Abstract
Purpose
Based on the anatomy of the deep medial collateral ligament (MCL), it was hypothesized that at least part of its cross-sectional insertion area is jeopardized while performing a standard tibial cut in conventional total knee arthroplasty (TKA). The aim of this study was to determine whether it is anatomically possible to preserve the tibial deep MCL insertion during conventional TKA.
Methods
Thirty-three unpaired cadaveric knee specimens were used for this study. Knees with severe varus/valgus deformity or damage to the medial structures of the knee were excluded. In the first part of the study, the dimensions of the tibial insertion of the deep MCL and its relationship to the joint line were recorded. Next, the cross-sectional area of the deep MCL insertion was determined using calibrated digital photographic analysis. In the second part, the effect of a standard 9-mm 3° sloped tibial cut on the structural integrity of the deep MCL cross-sectional insertion area was determined using conventional instrumentation.
Results
The proximal border of the deep MCL insertion site on the tibia was located on average 4.7 ± 1.2 mm distally to the joint line. After performing a standard 9-mm 3° sloped tibial cut, on average 54 % of the deep MCL insertion area was resected. In 29 % of the cases, the deep MCL insertion area was completely excised.
Conclusion
The deep MCL cannot routinely be preserved in conventional TKA. The deep MCL insertion is at risk and may be jeopardized in case of a tibial cut 9 mm below the native joint line. As the deep MCL is a distinct medial stabilizer and plays an important role in rotational stability, this may have implications in future designs of both unicondylar and total knee arthroplasty, but further research is necessary.
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References
Ahlback S (1968) Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh) 277:7–72
Bartel DL, Marshall JL, Schieck RA, Wang JB (1977) Surgical repositioning of the medial collateral ligament. An anatomical and mechanical analysis. J Bone Joint Surg Am 59(1):107–116
De Maeseneer M, Van Roy F, Lenchik L, Barbaix E, De Ridder F, Osteaux M (2000) Three layers of the medial capsular and supporting structures of the knee: MR imaging-anatomic correlation. Radiographics 20 Spec No:S83–S89
Engh GA (2003) The difficult knee: severe varus and valgus. Clin Orthop Relat Res 416:58–63
Feyen H, Van Opstal N, Bellemans J (2012) Partial resection of the PCL insertion site during tibial preparation in cruciate-retaining TKA. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-012-1997-3
Griffith CJ, LaPrade RF, Johansen S, Armitage B, Wijdicks C, Engebretsen L (2009) Medial knee injury: part 1, static function of the individual components of the main medial knee structures. Am J Sports Med 37(9):1762–1770
Klein R, Serpe L, Kester MA, Edidin A, Fishkin Z, Mahoney OM, Schmalzried TP (2003) Rotational constraint in posterior-stabilized total knee prostheses. Clin Orthop Relat Res 410:82–89
LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L (2007) The anatomy of the medial part of the knee. J Bone Joint Surg Am 89(9):2000–2010
Laprade RF, Wijdicks CA (2012) The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther 42(3):221–233
Liu F, Yue B, Gadikota HR, Kozanek M, Liu W, Gill TJ, Rubash HE, Li G (2010) Morphology of the medial collateral ligament of the knee. J Orthop Surg Res 5:69
Ochsner JL Jr, McFarland G, Baffes GC, Cook SD (1993) Posterior cruciate ligament avulsion in total knee arthroplasty. Orthop Rev 22(10):1121–1124
Ritter MA, Faris GW, Faris PM, Davis KE (2004) Total knee arthroplasty in patients with angular varus or valgus deformities of ≥20 degrees. J Arthroplasty 19(7):862–866
Robinson JR, Bull AM, Amis AA (2005) Structural properties of the medial collateral ligament complex of the human knee. J Biomech 38(5):1067–1074
Robinson JR, Bull AM, Thomas RR, Amis AA (2006) The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med 34(11):1815–1823
Robinson JR, Sanchez-Ballester J, Bull AM, Thomas Rde W, Amis AA (2004) The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Joint Surg Br 86(5):674–681
Selvarajah E, Hooper G (2009) Restoration of the joint line in total knee arthroplasty. J Arthroplasty 24(7):1099–1102
Sims WF, Jacobson KE (2004) The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med 32(2):337–345
Slocum DB, Larson RL (1968) Rotatory instability of the knee. Its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg Am 50(2):211–225
Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 61(1):56–62
Wijdicks CA, Griffith CJ, LaPrade RF, Spiridonov SI, Johansen S, Armitage BM, Engebretsen L (2009) Medial knee injury: part 2, load sharing between the posterior oblique ligament and superficial medial collateral ligament. Am J Sports Med 37(9):1771–1776
Yagishita K, Muneta T, Ikeda H (2003) Step-by-step measurements of soft tissue balancing during total knee arthroplasty for patients with varus knees. J Arthroplasty 18(3):313–320
Acknowledgments
The statistical analysis of the data was done by the Biostatistical Centre of the School of Public Health of the Catholic University Leuven. The authors also wish to thank Ronny De Corte, VSP/VIP Manager European Centre for Knee Research, Smith & Nephew (Technologielaan 11 bis, 3001 Leuven, Belgium) for providing technical assistance. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical standard
This cadaveric study has been approved by the ethics committee and has therefore been performed in accordance with the ethical standards.
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Maes, M., Luyckx, T. & Bellemans, J. Does a conservative tibial cut in conventional total knee arthroplasty violate the deep medial collateral ligament?. Knee Surg Sports Traumatol Arthrosc 22, 2735–2739 (2014). https://doi.org/10.1007/s00167-013-2606-9
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DOI: https://doi.org/10.1007/s00167-013-2606-9