Pie-crusting technique of medial collateral ligament for total knee arthroplasty in varus deformity: A systematic review
Mehdi Motififard1, Hadi Ravanbod2, Rashed Rahmati3, Mohammad Saleki3
1 Department of Orthopedic Surgery, Kashani University Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Orthopedic Surgery, School of Medicine, Al-Zahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Orthopedics, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||05-Aug-2021|
|Date of Acceptance||25-Sep-2021|
|Date of Web Publication||30-May-2023|
Dr. Mohammad Saleki
Hezar Jerib Avenue, School of Medicine, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: We aimed to better understand the outcomes/complications of pie-crusting technique using blade knife during total knee arthroplasty (TKA) in patients with knee genu varum deformity.
Materials and Methods: A systematic search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. English and Persian language articles were considered on the use of pie-crusting technique during TKA in patients with knee genu varum/varus deformity using related keywords and Medical Subject Headings terms with reported postoperative complications and outcomes.
Results: Primary search resulted in 81 studies of them 9 included in our study (ages ranged: 19 years to 62 years). No perioperative complications and/or any significant differences between pie-crusting and control group were observed. Except for two studies that found no significant positive effect for the use of pie-crusting, other studies found pie-crusting a useful and promising technique. Four studies found significant improvement in pie-crusting group compared to control in terms of functional Knee Society Score (KSS), range of motion (ROM), medial gap, and the knee-specific KKS. Three records found no significant differences in terms of functional KSS, ROM; however, they reported fewer use of constrained inserts or a reasonable correction of femoral tibial angle. No serious complications were reported.
Conclusions: Due to the inconsistency of the results on the efficiency and outcomes of pie-crusting, we cannot make a firm conclusion and more high-quality studies are needed in this regard. However, this method can be considered as a safe method which depends on the skill of surgeon.
Keywords: Arthroplasty, instability, medial collateral ligament, pie-crusting, systematic review, total knee replacement
|How to cite this article:|
Motififard M, Ravanbod H, Rahmati R, Saleki M. Pie-crusting technique of medial collateral ligament for total knee arthroplasty in varus deformity: A systematic review. Adv Biomed Res 2023;12:138
|How to cite this URL:|
Motififard M, Ravanbod H, Rahmati R, Saleki M. Pie-crusting technique of medial collateral ligament for total knee arthroplasty in varus deformity: A systematic review. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:138. Available from: https://www.advbiores.net/text.asp?2023/12/1/138/377861
| Introduction|| |
Genu varum weakens the lateral structure and consequently makes it difficult to improve the stability of patients' knee joint using conventional correction methods., Genu varum or varus has a great negative impact on the quality of life of the patient's due to impairment of their ability to live independently. Total knee arthroplasty (TKA) is a promising and relatively new treatment approach which can improve the quality of life of these patients effectively. Preparation of medial structures of the knee for varus deformity correction is one of the most important factors during TKA.,
Various soft tissue release techniques were developed to correct an unbalanced joint. Among these techniques, the traditional release method, also known as the insall release method, has become a popular method for releasing contractile soft tissue with clinically verifiable results reported by several studies.,,,, However, some studies have found the complications of this procedure to be worrisome including unstable knees due to excessive release or increased joint line ultimately might lead to patellar and osteoarthritis due to arterial damage around the joint.,,
The needle multiple puncture technique for medial collateral ligament (MCL) release is widely used in varus deformity in total arthroplasty surgery, and the pie-crusting technique using blade knife in recent years has been considered as a damage-control method to release soft tissue of lateral structures in total valgus deformity arthroplasty.,,,, Some studies have reported this method is effective and uncomplicated in releasing the medial tissues of the knee with a blade knife.,, However, many surgeons still oppose the use of this technique due to iatrogenic damage to the superficial part of the MCL and possible instability of the knee joint.,,, In a study on cadaveric knees, the safety of this technique on MCL showed that surgeons should be careful in using this technique because the failure mechanisms of this technique are different from those commonly used.
