Skip to main content
Log in

Partial release of the superficial medial collateral ligament for open-wedge high tibial osteotomy

A human cadaver study evaluating medial joint opening by stress radiography

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

To perform an open-wedge high-tibial osteotomy (HTO), the medial proximal tibia is frequently exposed by partial distal release of the overlying insertion of the medial collateral ligament (MCL). Biomechanically, any release of the MCL can increase knee laxity when valgus stress is applied. Clinically however, post-surgical valgus instability following HTO with partial MCL release is an uncommon complication. It is known that the open-wedge procedure can re-tention an intact MCL by the width of the base of the wedge. However, this re-tentioning effect is uncertain in small wedge sizes, preexisting medial compartment laxity and in the presence of a partially detached MCL. Considering the good clinical results after HTO, we hypothesized that a partial release of the superficial MCL for HTO does not play a crucial role in stabilizing valgus forces in the human knee. We therefore measured the effect of partial versus complete release of the superficial MCL to determine medial knee laxity represented by the amount of medial joint opening (MJO) under valgus stress in this human cadaver study. In ten knee pairs, the superficial and deep MCL were sectioned in sequence with a standardized abduction force of 15 kp with a Scheuba apparatus applied. In group 1 (5 knee pairs), the superficial MCL was completely sectioned whereas in group 2 (5 knee pairs), sectioning of the superficial MCL was restricted to the anterior border to mimic the surgical exposure for an HTO. To account for the interindividual variability of ligamentous laxity, only increments of MJO within knee pairs were statistically evaluated. Stress radiography did not reveal any significant differences in increments of MJO between knee pair specimens with complete versus partial release of the superficial MCL. We disproved our hypothesis and concluded that the anterior fibers of the superficial MCL do play a crucial role in maintaining valgus stability in this biomechanical setting. Therefore, the release of the superficial MCL for open-wedge HTO should be kept to a minimum to decrease the potential of late valgus instability. This is especially important in patients with small wedge sizes and medial compartment laxity since the anterior MCL fibers are the main contributor to medial joint stability and the re-tentioning effect of the remaining MCL fibers is presumably decreased.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Brantigan O, Voshell A (1943) The tibial collateral ligament: its function, its bursae, and its relation to the medial meniscus. J Bone Joint Surg 25:121–131

    Google Scholar 

  2. Conn K, Clarke M, Hallett J (2002) A simple guide to determine the magnification of radiographs and to improve the accuracy of preoperative templating. J Bone Joint Surg Br 84:269–272

    Article  CAS  PubMed  Google Scholar 

  3. Coventry MB (1985) Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am 67:1136–1140

    CAS  PubMed  Google Scholar 

  4. De Simoni C, Staubli A (2000) Neue Fixationstechnik für mediale open-wedge Osteotomien der proximalen Tibia. Schweiz Med Wochenschrift 119:130

    Google Scholar 

  5. Ellsasser J, Reynolds F, Omohundro J (1974) The nonoperative treatment of collateral ligament injuries of the knee in professional football players. J Bone Joint Surg Am 56:1185–1190

    CAS  PubMed  Google Scholar 

  6. Fowler P, Tan L, Brown G (2000) Medial opening wedge high tibial osteotomy: how I do it. Operat Techniq Sports Med 8:32–38

    Article  Google Scholar 

  7. Fujie H, Livesay G, Woo S, Kashiwaguchi S, Blomstrom G (1995) The use of a universal force-moment sensor to determine in-situ forces in ligaments: a new methodology. J Biomech Eng 117:1–7

    CAS  PubMed  Google Scholar 

  8. Grood ES, Noyes FR, Butler DL, Suntay WJ (1981) Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. J Bone Joint Surg Am 63:1257–1269

    CAS  PubMed  Google Scholar 

  9. Hallen LG, Lindahl O (1965) Rotation in the knee-joint in experimental injury to the ligaments. Acta Orthop Scand 36:400–407

    CAS  PubMed  Google Scholar 

  10. Hughston JC, Andrews JR, Cross MJ, Moschi A (1976) Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am 58:159–172

    CAS  PubMed  Google Scholar 

  11. Hughston JC, Eilers AF (1973) The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am 55:923–940

    CAS  PubMed  Google Scholar 

  12. Indelicato P (1983) Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am 65:323–329

    CAS  PubMed  Google Scholar 

  13. Kennedy JC, Fowler PJ (1971) Medial and anterior instability of the knee. An anatomical and clinical study using stress machines. J Bone Joint Surg Am 53:1257–1270

    CAS  PubMed  Google Scholar 

  14. Lobenhoffer P, De Simoni C, Staubli A (2002) Open-wedge high-tibial osteotomy with rigid plate fixation. Techniq Knee Surg 1:93–105

    Google Scholar 

  15. Lobenhoffer P, Agneskirchner JD (2003) Improvements in surgical technique of valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 11(3):132–138

    PubMed  Google Scholar 

  16. Markolf KL, Mensch JS, Amstutz HC (1976) Stiffness and laxity of the knee–the contributions of the supporting structures. A quantitative in vitro study. J Bone Joint Surg Am 58:583–594

    CAS  PubMed  Google Scholar 

  17. Matsamuto H, Suda Y, Otani T, Niki Y, Seedhom B, Fujikawa K (2001) Roles of the anterior cruciate ligament and the medial collateral ligament in preventing valgus instability. J Orthop Sci 6:28–32

    Article  PubMed  Google Scholar 

  18. Paley D, Bhatnagar J, Herzenberg J, Bhave A (1994) New procedures for tightening knee collateral ligaments in conjunction with knee realignment osteotomy. Orthop Clin North Am 25:533–555

    CAS  PubMed  Google Scholar 

  19. Patond KR, Lokhande AV (1993) Medial open wedge high tibial osteotomy in medial compartment osteoarthrosis of the knee. Natl Med J India 6:104–108

    CAS  PubMed  Google Scholar 

  20. Scheuba G, Vosskohler E (1983) [Diagnosis of ligament injuries of the upper ankle joint]. Unfallchirurgie 9:341–344

    CAS  PubMed  Google Scholar 

  21. Slocum DB, Larson RL, James SL (1974) Late reconstruction of ligamentous injuries of the medial compartment of the knee. Clin Orthop 100:23–55

    Google Scholar 

  22. Warren LA, Marshall JL, Girgis F (1974) The prime static stabilizer of the medical side of the knee. J Bone Joint Surg Am 56:665–674

    CAS  PubMed  Google Scholar 

  23. Winker KH, Weller S (1990) Extra-ligamentous valgisation additive tibial head osteotomy. Indications-technic-complications-errors. Critical analysis. Z Orthop Ihre Grenzgeb 128:58–62

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Dietrich Pape.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pape, D., Duchow, J., Rupp, S. et al. Partial release of the superficial medial collateral ligament for open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 14, 141–148 (2006). https://doi.org/10.1007/s00167-005-0649-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-005-0649-2

Keywords

Navigation