Biomechanical Validation of Medial Pie-Crusting for Soft-Tissue Balancing in Knee Arthroplasty

Mihalko, William M.; Woodard, Erik; Hebert, Casey T.; Crockarell, John R.; Williams, John L.

doi:10.1016/j.arth.2014.09.005

Cited by 33 publications

(26 citation statements)

References 25 publications

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“…14 The biomechanical studies by Gardiner et al 10,29 showed that the posterior MCL, proximal to the knee joint line, receives the highest strains with the knee in extension during an applied valgus load. In contrast, the cadaveric biomechanical study by Mihalko et al, 30 comparing lengthening of the anterior half of the medial soft-tissue sleeve versus lengthening of the posterior half, reported improvement in medial joint space opening in knee flexion with anterior release. However, only 5 cadaveric specimens were used in each treatment group.…”

Section: Discussionmentioning

confidence: 90%

Percutaneous Superficial Medial Collateral Ligament Release Outcomes During Medial Meniscal Arthroscopy: A Systematic Review

Gaudiani

Knapik²,

Kaufman

et al. 2020

Arthroscopy, Sports Medicine, and Rehabilitation

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Purpose: To systematically review the literature to better understand the technique, outcomes, and complications after percutaneous superficial medial collateral ligament (sMCL) lengthening during knee arthroscopy to address isolated medial meniscal pathology. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. The inclusion criteria consisted of English-language articles or articles with English-language translations documenting the use of percutaneous sMCL lengthening during arthroscopic knee surgery to treat isolated meniscal pathology (repair vs meniscectomy) with reported postoperative outcomes and complications. Results: Four studies met the inclusion criteria, consisting of a total of 192 patients undergoing percutaneous sMCL lengthening. No perioperative complications related to iatrogenic chondral damage, fracture, or additional meniscal injury were reported. Mild postoperative pain at the medial needle tract site lasting up to 15 days after surgery was reported in 52% of patients (46 of 88). At final follow-up, laxity on valgus stress testing showed a range from 0 to 1.1 mm with a range from e0.3 to 0.9 of radiographic medial joint space widening compared with preoperative radiographs. The length of follow-up ranged from 1.5 to 24 months. Conclusions: The percutaneous "pie-crusting" technique remains the most commonly reported technique to lengthen the sMCL during arthroscopic meniscal surgery. Percutaneous lengthening represents a safe and effective method of increasing medial joint space visualization, with no reported perioperative or postoperative complications and with minimal, likely clinically insignificant residual joint laxity after surgery on valgus stress testing at final follow-up compared with preoperative values. Level of Evidence: Level IV, systematic review of Level IV studies.

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Section: Discussionmentioning

confidence: 90%

Percutaneous Superficial Medial Collateral Ligament Release Outcomes During Medial Meniscal Arthroscopy: A Systematic Review

Gaudiani

Knapik²,

Kaufman

et al. 2020

Arthroscopy, Sports Medicine, and Rehabilitation

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“…The difficulty during operation is that the posteromedial compartment is difficult to expose clearly because of the narrow joint gap, which results in a limited visual field of the posterior meniscus and a lack of space for manipulation of the surgical instruments under arthroscopy [2][3][4][5][6]. Consequently, it is important for arthroscopic surgeons to seek other methods to enlarge the posteromedial space of the knee joint, one of which is the use of the pie-crusting release technique to release the medial structure of the knee under arthroscopy in order to increase the medial joint gap, and ultimately improve the intraoperative visual field and operation space [15][16][17]. In total knee arthroplasty, in order to achieve the lateral and medial balance of the extension and flexion gap, Mihalko et al performed piecrusting acupuncture release of the MCL, and the joint space during flexion and extension was simultaneously increased and balanced [15].…”

Section: Discussionmentioning

confidence: 99%

Arthroscopic pie-crusting release of the posteromedial complex of the knee for surgical treatment of medial meniscus injury

Han

Wang

et al. 2020

BMC Musculoskelet Disord

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Background: An arthroscopic narrow posteromedial gap of the knee may cause failure of a meniscus operation. The posteromedial complex (PMC) of the knee, including the posterior part of the medial collateral ligament (MCL) and the posterior oblique ligament (POL), has a restrictive effect on the opening of the posteromedial gap of the knee in the half-extension position. Thus, we evaluated the radiological and clinical results of pie-crusting release of the PMC for arthroscopic meniscal surgery in tight knees. Methods: Sixty patients with posterior injury of the medial meniscus were reviewed. All patients accepted arthroscopic pie-crusting release of the PMC. Fourty patients accepted meniscoplasty, and 20 patients accepted meniscal suturing. To evaluate the arthroscopic opening of the medial gap in 20°half-extension under 11-kg valgus stress, the width of the medial space before and after release were measured. During follow-up, the medial stability was evaluated by radiographic measurements of the joint space width (JSW) in 20°half-extension. Magnetic resonance imaging (MRI) was conducted to evaluate healing of the MCL and meniscus. Knee functions were evaluated using VAS (visual analogy score), Lysholm, IKDC (International Knee Documentation Committee) and Tegner scoring systems. Results: In all patients, meniscus operations were performed without iatrogenic cartilage injury. After PMC release, the arthroscopic width of the medial space was 5.7 ± 0.5 mm, larger than that before release (2.5 ± 0.5 mm, p < 0.01). The follow-up time was 21.93 ± 7.04 months, there was no residual valgus laxity of the knee. The radiographic JSW was 5.97 ± 0.8 mm preoperatively, 9.2 ± 1.1 mm in the 1st week postoperatively, and 6.1 ± 0.9 mm by the 3rd postoperative month, showing no differences between preoperative and 3 months postoperative measurement (p > 0.05). For sutured meniscus, MRI showed healing in 15 patients while five had two-grade abnormal signals. VAS,