To best of our knowledge, no systematic review has been conducted to investigate the effects and safety of pie-crusting technique on the different parameters of the knee for varus deformity. The aim of this study was to systematically evaluate and summarize the clinical outcome and complications of pie-crusting of the medial side of the knee during TKA in patients with knee genu varum deformity.
| Materials and Methods|| |
A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using a PRISMA checklist. Databases of Google Scholar, PubMed, Web of Science, Scopus, and scientific information database were searched systematically from 1990 to 2021. Inclusion criteria were studies in Persian or English, evaluating the clinical outcome of pie-crusting of the medial side of the knee during TKA in patients with knee in genu varum/varus deformity. The utilized keywords were the followings: “total knee arthroplasty,” “pie-crusting,” “genu varum” “genu varus,” “varus,” and “medial collateral ligament.” The following data were extracted from enrolled articles: first author's name, publication year, country, study design, number of patients in pie-crusting group, knee brace usage, knee instability, outcomes, and complications. All the studies were entered in reference management EndNote software, and then, duplicates were removed followed by excluding the articles with undesired title and/or abstracts, conferences and abstracts, non-English and non-Persian articles, and studies published before 1990.
| Results|| |
The process of study selection has shown in [Figure 1]. After removing duplications and unrelated articles, 13 studies were remained and one record was excluded because it was about valgus deformity. Another study was also removed because it introduced and used a new method called femoral origin release of the medial collateral ligament. One study was discarded because it did not provide any specific and separate data on patients in varus deformity. At last, we excluded one record since it was about medial epicondylar osteotomy method. Finally, 9 studies were selected.,,,,,,,, The summary of the outcomes of pie-crusting technique and patient follow-up for varus deformity during TKA has been listed in [Table 1].
|Figure 1: Flowchart of study selection procedure in this systematic review|
Click here to view
|Table 1: The summary of the outcomes of pie-crusting technique for varus deformity during total knee arthroplasty|
Click here to view
| Discussion|| |
We performed this systematic literature review to evaluate clinical outcomes on different parameters after using pie-crusting technique during TKA in patients with varus deformity. In these recruited studies, men were treated more often than women, patients' ages ranged from 19 to 62 years. Except for two studies that opposed the efficiency and safety of pie-crusting technique,, other studies found pie-crusting a useful and promising technique.,,,,, Among the studies evaluated this usefulness of this technique, one record reported some cases with knee instability followed by using pie-crusting technique during TKA, however, others reported no case of knee instability. Bracing was used for a mean of 4 weeks after percutaneous lengthening in two studies., At the final follow-up, no reports of any postoperative complications were found. Five studies reported improvement in KSS and range of motion (ROM) score and improving medial gap,,,, and two records found no significant improvement in terms of KSS and ROM.,
The knee joint plays a very important role in supporting the body and transferring its weight during static and dynamic activities.,, Knee deformities cause premature osteoarthritis changes by unequal application of force to the internal and external structures of the knee. In general, the most common cause of varus deformity is osteoarthritis, followed by rheumatoid arthritis and traumatic arthritis. Recommended treatments for this deformity include supportive measures, tibial osteotomy, and, finally, knee arthroplasty. There are many concerns about the techniques required for total arthroplasty in these patients.
Preparation of medial structures of the knee is one of the most important factors involved in TKA in patients with genu varum. Improper balance of medial knee structures causes premature failure after surgery.,,, Several techniques have been proposed to create this balance.,,, So far, no definitive standard for the technique of releasing the medial structures of the knee has been presented. Normally, the superficial part of the MCL is released subperiosteally to balance the medial structures in the varus knees.,, In one study, it was shown that by releasing surface MCL subperiosteally from the tibial insertion site by nearly 20 mm, the medial gap will be increased. Although in moderate deformity of the knee, less than a 10 mm increase in medial gap is required, the use of this common technique results in the loss of sufficient MCL tension and instability in the knee. Therefore, the use of this technique to increase the medial gap is discussed, while it depends on the skill of the surgeon. Aglietti et al. mentioned that pie-crusting is a reliable technique for correcting moderate-to-severe fixed valgus deformities and the rate of complication is very low while the mid-term outcomes are reasonable. Pie-crusting first introduced by Agneskirchner for soft-tissue balancing during TKA.,, The advantages of percutaneous release method are the release without compromising the synovial membrane, reducing the risk of intra-articular septic complications, while avoiding intra-articular structures that may prevent the tools needed in the intra-external method from being placed to use deep MCL.
