The pie-crust surgical technique for medial collateral ligament release: enhancing visualization of the medial compartment in knee arthroscopy

Abstract

This study presents a comprehensive surgical technique for performing a 'pie-crust' release of the medial collateral ligament (MCL) to enhance visualization of the medial compartment during arthroscopic knee procedures. The primary objective of this research is to improve the precision of diagnosis and treatment for injuries specifically affecting the posterior horn and posterior root of the medial meniscus. Arthroscopic knee procedures have become increasingly common in orthopedic surgery, offering the advantage of minimally invasive techniques for treating a wide range of knee conditions. However, accessing and visualizing the posterior structures within the medial compartment can be challenging. To overcome this limitation, the surgical technique presented in this study offers a systematic approach that includes patient positioning, precise identification of anatomical landmarks, and a detailed, step-by-step procedural description. The process begins with meticulous marking of anatomical landmarks to provide reference points. Precisely identifying the location for the MCL release is of utmost importance. This involves making needle punctures with guidance from arthroscopic visualization and applying valgus strain to the knee as necessary. One of the key advantages of this described surgical technique is its focus on safety and efficacy. Surgeons can work more confidently and precisely by reducing the risk of iatrogenic cartilage damage and facilitating access to the posterior structures within the medial compartment. Clinical outcomes from this approach have demonstrated consistently favorable results, leading to improved patient recovery and reduced complications. Furthermore, it is noteworthy that the postoperative use of a brace is not mandatory, adding to the appeal of this technique for both patients and surgeons. This surgical technique's enhanced visualization and optimized treatment outcomes make it a valuable tool in the arsenal of orthopedic surgeons specializing in knee arthroscopy. In conclusion, this study's surgical technique has the potential to significantly improve the diagnosis and treatment of patients with meniscal injuries in the medial compartment, ultimately leading to better clinical outcomes and patient satisfaction.

Keywords: Knee; arthroscopy; medial collateral ligament (MCL); pie-crust; surgical technique.

Figure 1

The knee is positioned at 90°, with a lateral post just proximal to the thigh and a fixed roller under the foot. (A) Right knee with a lateral point of view. (B) Left knee with a medial point of view.

Figure 2

Identification of the main distal femur and proximal tibia anatomical landmarks.

Figure 3

Identification of the MCL landmark. sMCL, superficial MCL; MCL, medial collateral ligament.

Figure 4

Identification of the MCL landmark in detail. Proximal insertion of MCL (yellow circle); medial meniscus and joint-line (red lines); target area for pie-crusting (green line). sMCL, superficial MCL; MCL, medial collateral ligament.

Figure 5

Needle insertion point—during valgus stress of the knee. The target area can be found in the joint line, above the medial meniscus and along the posterior 1/3 of the MCL. sMCL, superficial MCL; MCL, medial collateral ligament.

Figure 6

Knee medial compartment before pie-crusting. White lines indicate the opening of the posterior joint space visible on arthroscopy.

Figure 7

Knee medial compartment after pie-crusting. White lines indicate the opening of the posterior joint space visible on arthroscopy.

Figure 8

The posteromedial corner of the knee. The figure was reprinted with permission from the study conducted by D’Ambrosi et al. (10). sMCL, superficial MCL; MCL, medial collateral ligament; POL, posterior oblique ligament; SM, semimembranosus.