Trouble Shooting: Intraoperative MCL Injury


Lesion type

Frequency*

Cause

Reference

Femoral avulsion

1/48


[8]

1/16

Osteopenic patient

[3]

Mid-substance

24/48


[8]

1/8

Transection with saw during tibial cut

[9]

7/7

Unknown, possibly due to saw during tibial cut, sharp instrumentation used for subperiosteal tibial MCL elevation, or medial meniscus excision

[11]

28/37

During tibial resection or femoral posterior condyle resection

[13]

12/16

Saw blade during tibial cut or sharp instrument used for subperiosteal elevation

[3]

11/15


[15]

22/23


[16]

9/9


[18]

1/1


[19]

Tibial avulsion

20/48


[8]

7/8

From hyperflexion to extension with the trial component not perfectly placed

[9]

15/15

During medial soft tissue release at the tibia using narrow osteotome

[12]

9/37

During hyperflexion for exposition

[13]

3/16

Medially placed retractors or sharp instrument used for subperiosteal elevation

[3]

1/23


[16]

Stretching

2/7


[11]


* Frequency: specific lesion type/total number of MCL lesions for each reference





19.3 Intraoperative Findings


Intraoperative MCL injury diagnosis can sometimes be neglected. It is imperative to know what signs to expect from this kind of lesion in order to recognize it, as it can sometimes present as a hidden injury. A sudden unexpected medial laxity is a common reported finding [9, 16]. A sudden excessive exposure or unstable forward movement of the tibia is also an indicative of intraoperative MCL damage [15]. Also, it can be recognized as a medial laxity when there was no preoperative medial instability or during ligament balance with trial components or, more uncommon, after the final implants were cemented into place [3, 13]. Occasionally, a popping sound can be heard, and increased laxity at 30° and 90° can be confirmed in some MCL tibial avulsions [13].


19.4 Treatment Types


There is a myriad of different treatments according to MCL lesion type. Table 19.2 displays this information.


Table 19.2
Treatment types
















































































Treatment type

Failure rate*

Peculiarity

Reference

Femoral reinsertion

0/1

Screw and washer

[8]

0/1

Screw and washer

[3]

Tibial reinsertion

0/20

Screw and washer and/or suture anchors and/or sutures to the bone

[8]

0/2

Suture anchors on the medial tibial plateau level added to bicortical screw ligament fixation

[9]

0/9

Staples

[13]

0/3

Suture anchor. Preoperative valgus excluded

[3]

Primary repair

2/3


[13]

0/10


[16]

0/9


[18]

Primary repair + cast

2/4

4 weeks casting

[13]

Primary repair + bracing

0/47

6 weeks bracing

[8]

0/2

4 weeks bracing

[11]

0/12

6 weeks bracing. Preoperative valgus excluded

[3]

Repair + increase tibial insert thickness (larger insert than the trial)

0/3

The only failure occurred in a patient that poly-insert thickness was not increased in comparison to the trial

[9]

Repair + augmentation

0/5

Augmentation with quadriceps free graft

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Sep 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Trouble Shooting: Intraoperative MCL Injury

Full access? Get Clinical Tree

Get Clinical Tree app for offline access