Goudarz Mehdikhani et al. used an algorithmic method of pie-crusting recommended previously by Bellemans et al. which included the resection of the posterior osteophytes as the initial balancing gesture. They found that the use of constrained inserts was significantly lower in the pie-crusting group than the control group, and the difference in the constrained inserts applying was not significant in patients with mild and moderate deformity but it was only significant in those with severe deformity. They found no significant differences between pie-crusting and control groups in terms of functional KSS, ROM, and the knee-specific KKS. However, He et al. during their study on pie-crusting group including 36 patients (26 females and 10 males) with 39 knees concluded that pie-crusting method is effective, reliable, and safe to release superficial MCL (sMCL) for TKA. To perform pie-crusting, they made three to five small incisions in the middle of the ligament material with a scalpel or a scraping needle, and the contraction gap was gradually released with the diffuser simultaneously. The release range was controlled in range of 2–5 mm. Comparing the radiographic result of traditional release group with pie-crusting group showed a reasonable correction of femoral tibial angle (P = 0.045) in the latter group indicated a higher valgus degree. Tibia osteotomy volume and plate thickness found to be greater in pie-crusting. Knee functional parameters improved significantly in terms of flexion contraction, ROM, and KSS points in the follow-up cases compared to their status before the operation. In their study, four out of 26 patients used braces to prevent knee instability, and all four removed the braces after some time without signs or symptoms of unstable knees. There was only one case with severe pain around patella restricted daily activities such as climbing stairs and walking; however, no hemarthrosis cases were reported in their study during follow-up period. The joint line levels were elevated approximately 2 mm using pie-crusting after surgery.
In study by Ha et al., selective medial release method was performed for medial tightness applying pie-crusting. They found that out of 729 knees, 328 needed pMCL/PMCS scaling to release internal contractions. The ROM was improved from 127.4 to 140.8 and the KSS score from 52 to 83.4. The KSS function scores improved from 58.2 to 91.9 points. No patient disclosed signs of knee instability at the latest follow-up visit. No other specific medical complications related to this technique (bleeding, hematoma formation, constrained prosthesis, nerve injury) were reported. Controlled enhancement of sMCL allows for improved visualization and access to tools with the usage of percutaneous pie-crusting method.
However, studies on medial pie-crusting are not enough but it seems useful method for increasing medial gap especially in flexion. This theory has not been confirmed in Cadaveric studies. Several studies reported improvement in post-operative KSS and Functional KS after pie-crusting compared with pre-operative scores but in studies the control group was not considered for comparison. Therefor it is not possible to comment on the preference of this method over the traditional method. Some studies reported instability and CCK surgery has been less than the traditional method. Due to the inconsistency of the results on the efficiency and outcomes of pie-crusting we cannot make a firm conclusion and more high-quality studies are needed in this regard. However, this method can be considered as a safe method which depends on the skill of surgeon.
One of the main limitations of this study was that all the included studies were observational and they will have all the limitations of this category of studies.
| Conclusions|| |
It can be concluded that pie-crusting is a reliable method for correcting varus deformity (genu varum) and this technique is associated with low risk of instability, however in terms of knee society score (KSS) and range of motion (ROM) results of different articles are inconsistent and more studies are needed to confirm the conclusion.
Financial support and sponsorship
This article resulted from an independent research without financial support.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zhao MW, Tian H, Zeng L, Li BG, Zhang FL, Li LY. Evaluation and analysis of the tibial coronal alignment after total knee replacement with the extramedullary tibial cutting guided by the tibial tubercle and anterior tibial tendon in Chinese patients. Beijing Da Xue Xue Bao Yi Xue Ban 2016;48:351-5.
Zhao MW, Wang L, Zeng L, Hu YQ, Hu JX, Tian H. Effect of femoral resection on coronal overall alignment after conventional total knee arthroplasty. Chin Med J (Engl) 2016;129:2535-9.
Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: Improving outcomes with a multidisciplinary approach. J Multidiscip Healthc 2018;11:63-73.
Hazratwala K, Matthews B, Wilkinson M, Barroso-Rosa S. Total knee arthroplasty in patients with extra-articular deformity. Arthroplast Today 2016;2:26-36.
Sorrells RB, Murphy JA, Sheridan KC, Wasielewski RC. The effect of varus and valgus deformity on results of cementless mobile bearing TKA. Knee 2007;14:284-8.
Engh GA. The difficult knee: severe varus and valgus. Clin Orthopaedics Related Res (1976-2007) 2003;416:58-63.
Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R, Ranawat AS. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. J Bone Joint Surg Am 2004;86:2671-6.
Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am 2005;87 Suppl 1:271-84.
Teeny SM, Krackow KA, Hungerford DS, Jones MA. Primary total knee arthroplasty in patients with severe varus deformity. A comparative study. Clin Orthopaedics Related Res 1991;273:19-31.
Karachalios T, Sarangi PP, Newman JH. Severe varus and valgus deformities treated by total knee arthroplasty. J Bone Joint Surg Br 1994;76:938-42.
Cameron HU, Hunter GA. Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthopaedics Related Res 1982;170:141-6.
Schwarzkopf R, Hadley S, Abbasi M, Meere PA. Computer-assisted surgery patterns of ligamentous deformity of the knee: A clinical and cadaveric study. J Knee Surg 2013;26:233-8.
Dragosloveanu S, Cristea S, Stoica C, Dragosloveanu C. Outcome of iatrogenic collateral ligaments injuries during total knee arthroplasty. Eur J Orthop Surg Traumatol 2014;24:1499-503.
Bellemans J, Vandenneucker H, Van Lauwe J, Victor J. A new surgical technique for medial collateral ligament balancing: Multiple needle puncturing. J Arthroplasty 2010;25:1151-6.
Tanaka K, Muratsu H, Mizuno K, Kuroda R, Yoshiya S, Kurosaka M. Soft tissue balance measurement in anterior cruciate ligament-resected knee joint: Cadaveric study as a model for cruciate-retaining total knee arthroplasty. J Orthop Sci 2007;12:149-53.
Aglietti P, Lup D, Cuomo P, Baldini A, De Luca L. Total knee arthroplasty using a pie-crusting technique for valgus deformity. Clin Orthop Relat Res 2007;464:73-7.
Agneskirchner JD, Lobenhoffer P. Arthroscopic meniscus surgery: Technical-operative methods. Unfallchirurg 2004;107:795-801.
Agneskirchner J, Bernard M, Lobenhoffer P. Improved overview of arthroscopic interventions on the posterior horn of the medial meniscus by percutaneous needling of the medial ligament. Arthroscopy 2005;18:69-70.
Koh HS, In Y. Semimembranosus release as the second step of soft tissue balancing in varus total knee arthroplasty. J Arthroplasty 2013;28:273-8.
Verdonk PC, Pernin J, Pinaroli A, Ait Si Selmi T, Neyret P. Soft tissue balancing in varus total knee arthroplasty: An algorithmic approach. Knee Surg Sports Traumatol Arthrosc 2009;17:660-6.
Kwak DS, In Y, Kim TK, Cho HS, Koh IJ. The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016;24:188-94.
Bellemans J. Multiple needle puncturing: Balancing the varus knee. Orthopedics 2011;34:e510-2.
Meneghini RM, Daluga AT, Sturgis LA, Lieberman JR. Is the pie-crusting technique safe for MCL release in varus deformity correction in total knee arthroplasty? J Arthroplasty 2013;28:1306-9.
Lee SY, Yang JH, Lee YI, Yoon JR. A novel medial soft tissue release method for varus deformity during total knee arthroplasty: Femoral origin release of the medial collateral ligament. Knee Surg Relat Res 2016;28:153-60.
Moore RE, Conditt MA, Roche MW, Verstraete MA. How to quantitatively balance a total knee? A surgical algorithm to assure balance and control alignment. Sensors (Basel) 2021;21:700.
Mirzatolooei F, Tabrizi A, Taleb H, Hashemian MK, Safari MB. Primary results of medial epicondylar osteotomy in patients with severe bilateral varus knee candidate for total knee replacement. J Knee Surg 2021;34:142-6.
Goudarz Mehdikhani K, Morales Moreno B, Reid JJ, de Paz Nieves A, Lee YY, González Della Valle A. An algorithmic, pie-crusting medial soft tissue release reduces the need for constrained inserts patients with severe varus deformity undergoing total knee arthroplasty. J Arthroplasty 2016;31:1465-9.
Amundsen S, Lee YY, González Della Valle A. Algorithmic pie-crusting of the medial collateral ligament guided by sensing technology affects the use of constrained inserts during total knee arthroplasty. Int Orthop 2017;41:1139-45.
