Effectiveness and Safety of Needle Medial Collateral Ligament Pie-Crusting in Total Knee Arthroplasty: A Cadaveric Study

Abstract

Medial collateral ligament (MCL) pie-crusting technique in total knee arthroplasty (TKA) is one of the methods of medial release. The effects and risks of blade pie-crusting have been reported in previous studies. However, only a few have reported the safety and efficacy of needle pie-crusting. In this cadaveric study, we quantitatively evaluated the amount of gap change by MCL needle pie-crusting. We investigated five knees of four fresh human cadavers and performed posterior-stabilized TKA. Only deep MCL release as the medial release was conducted. We punctured the MCL from the deep layer to the superficial layer using a 18 G needle in a 90-degree flexion position for 0, 10, 20, 50, 75, and 100 times. Medial and lateral gaps were measured accurately with a balancer at determined times in 0 and 90-degree flexion positions. Changes in medial and lateral gaps were not significant differences in flexion and extension position. However, in 90-degree flexion, medial gap changes were tended to be larger than lateral gap changes. A 0.6 mm additional medial release and a 0.2 mm additional lateral release were found per 10 times pie crust in flexion position (100 times, p: 0.08). However, large differences existed among the cases. Needle pie-crusting is safer than blade pie-crusting because of the small efficacy of one-time pie crust. MCL needle pie-crusting showed varied effects for each case. This result indicates the risk of relaxation of an unexpected gap. Caution should be taken when choosing between needle pie-crusting and blade pie-crusting.

Keywords

total knee arthroplasty - medial collateral ligament - needle pie-crusting - gap - cadaveric study

Note

This is a cadaveric study, which was performed at a dedicated institution and not at our institution. We had permission for conducting this cadaveric study.

• References

• 1 Russell S, Alexander N, Tyler M, Neil S. A systematic approach to soft-tissue balancing in primary varus total knee arthroplasty. UPOJ 2015; 25: 71-74
• 2 Luring C, Hüfner T, Perlick L, Bäthis H, Krettek C, Grifka J. The effectiveness of sequential medial soft tissue release on coronal alignment in total knee arthroplasty: using a computer navigation model. J Arthroplasty 2006; 21 (03) 428-434
• 3 Yagishita K, Muneta T, Ikeda H. Step-by-step measurements of soft tissue balancing during total knee arthroplasty for patients with varus knees. J Arthroplasty 2003; 18 (03) 313-320
• 4 Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P. Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification. Knee 2005; 12 (04) 257-266
• 5 Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P. Tibiofemoral instability in primary total knee replacement: A review Part 2: diagnosis, patient evaluation, and treatment. Knee 2005; 12 (05) 336-340
• 6 Vince KG. Why knees fail. J Arthroplasty 2003; 18 (03) (Suppl. 01) 39-44
• 7 Callaghan JJ, O'rourke MR, Saleh KJ. Why knees fail: lessons learned. J Arthroplasty 2004; 19 (04) (Suppl. 01) 31-34
• 8 Fehring TK, Valadie AL. Knee instability after total knee arthroplasty. Clin Orthop Relat Res 1994; (299) 157-162
• 9 Verdonk PC, Pernin J, Pinaroli A, Ait Si Selmi T, Neyret P. Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach. Knee Surg Sports Traumatol Arthrosc 2009; 17 (06) 660-666
• 10 Matsueda M, Gengerke TR, Murphy M, Lew WD, Gustilo RB. Soft tissue release in total knee arthroplasty. Cadaver study using knees without deformities. Clin Orthop Relat Res 1999; (366) 264-273
• 11 Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA. Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 2009; 17 (12) 766-774
• 12 Mullaji A, Marawar S, Sharma A. Correcting varus deformity. J Arthroplasty 2007; 22 (04) (Suppl. 01) 15-19
• 13 Mullaji AB, Padmanabhan V, Jindal G. Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees. J Arthroplasty 2005; 20 (05) 550-561
• 14 Kwak DS, In Y, Kim TK, Cho HS, Koh IJ. The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24 (01) 188-194
• 15 Koh IJ, Kwak DS, Kim TK, Park IJ, In Y. How effective is multiple needle puncturing for medial soft tissue balancing during total knee arthroplasty? A cadaveric study. J Arthroplasty 2014; 29 (12) 2478-2483
• 16 Bellemans J. Multiple needle puncturing: balancing the varus knee. Orthopedics 2011; 34 (09) e510-e512
• 17 Markolf KL, Mensch JS, Amstutz HC. Stiffness and laxity of the knee--the contributions of the supporting structures. A quantitative in vitro study. J Bone Joint Surg Am 1976; 58 (05) 583-594
• 18 Kadoya Y, Kobayashi A, Komatsu T, Nakagawa S, Yamano Y. Effects of posterior cruciate ligament resection on the tibiofemoral joint gap. Clin Orthop Relat Res 2001; (391) 210-217
• 19 Warren LA, Marshall JL, Girgis F. The prime static stabilizer of the medical side of the knee. J Bone Joint Surg Am 1974; 56 (04) 665-674
• 20 Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 1979; 61 (01) 56-62
• 21 LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am 2007; 89 (09) 2000-2010
• 22 Koh HS, In Y. Semimembranosus release as the second step of soft tissue balancing in varus total knee arthroplasty. J Arthroplasty 2013; 28 (02) 273-278
• 23 Yoon JR, Oh KJ, Wang JH, Yang JH. Does patella position influence ligament balancing in total knee arthroplasty?. Knee Surg Sports Traumatol Arthrosc 2015; 23 (07) 2012-2018