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Weakening of the knee ligament complex due to sequential medial release in total knee arthroplasty

  • Florian VöllnerEmail author
  • Johannes Fischer
  • Markus Weber
  • Felix Greimel
  • Achim Benditz
  • Tobias Renkawitz
  • Joachim Grifka
  • Benjamin Craiovan
Knee Arthroplasty
  • 14 Downloads

Abstract

Purpose

The purpose of this study was to investigate the effects of sequential medial release on the stiffness and collateral stability of the ligament complex of the knee. Irrespective of the implantation technique used, varus deformity frequently requires release of the capsular ligament complex. Yet, no data are available on how stiffness and stability of the knee ligament complex are weakened by such release.

Methods

After total knee arthroplasty, ten healthy Thiel-fixed knee joints were subjected to sequential medial release consisting of six release steps. After each step, stiffness and stability were determined at 0°, 30°, 60°, and 90°.

Results

Sequential medial release increasingly weakened the ligament complex. In extension, release of the anteromedial tibial sleeve 4 cm below the joint line already weakened the ligament complex by approximately 13%. Release 6 cm below the joint line reduced stiffness and stability by 15–20% over the entire range of motion. After detachment of the medial collateral ligament, stability was only about 60% of its initial value.

Conclusion

Our study showed for the first time the association between medial release and stiffness and stability of the knee ligament complex. To maintain stability, vigorous detachment of the knee ligament complex should be avoided. Release of the anteromedial tibial sleeve already initiates loss of stability. The main stabiliser is the medial ligament, which should never be completely detached.

Level of evidence

IV.

Keywords

Medial release Knee balancer Ligament balance Ligament stiffness Soft-tissue balance Total knee arthroplasty 

Notes

Acknowledgements

The authors thank Professor Friedrich Anderhuber (Institute of Anatomy at the Medical University of Graz, Austria) for providing the specimens for this investigation. The authors thank Martin Bauer and his team (Brainlab, Feldkirchen, Germany) for providing the navigation devices and the detailed information on the processed data. Furthermore, we thank Monika Schöll for the linguistic review of our manuscript.

Funding

There is no funding source.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

According to the local ethical committee, no approval was necessary.

Informed consent

For this type of study, formal consent is not required.

