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]
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
Related posts: Intraoperative Soft-Tissue Balance and Clinical Results (ROM, Function)
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