Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty

第一作者:Daniel D. Bohl

2016-01-14 点击量:738   我要说

Daniel D. Bohl,Nathan G. Wetters,Daniel J. Del Gaizo,Joshua J. Jacobs,Aaron G. Rosenberg,

Craig J. Della Valle


Background:

Optimal treatment for intraoperative injury to the medial collateral ligament (MCL) during primary total knee arthroplasty remains controversial. While some advocate primary ligament repair and a period of bracing, others suggest conversion to a knee prosthesis with increased intrinsic constraint. The purpose of this study was to characterize the outcomes of primary repair followed by bracing.

Methods:

We performed a retrospective review of consecutive primary total knee arthroplasties to identify patients with intraoperative MCL laceration or avulsion treated with primary repair. Midsubstance lacerations were treated with end-to-end suture repair, whereas a screw-and-washer construct, suture, and/or suture anchors were used for reattachment of avulsions. All patients were instructed to wear an unlocked hinged knee brace for six weeks postoperatively. Patients were evaluated at a minimum of two years postoperatively for evidence of instability or other modes of failure and complications.

Results:

An intraoperative MCL injury occurred during forty-eight (1.2%) of the 3922 total knee arthroplasties that had been performed. One patient died less than two years postoperatively, one was lost to follow-up, and one underwent an intraoperative conversion to a constrained total knee arthroplasty, leaving forty-five total knee arthroplasties available for study. There were twenty-four midsubstance lacerations and twenty-one avulsions; thirty-five of these injuries occurred during a cruciate-retaining total knee arthroplasty and ten, during a posterior-stabilized total knee arthroplasty. At a mean of ninety-nine months (range, twenty-four to 214 months), there were no symptoms or physical examination findings of instability. The mean Hospital for Special Surgery knee score increased from 47 preoperatively to 85 at the time of follow-up (p < 0.001). Five knees required intervention for stiffness (four manipulations and one revision), and two required revision for aseptic loosening.

Conclusions:

Our results suggest that intraoperative MCL injury can be treated with primary repair followed by hinged knee bracing without the need for increased prosthetic constraint. Stiffness, however, was a common complication.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The integrity of the medial collateral ligament (MCL) is important for the function and longevity of a nonconstrained total knee prosthesis, and instability is a common cause of revision procedures. Intraoperative injury to the MCL is a rare but important complication of total knee arthroplasty, with recent studies demonstrating rates from 0.5% to 3%. Even higher rates (up to 8%) have been reported in some populations, such as morbidly obese patients.

The optimal management of intraoperative injury to the MCL remains controversial. Many authors have recommended intraoperative conversion to a more constrained prosthesis, which can substitute for the MCL by providing resistance to valgus stress. An alternative strategy is primary repair of the MCL followed by protective bracing. In a 2001 report on sixteen cruciate-retaining total knee arthroplasties complicated by MCL injury, Leopold et al. described good results at a mean of four years after primary MCL repair followed by protective bracing. Other authors have also described their results with this technique.

The purpose of the present report is to describe our expanded experience with direct repair of the MCL, which includes longer-term follow-up of the original cases described by Leopold et al.. Unlike the prior analysis, the present study also includes knees in which a posterior-stabilized design was implanted as well as knees with a preoperative valgus deformity. All of these cases were from our institution.


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