References

  1. 1.
    Audigé L, Bhandari M, Kellam J (2004) How reliable are reliability studies of fracture classifications? A systematic review of their methodologies. Acta Orthop Scand 75:184–194CrossRefGoogle Scholar
  2. 2.
    Aunan E, Kibsgård T, Clarke-Jenssen J, Röhrl SM (2012) A new method to measure ligament balancing in total knee arthroplasty: laxity measurements in 100 knees. Arch Orthop Trauma Surg 132:1173–1181CrossRefGoogle Scholar
  3. 3.
    Aunan E, Kibsgård T, Röhrl SM (2017) Minimal effect of patella eversion on ligament balancing in cruciate-retaining total knee arthroplasty. Arch Orthop Trauma Surg 137:387–392CrossRefGoogle Scholar
  4. 4.
    Bellemans J, Vandenneucker H, Van Lauwe J, Victor J (2010) A new surgical technique for medial collateral ligament balancing. J Arthroplasty 25:1151–1156CrossRefGoogle Scholar
  5. 5.
    Beltran J, Matityahu A, Hwang K, Jbara M, Maimon R, Padron M, Mota J, Beltran L, Sundaram M (2003) The distal semimembranosus complex: normal MR anatomy, variants, biomechanics and pathology. Skelet Radiol 32:435–445CrossRefGoogle Scholar
  6. 6.
    Fessel G, Frey K, Schweizer A, Calcagni M, Ullrich O, Snedeker JG (2011) Suitability of Thiel embalmed tendons for biomechanical investigation. Ann Anat Anat Anz 193:237–241CrossRefGoogle Scholar
  7. 7.
    Griffin FM, Insall JN, Scuderi GR (2000) Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty 15:970–973CrossRefGoogle Scholar
  8. 8.
    He X, Cai H, Zhang K (2018) Pie-crusting technique is effective and safe to release superficial medial collateral ligament for total knee arthroplasty. J Orthop Transl 13:33–40Google Scholar
  9. 9.
    Herschmiller T, Grosso MJ, Cunn GJ, Murtaugh TS, Gardner TR, Geller JA (2017) Step-wise medial collateral ligament needle puncturing in extension leads to a safe and predictable reduction in medial compartment pressure during TKA. Knee Surg Sports Traumatol Arthrosc 26(6):1759–1766CrossRefGoogle Scholar
  10. 10.
    Hunt NC, Ghosh KM, Athwal KK, Longstaff LM, Amis AA, Deehan DJ (2014) Lack of evidence to support present medial release methods in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:3100–3112CrossRefGoogle Scholar
  11. 11.
    Lee S-Y, Yang J-H, Lee Y-I, Yoon J-R (2016) A novel medial soft tissue release method for varus deformity during total knee arthroplasty: femoral origin release of the medial collateral ligament. Knee Surg Relat Res 28:153–160CrossRefGoogle Scholar
  12. 12.
    Luring C, Bäthis H, Hüfner T, Grauvogel C, Perlick L, Grifka J (2006) Gap configuration and anteroposterior leg axis after sequential medial ligament release in rotating-platform total knee arthroplasty. Acta Orthop 77:149–155CrossRefGoogle Scholar
  13. 13.
    Luring C, Hüfner T, Perlick L, Bäthis H, Krettek C, Grifka J (2006) The effectiveness of sequential medial soft tissue release on coronal alignment in total knee arthroplasty. J Arthroplasty 21:428–434CrossRefGoogle Scholar
  14. 14.
    Matsueda M, Gengerke TR, Murphy M, Lew WD, Gustilo RB (1999) Soft tissue release in total knee arthroplasty: cadaver study using knees without deformities. Clin Orthop 366:264CrossRefGoogle Scholar
  15. 15.
    Pedersen R (2016) The medial and posteromedial ligamentous and capsular structures of the knee: review of anatomy and relevant imaging findings. Semin Musculoskelet Radiol 20:012–025CrossRefGoogle Scholar
  16. 16.
    Robinson JR, Bull AM, Amis AA (2005) Structural properties of the medial collateral ligament complex of the human knee. J Biomech 38:1067–1074CrossRefGoogle Scholar
  17. 17.
    Sugita T, Amis AA (2001) Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 29:466–472CrossRefGoogle Scholar
  18. 18.
    Thiel W (1992) The preservation of the whole corpse with natural color. Ann Anat Anat Anz Off Organ Anat Ges 174:185–195CrossRefGoogle Scholar
  19. 19.
    Verdonk PCM, Pernin J, Pinaroli A, Selmi TAS, Neyret P (2009) Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach. Knee Surg Sports Traumatol Arthrosc 17:660–666CrossRefGoogle Scholar
  20. 20.
    Völlner F, Pilsl U, Craiovan B, Zeman F, Schneider M, Wörner M, Grifka J, Weber M (2017) Stability of knee ligament complex of Thiel-embalmed cadaver compared to in vivo knee. J Mech Behav Biomed Mater 71:392–396CrossRefGoogle Scholar
  21. 21.
    Whiteside LA, Saeki K, Mihalko WM (2000) Functional medical ligament balancing in total knee arthroplasty. Clin Orthop Relat Res 380:45–57CrossRefGoogle Scholar
  22. 22.
    Wijdicks CA, Ewart DT, Nuckley DJ, Johansen S, Engebretsen L, LaPrade RF (2010) Structural properties of the primary medial knee ligaments. Am J Sports Med 38:1638–1646CrossRefGoogle Scholar
  23. 23.
    Wilke H-J, Werner K, Häussler K, Reinehr M, Böckers TM (2011) Thiel-fixation preserves the non-linear load-deformation characteristic of spinal motion segments, but increases their flexibility. J Mech Behav Biomed Mater 4:2133–2137CrossRefGoogle Scholar
  24. 24.
    Wilson WT, Deakin AH, Payne AP, Picard F, Wearing SC (2012) Comparative analysis of the structural properties of the collateral ligaments of the human knee. J Orthop Sports Phys Ther 42:345–351CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Regensburg University Medical CentreAsklepios Klinikum Bad AbbachBad AbbachGermany

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