Comparing available options from more constrained implants to primary repairs of the MCL, which one do you think is the best way to manage iatrogenic MCL injuries during total knee arthroplasty?
Thank you Dr Shahi for a very relevant question. Iatrogenic MCL injuries during TKA is every knee surgeon's nightmare! It's fortunately rare. I have been lucky (or unlucky depending on how you look at it!!) to have seen and performed a few different techniques to get out of a rather unhappy situation!.
I personally think whats most important is to recognise the injury as i am sure, a lot of these go unnoticed! There is no doubt that failure to recognise this injury results in a poorly balanced knee in a very unhappy patient, leading to accelerated wear and loosening.
Some of the variables to be considered are the severity and type of injury (mid substance tear or bony avulsion), age of the patient, your experience and comfort level in treating these, the system being used and whats available to you on the shelf. Some systems like the Triathlon will let you use a more constrained poly insert on a universal tibial plate and i have used this with good effect. I am a Cruciate retainer predominantly and the PCL is definitely a secondary stabiliser to the MCL in imparting medial stability.
I, just like most others, would like to use the least constraint possible, so as to improve implant longevity. Hence, i would prefer to carry out a suture anchor stabilisation or direct repair with or without augmentation (depending on where it is torn), a more constrained insert and protect in a hinged knee brace if possible, especially in a younger patient. In a older person, i will have a lower threshold in using a varus-valgus constrained implant. I have attached few publications which discuss these relevant points. Hope you find these useful
http://www.jisrf.org/pdfs/rr.4.2.17.pdf
Article Primary Repair of Intraoperative Disruption of the Medial Co...
Article Management of Intraoperative Medial Collateral Ligament Inju...
Hi,
I find the input of Dr. Prasad very interesting, and this is the approach that I follow in this very unhappy situation. Unfortunately, sometimes it is necessary to go through several operations and the results are still unsatisfactory.
Thank You Dr Tanchev. You are very right. No matter what one does, the patients are unhappy and the results unsatisfactory. Therefore, it is best avoided.
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