Motififard M, Sheikhbahaei E, Piri Ardakani M, Cheraghsahar H, Shahzamani A. Intraoperative repair for iatrogenic MCL tear due to medial pie-crusting in TKA yields satisfactory mid-term outcomes. Knee Surg Sports Traumatol Arthrosc 2021;29:3246-53.
He X, Cai H, Zhang K. Pie-crusting technique is effective and safe to release superficial medial collateral ligament for total knee arthroplasty. J Orthop Translat 2018;13:33-40.
Ha CW, Park YB, Lee CH, Awe SI, Park YG. Selective medial release technique using the pie-crusting method for medial tightness during primary total knee arthroplasty. J Arthroplasty 2016;31:1005-10.
Crockarell JW. Medial pie-crusting for varus deformity in total knee arthroplasty. Curr Orthop Pract 2015;26:624-8.
Ahn JH, Yang TY, Lee JY. Reduction osteotomy vs. pie-crust technique as possible alternatives for medial release in total knee arthroplasty and compared in a prospective randomized controlled trial. J Arthroplasty 2016;31:1470-5.
Krackow KA, Mihalko WM. The effect of medial release on flexion and extension gaps in cadaveric knees: Implications for soft-tissue balancing in total knee arthroplasty. Am J Knee Surg 1999;12:222-8.
Gaudiani MA, Knapik DM, Kaufman MW, Salata MJ, Voos JE, Karns MR. Percutaneous superficial medial collateral ligament release outcomes during medial meniscal arthroscopy: A systematic review. Arthrosc Sports Med Rehabil 2020;2:e153-9.
Apostolopoulos AP, Nikolopoulos DD, Polyzois I, Nakos A, Liarokapis S, Stefanakis G, et al.
Total knee arthroplasty in severe valgus deformity: Interest of combining a lateral approach with a tibial tubercle osteotomy. Orthop Traumatol Surg Res 2010;96:777-84.
Nikolopoulos DD, Polyzois I, Apostolopoulos AP, Rossas C, Moutsios-Rentzos A, Michos IV. Total knee arthroplasty in severe valgus knee deformity: Comparison of a standard medial parapatellar approach combined with tibial tubercle osteotomy. Knee Surg Sports Traumatol Arthrosc 2011;19:1834-42.
Kawakami H, Sugano N, Yonenobu K, Yoshikawa H, Ochi T, Nakata K, et al.
Change in the locus of dynamic loading axis on the knee joint after high tibial osteotomy. Gait Posture 2005;21:271-8.
Ang CL, Fook S, Chia SL, Chin PL, Lo NN, Yeo SJ. Unconstrained arthroplasty in type II valgus knees: Posterior stabilized or cruciate retaining? Knee Surg Sports Traumatol Arthrosc 2014;22:666-73.
Dorr LD, Boiardo RA. Technical considerations in total knee arthroplasty. Clin Orthopaedics Related Res 1986;205:5-11.
Luring C, Hüfner T, Perlick L, Bäthis H, Krettek C, Grifka J. The effectiveness of sequential medial soft tissue release on coronal alignment in total knee arthroplasty: Using a computer navigation model. J Arthroplasty 2006;21:428-34.
Matsumoto T, Kuroda R, Kubo S, Muratsu H, Mizuno K, Kurosaka M. The intra-operative joint gap in cruciate-retaining compared with posterior-stabilised total knee replacement. J Bone Joint Surg Br 2009;91:475-80.
Winemaker MJ. Perfect balance in total knee arthroplasty: The elusive compromise. J Arthroplasty 2002;17:2-10.
Yagishita K, Muneta T, Ikeda H. Step-by-step measurements of soft tissue balancing during total knee arthroplasty for patients with varus knees. J Arthroplasty 2003;18:313-20.
Laskin RS. Total knee replacement with posterior cruciate ligament retention in patients with a fixed varus deformity. Clin Orthopaedics Related Res 1996;331:29-34.
Whiteside LA, Saeki K, Mihalko WM. Functional medial ligament balancing in total knee arthroplasty. Clin Orthopaedics Related Res 2000;380:45-57.
Mullaji A, Sharma A, Marawar S, Kanna R. Quantification of effect of sequential posteromedial release on flexion and extension gaps: A computer-assisted study in cadaveric knees. J Arthroplasty 2009;24:795-805.