Outside-In Deep Medial Collateral Ligament Release During Arthroscopic Medial Meniscus Surgery

Abstract

Arthroscopic partial medial meniscectomy is a very common orthopaedic procedure performed for symptomatic, irreparable meniscus tears. It is usually associated with a very good outcome and minimal complications. In some patients with tight medial compartment, the posterior horn of the medial meniscus can be difficult to visualize, and access in this area with instruments may be challenging. To increase the opening of the medial compartment, after valgus-extension stress position of the knee, different techniques of deep medial collateral ligament release have been described. The outside-in pie-crusting technique shown in this technical note has documented effectiveness and good outcomes with minimal or no morbidity.

Fig 1

A 4-mm tip probe introduced through the anteromedial portal measuring the distance between the medial femoral condyle (MFC) and the medial tibial plateau (MTP). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.

Fig 2

A probe introduced through the anteromedial portal evaluating the tear in the posterior horn of the medial meniscus. Part of the tear (star) can be seen and palpated. Note the poor visualization in the posterior horn (triangle). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Fig 3

A 4.2-mm shaver blade introduced through the anteromedial portal trying to reach the tear in the posterior horn of the medial meniscus. Note the inability to pass between the medial femoral condyle (MFC) and the tibial plateau (MTP) (arrows). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.

Fig 4

Basket forceps (Linear Wide Bite Punch, 3.3 mm diameter, 130 mm, Conmed, Linvatec) introduced through the anteromedial portal trying to reach the tear in the posterior horn of the medial meniscus. Note the inability to pass between the medial femoral condyle (MFC) and the tibial plateau (MTP) (arrows). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.

Fig 5

Eighteen-gauge (1.2 × 40) hypodermic needle (KD-FINE) introduced in the desired location, in the posteromedial compartment between the meniscus and the tibial plateau to release the deep medial collateral ligament. Camera in the anterolateral viewing portal. Right knee. Standard valgus-extension stress position. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Fig 6

A 4-mm tip probe introduced through the anteromedial portal measuring the distance between the medial femoral condyle (MFC) and the medial tibial plateau (MTP) showing the increased space in the medial compartment as compared with Figure 1, obtained after the outside-in release of the deep medial collateral ligament. Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.

Fig 7

The probe introduced through the anteromedial portal evaluating the tear in the posterior horn of the medial meniscus. Note the improved visualization and access to the tear site (stars) as compared with Figure 2. Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position. (MFC, medial femoral condyle; MTP, medial tibial plateau.)

Fig 8

Basket forceps (Linear Wide Bite Punch, 3.3 mm diameter, 130 mm, Conmed, Linvatec) introduced through the anteromedial portal performing the meniscectomy in the posterior horn of the medial meniscus. Note the good clearance between the medial femoral condyle (MFC) and the tibial plateau (MTP) (arrows). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.

Fig 9

A 4.2-mm shaver blade introduced through the anteromedial portal to the tear site in the posterior horn of the medial meniscus. Note the good clearance between the medial femoral condyle (MFC) and the tibial plateau (MTP) (arrows). Camera in the standard anterolateral viewing portal. Right knee. Standard valgus-extension stress position.