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“…The difficulty during operation is that the posteromedial compartment is difficult to expose clearly because of the narrow joint gap, which results in a limited visual field of the posterior meniscus and a lack of space for manipulation of the surgical instruments under arthroscopy [2][3][4][5][6]. Consequently, it is important for arthroscopic surgeons to seek other methods to enlarge the posteromedial space of the knee joint, one of which is the use of the pie-crusting release technique to release the medial structure of the knee under arthroscopy in order to increase the medial joint gap, and ultimately improve the intraoperative visual field and operation space [15][16][17]. In total knee arthroplasty, in order to achieve the lateral and medial balance of the extension and flexion gap, Mihalko et al performed pie-crusting acupuncture release of the MCL, and the joint space during flexion and extension was simultaneously increased and balanced [13].…”

Section: Discussionmentioning

confidence: 99%

“…In total knee arthroplasty, in order to achieve the lateral and medial balance of the extension and flexion gap, Mihalko et al performed pie-crusting acupuncture release of the MCL, and the joint space during flexion and extension was simultaneously increased and balanced [13]. Bellemans et al used this technique to release the MCL with a 19-G needle in the vicinity of the knee joint line, which produced a mean 2.4 mm increase of the medial joint space [15]. It has been reported that application of this technique to the opening of the medial space of the knee joint under arthroscopy, whether through an open skin incision or percutaneous acupuncture for MCL release, improves the medial visual field [2,6,[18][19][20].…”

Section: Discussionmentioning

confidence: 99%

Arthroscopic pie-crusting release of the posteromedial c omplex of the knee for surgical treatment of medial meniscus injury

Han

Wang

et al. 2020

Preprint

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Background: The posteromedial complex (PMC), including the posterior part of the MCL and the posterior oblique ligament (POL), has a restrictive effect on the opening of the posteromedial gap of the knee in the half-extension position. We evaluated the radiological and clinical results of pie-crusting release of the PMC for arthroscopic meniscal surgery in tight knees.Methods: Sixty patients with posterior injury of the medial meniscus were reviewed. All patients accepted arthroscopic pie-crusting release of the PMC. Fourty patients accepted meniscoplasty, and 20 patients accepted meniscal suturing. To evaluate the arthroscopic opening of the medial gap in 20° half-extension under 11-kg valgus stress, the width of the medial space before and after release were measured. During follow-up, the medial stability was evaluated by radiographic measurements of the joint space width (JSW). MRI was conducted to evaluate healing of the MCL and meniscus. Knee functions were evaluated using VAS, Lysholm, IKDC and Tegner scoring systems.Results: In all patients, meniscus operations were performed without iatrogenic cartilage injury. After PMC release, the arthroscopic width of the medial space was 5.7 ± 0.5 mm, larger than that before release (2.5 ± 0.5 mm, p < 0.01). The follow-up time was 21.93 ± 7.04 months, there was no residual valgus laxity of the knee. The radiographic JSW was 5.97 ± 0.8 mm preoperatively, 9.2 ± 1.1 mm in the 1st week postoperatively, and 6.1 ± 0.9 mm by the 3rd postoperative month, showing no differences between preoperative and 3 months postoperative measurement (p > 0.05). For sutured meniscus, MRI showed healing in 15 patients while five had two-grade abnormal signals. VAS, Lysholm, IKDC and Tegner scores were 1.80 ± 0.51, 80.08 ± 3.74, 82.17 ± 4.64 and 5.48 ± 0.59, respectively, showing significant differences compared with the preoperative scores (5.57 ± 0.69, 48.17 ± 4.22, 51.42 ± 4.02 and 3.20 ± 0.68, respectively, P < 0.01).Conclusions: Pie-crusting release of the PMC can increase the posteromedial space and improve the visual field of the knee under arthroscopy, while neither causing no residual valgus instability of the knee nor affecting the clinical outcome at the final follow-up.

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Biomechanical Validation of Medial Pie-Crusting for Soft-Tissue Balancing in Knee Arthroplasty

Cited by 33 publications

References 25 publications

Percutaneous Superficial Medial Collateral Ligament Release Outcomes During Medial Meniscal Arthroscopy: A Systematic Review

Percutaneous Superficial Medial Collateral Ligament Release Outcomes During Medial Meniscal Arthroscopy: A Systematic Review

Arthroscopic pie-crusting release of the posteromedial complex of the knee for surgical treatment of medial meniscus injury

Arthroscopic pie-crusting release of the posteromedial c omplex of the knee for surgical treatment of medial meniscus injury

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