Outside-In Deep Medial Collateral Ligament Release During Arthroscopic Medial Meniscus Surgery

Abstract

Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic, irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgus-extension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.

Objective Measurement of Medial Joint Space Widening with Percutaneous “Pie Crust” Release of Medial Collateral Ligament during Knee Arthroscopy

“…Piecrusting technique is widely performed, minimally invasive, useful, and safe. [2][3][4][5][6][7] Although there are several reports that adequate widening of the posteromedial compartment is obtained by this technique, there is no data about the numeric increase in the medial joint space.…”

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

“…19 Advantages of the percutaneous release technique include release without compromising the synovial membrane, decreasing the risk of intra-articular septic complications, 17 while avoiding intra-articular structures that may impede instrument insertion required during the inside-out approach used to lengthen the deep MCL. 14 Percutaneous, outside-in lengthening is preferable when addressing the sMCL as a result of the MCL possessing an extra-articular course around the knee. 17 This technique involves perforating the sMCL near the posteromedial compartment with a hypodermic needle during arthroscopy.…”

“…Percutaneous, inside-out lengthening, or "pie crusting," first described by Agneskirchner and Lobenhoffer, 13 represents a minimally invasive technique involving repeated puncturing of the medial capsuloligamentous structures with an intramuscular needle to lengthen the superficial medial collateral ligament (sMCL). 14 Variants of the traditionally described pie-crusting method include an inside-out technique in which the needle is inserted through the anteromedial arthroscopy portal to lengthen the deep MCL 15 and release of the sMCL using an open approach with subperiosteal stripping. 16 With results from the percutaneous technique being the most commonly reported, concerns for iatrogenic MCL rupture, residual laxity, saphenous nerve injury, postoperative instability, and other potential complications after lengthening exist and warrant evaluation.…”

All-Inside Lateral Meniscal Repair via Anterolateral Portal Increases Risk of Vascular Injury: A Cadaveric Study

“…We used a percutaneous medial collateral ligament release to aid access to the posterior horn of the medial meniscus. The use of this technique was described by Todor et al 11 when encountering this difficulty.…”

“…To be consistent with clinical scenarios, we used a described technique for percutaneous medial collateral ligament release to open the medial compartment to aid access to the posterior horn in all specimens. 11 Despite careful identification and preservation of the posterior neurovascular structures, there is always the possible effect on the position of the structures during the dissection, which also may in part contribute to some outliers and the wide range in some of the distance measurements. Another factor that may have influenced our distance measurements was our choice of portal positions at 5 mm medial and lateral to the patellar tendon (rather than the standard positioning 1 cm medial and 1 cm lateral to the patellar tendon) to obtain the best trajectory to the posterior horn of each meniscus.…”