique au crochet par abord postéromédial des lésions postérieures du ménisque médial permet un taux de cicatrisation élevé sans augmenter la morbidité liée à l’abord supplémentaire.
Étude de niveau IV.
The effect of percutaneous release of the medial collateral ligament in arthroscopic medial meniscectomy on functional outcome
2016, Knee
Citation Excerpt :
These results confirm that decompression of the medial compartment of the knee in patients with mild chondropathies does not affect stability and, in fact, favors functional recovery. In 2001, Leon et al. [14] described arthroscopic decompressive medial release of the varus arthritic knee. From an intra-articular position, they sectioned the medial capsule together with the posterior portion of the MCL.
Pie crusting (PC) of the medial collateral ligament (MCL) in the knee has been used empirically to achieve more space in the medial compartment during knee arthroscopy. However, there are no reported studies analyzing the functional results of the application of the PC technique to the MCL in patients undergoing arthroscopic meniscectomy of the medial meniscus, and to determine the rate of iatrogenic injury and associated morbidity.
The patient was in a supine position with a tourniquet and a side post. Percutaneous controlled release of the posterior part of the MCL was performed using an intramuscular needle, and a mild valgus force was applied while viewing with the arthroscope of the controlled progressive gain in medial compartment space.
A retrospective clinical study of 140 patients undergoing arthroscopic meniscectomy with or without MCL PC was conducted. Tegner and Lysholm tests and visual analogue scales were used to assess pain and functional results.
The patients in the group with meniscectomy and PC had higher scores on the Lysholm scale, less pain at rest after two months, and achieved significantly better pain control during physical activity at six months. No complication, residual instability, or iatrogenic injury to the cartilage were observed in the meniscectomy plus PC group.
The MCL PC technique for medial meniscectomy is a safe and effective way to reduce iatrogenic injury to the cartilage and does not affect knee stability. Decompression of the medial compartment results in better functional outcomes at two months and lesser pain during physical activity at six months.
Arthroscopic Trans-Portal Deep Medial Collateral Ligament Pie-Crusting Release
2013, Arthroscopy Techniques
Citation Excerpt :
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
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 pie-crusting release, which allows access to the medial meniscus through the anterior approach to provide good visualization of the footprint and sufficient working space.

View all citing articles on Scopus

^*: Address correspondence and reprint requests to Todd B. Guthrie, M.D., Park Ridge Orthopedics P.A., 27 Doctor’s Dr, Fletcher, NC 28732, U.S.A. E-mail: [email protected]

View full text

Article preview

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Abstract

Section snippets

Preoperative selection

Operative procedure

Discussion

References (21)

Abduction-adduction moments at the knee during stair ascent and descent

J Biomech

Biomechanics of the knee: Methodological considerations in the in vivo kinematic analysis of the tibiofemoral and patellofemoral joint

Clin Biomech (Bristol, Avon)

Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation

Disabil Rehabil

A revised group exercise program for osteoarthritis of the knee

Physiother Res Int

A biomechanical study of the static stabilizing effect of knee braces on medial stability

Am J Sports Med

Joint loading with valgus bracing in patients with varus gonarthrosis

Clin Orthop

Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: A critical analysis of the reliability of gait analysis data

J Orthop Res

Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis

Arthritis Rheum

A relationship between gait and clinical changes following high tibial osteotomy

J Bone Joint Surg Am

Relationship between gait and clinical results after high tibial osteotomy

Clin Orthop

Cited by (22)

Percutaneous Partial Outside-In Release of Medial Collateral Ligament for Arthroscopic Medial Meniscus Surgery With Tight Medial Compartment by Finding a “Magic Point”

Does Release of the Superficial Medial Collateral Ligament Result in Clinically Harmful Effects After the Fixation of Medial Meniscus Posterior Root Tears?

Complications in posteromedial arthroscopic suture of the medial meniscus

Complications in posteromedial arthroscopic suture of the medial meniscus

The effect of percutaneous release of the medial collateral ligament in arthroscopic medial meniscectomy on functional outcome

Arthroscopic Trans-Portal Deep Medial Collateral Ligament Pie-Crusting Release

International Section: CubaArthroscopic decompressive medial release of the varus arthritic knee: Expanding the functional envelope*

Abstract

Section snippets

Preoperative selection

Operative procedure

Discussion

J Biomech

Clin Biomech (Bristol, Avon)

Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation

Disabil Rehabil

A revised group exercise program for osteoarthritis of the knee

Physiother Res Int

A biomechanical study of the static stabilizing effect of knee braces on medial stability

Am J Sports Med

Joint loading with valgus bracing in patients with varus gonarthrosis

Clin Orthop

Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: A critical analysis of the reliability of gait analysis data

J Orthop Res

Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis

Arthritis Rheum

A relationship between gait and clinical changes following high tibial osteotomy

J Bone Joint Surg Am

Relationship between gait and clinical results after high tibial osteotomy

Clin Orthop

International Section: Cuba
Arthroscopic decompressive medial release of the varus arthritic knee: Expanding the functional envelope*