Arthroscopic release of the deep medial collateral ligament to assist in exposure of the medial tibiofemoral compartment

Abstract

Arthroscopy of the knee is a widely used surgical procedure for addressing intra-articular pathology. In assessing the intra-articular structures, visualization is of paramount importance. The medial tibiofemoral compartment is often difficult to fully visualize in tight knees in which limited access can compromise surgical efficacy. Poor visualization can increase the possibility of a residual meniscal tear after attempted partial meniscectomy, as well as the possibility of iatrogenic chondral injury from arthroscopic instruments. We describe a technique that allows improved medial tibiofemoral visualization with release of the deep medial collateral ligament. We use standard arthroscopic portals, without the need for further incisions or stab holes and with minimal additional patient morbidity. This procedure allows easier exposure of the medial knee chondral surfaces and meniscus and easier use of arthroscopic instrumentation in the medial compartment.

Fig 1

Steps of arthroscopic deep MCL release in 1 patient. The medial compartment is visualized by a 30° arthroscope through standard (A) anterolateral and (B) anteromedial portals. With valgus stress placed on the knee near full extension, a 4-mm probe points to the medial femoral condyle. This shows the tight nature of the compartment and inadequate visualization of the posterior structures. (C) A sled is introduced into the medial compartment from the lateral portal, which will protect the tibial chondral surface during blade advancement. (D) A 3.0-mm banana blade is introduced over the meniscal repair sled underneath the medial meniscus to release the deep MCL. (E) The deep MCL is released, starting from the middle third of the medial meniscus, working posteriorly. (F) The release is continued posteriorly only as much as is needed to sufficiently visualize all posterior medial structures. After the release has been performed, the same 4-mm probe is seen from the (G) anteromedial and (H) anterolateral portals, showing improved visualization and identification of a bucket-handle medial meniscal tear that was previously obscured.

Fig 2

Banana blade. A slight curve is introduced into the blade to facilitate safe access to the undersurface of the medial meniscus.