The Outside-In, Percutaneous Release of the Medial Collateral Ligament for Knee Arthroscopy

Abstract

The outside-in, percutaneous release of the medial collateral ligament (MCL) is a technique used to increase the medial tibiofemoral joint space during arthroscopy to facilitate the use of instrumentation and improve visualization without causing iatrogenic cartilage damage. A recent systematic review of the literature has shown this technique to be efficacious and safe, with no evidence of associated short-or long-term complications. This technique has been used for this indication by the senior author without requiring any deviation from our institution's standard protocol for knee arthroscopy. In an attempt to standardize this technique's utilization and allow for further evaluation in the literature, the senior author's method for this percutaneous, outside-in approach of "pie crusting" the MCL is described.

Arthroscopic Procedure for Chronic Isolated Bucket-Handle Meniscal Tears

“…This is similar to the findings of Moran et al, Javidan et al, and Hinton. [8][9][10] We found out that releasing the medial meniscus does not lead to valgus instability following arthroscopic treatment for CIBHMT. This finding was similar to those of Moran et al, who found out that controlled release of the MCL in tight knees allowed easier handling in posterior medial meniscus tears and a better understanding of tear configurations, avoiding iatrogenic chondral damage and the MCL injury healed uneventfully.…”

“…5 This is not unconnected with the limited exposure of the medial compartment, leading to incomplete and inadequate repair that subsequently results in high failure rates in the early stages and osteochondral damage. 8 We do a subcutaneous release of the posterior fibers of the MCL to improve the exposure of the medial compartment for better visualization, anatomic reduction of the torn meniscus, and its surface attachment to the wall. This maneuver ensures a complete stable repair with good surface contact instead of the suture points contacts in poorly visualized joints.…”

“…This finding was similar to those of Moran et al, who found out that controlled release of the MCL in tight knees allowed easier handling in posterior medial meniscus tears and a better understanding of tear configurations, avoiding iatrogenic chondral damage and the MCL injury healed uneventfully. 8 Although, Lons et al 11 found out that that valgus laxity is still present at 6 weeks post-piecrusting of the MCL, more papers cited no mediolateral instability at the short-and long-term follow-up. It suffices to also mention that majority of the procedure carried out by Lons et al were meniscectomies (33 of 40 meniscal surgeries).…”

“…Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. 7 The outside-in, percutaneous release of the MCL is a technique used to increase the medial tibiofemoral joint space during arthroscopy to facilitate the use of instrumentation and improve visualization without causing iatrogenic cartilage damage 8 (Video 1). Thus, we routinely release the posteromedial fibers of the MCL using the subcutaneous pie-crusting technique at our previously described magic point (Figs 6-9).…”

Medial Meniscal Ramp Lesion Repair Through Anterior Portals Using a Medial Collateral Ligament Pie-Crusting Technique

“…8 Many previous studies have established that MCL release is a safe and minimally harmful technique. [16][17][18][19] MCL pie crusting has typically generated grade I MCL laxity without saphenous nerve or vein By means of medial collateral ligament release, the ramp lesion, which is usually covered by the medial femoral condyle, can be seen from the standard anterolateral viewing portal. By use of the FasT-Fix system from anteromedial portal, the ramp lesion is repaired.…”