AUCTORES
Globalize your Research
Chat with us
Research | DOI: https://doi.org/10.31579/2694-0248/011
Department of Orthopaedics, India
*Corresponding Author: Nishikant Kumar, Department of Orthopaedics, India
Citation: Nishikant Kumar, Andalib Kashani, John Mukhopadhaya , C.S.Yadav, Sumit Anand, et all (2021) Bilateral Mcl Avulsion Following Tka : A Case Report And Review Of Literature J. Clinical Orthopaedics and Trauma Care 3 (1); DOI: 10.31579/2694-0248/011
Copyright: © 2021 Nishikant Kumar, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 15 March 2021 | Accepted: 22 March 2021 | Published: 30 March 2021
Keywords: bilateral mcl avulsion; total knee replacement
this article describes a traumatic bilateral MCL avulsion in previously well-functioning total knee arthroplasty. A thorough physical examination with appropriate radiographic imaging study is required for proper evaluation and treatment of this injury, as it is associated with debilitating instability of the knee and accelerated wear and failure of the TKA.
a traumatic bilateral MCL avulsion after total knee arthroplasty is an extremely rare event, with no case reported in the English literature so far. This report describes a traumatic bilateral MCL avulsion of a previously well-functioning total knee arthroplasty in a 75 year old woman.
Case History
A 75 year-old female who underwent an uncomplicated sequential bilateral Posterior stabilised total knee replacement presented to the emergency department 15 days post operation with bilateral knee pain and swelling after slipping from stairs.
The patient had severe degenerative osteoarthritis bilateral knee limiting her activities of daily living (Figure 1).
She sustained bilateral knee injury on 15th post op of second surgery, when she slipped down the stairs. She immediately experienced pain and swelling in both of her knees and was unable to move her knees afterward. She was unable to ambulate secondary to pain and was brought to the emergency department.
Plain radiographs of bilateral knee AP & Lat views (Figure 4) and subsequent CT scans with 3D reconstructions demonstrated bilateral MCL avulsion. There was medial condyle fracture with implant loosening over left knee (Type III Lewis and Rorabeck, 1997) while there was MCL Avulsion with stable prosthesis (Type II Lewis and Rorabeck) of the left knee. On clinical examination distal neurovascular status of bilateral lower limbs were found to be intact.
Patient’s both the lower limb were stabilised on above knee slab and all Pre-anaesthetic check-ups were done and patient was posted for surgery after explaining risks to surgery. Both knee were approached sequentially considering the age and medical comorbidity.
Right knee was intervened first. Original skin incision was used, medial parapatellar approach made. Thoroughlavage done. Implants were found well fixed. There was bony avulsion of MCL with large chunk of medial femoral condyle. It was stabilised with lag screw and a T –type buttress plate was applied posteromedial. Tibial insert were removed and exchanged with constrained poly. The knee was stable throughout range of motion. Wound was closed in layer with drain inside.
Left knee was approached after a week (for the inflammatory markers to settle). It was also approached through the same midline skin incision and medial parapatellar approach under tourniquet control. The medial epicondyle was found crushed and hardly any bone was left to be fixed. (Figure 6) and femoral component was loose as well. There was no active sign of infection .So it was decided to revise in single stage. Femoral component were taken out. Tibial component was well fixed and it was taken out using saw blade and gentle hammering over osteotomies. It was taken out without taking out any native bone. (Figure 7)
After thorough lavage Hinge knee (Endomodel; Link) was put in after cementing over both femoral and tibial side. Old meniscal remnant was taken as a guide to ascertain the joint line. Wound was closed in layer with drain insitu.Knee immobilizer was applied.
Patient was given antibiotic prophylaxis for 5 days post op.
The ROM exercises were started next day of surgery on right side while over left side in which fixation was done it was delayed till 2 weeks. Patient was allowed partial weight bearing with walker and Knee immobilizer brace next day of second surgey.The patient's stay in hospital was uneventful, with gradual physiotherapy .Regular wound inspection was done and stiches were removed 2 weeks after second surgery.
Two weeks after her discharge, she was re-examined in the OPD. Swelling and ecchymosis in her both knee had subsided substantially. She kept on using walker and brace for a month and after a month she was advised to use stick for 2 month.
She recovered well in post op period. On subsequent visit at 3 month, 6 month and 1 year follow up she gained 0 to 120 deg movement in both knees without any laxity. She is able to ambulate and climb stairs independently.
A traumatic bilateral MCL avulsion after total knee arthroplasty is an extremely rare event, with no case reported in the English literature so far. Iatrogenic intraoperative disruption of the MCL is a known complication of TKA seen in about 2.2% of the patients that can affect patient outcome and satisfaction. [1, 2, 4]
The superficial MCL femoral attachment is approximately 1 cm anterior and distal to the adductor tubercle and consists of vertical and oblique fibers that coalesce with the anterior tibia approximately 4.5 cm distal to the medial joint line. The superficial MCL was reported to be the primary restraint to valgus forces by Wymenga et al, [5] who transected the ligament and showed a medial joint line opening of 3 to 5 mm with valgus stress. The roles of 2 fibre orientations that work in concert with each other were illustrated by Whiteside, [6] who systematically released the anterior fibres first, allowing greater laxity in increasing degrees of flexion, and then the posterior fibers, producing greater laxity in extension. The deep MCL consists of capsular extensions, is typically released during exposure of the posteromedial corner of a varus knee, and is considered a secondary restraint to valgus forces. MCL can be injured intraoperatively or postoperatively following subsequent trauma. It can be injured either from femoral side, midsubstance (most common) or from tibial attachment.
Protecting the MCL is an essential aspect of TKA and involves careful placement of retractors and meticulous care in soft tissue handling and bony resections (mostly posterior femoral cut). Morbidly obese and patients with stiff knee are more prone for intraoperative MCL injury. One common situation intraoperatively when MCL gets ruptured is when we try to forcefully negotiate trial insert with less created flexion space. This habit of forceful insertion should be inhibited and we should go on doing soft tissue release or revising bone cuts before putting trial components.
After u recognise MCL injury you first have to recognise the site of injury then it can be either repaired or augment with graft.
Femoral Avulsion- If MCL is avulsed from femoral attachment it can be sutured back using suture anchor or spike washers or staples. [9, 10]
Tibial avulsion- It can again be sutured back using anchors or staples. [4, 10, 12]
Midsubstance tear- Primary repair with mobilisation has shown bad result in various literatures. Some author recommend Primary repair and casting , which is also not very encouraging[4] .Good results have been documented with Primary repair and augmenting this repair with double hamstring graft, keeping tibial attachment of hamstring intact , fixing graft to medial epicondyle and tensioning it at 30 deg flexion. [12, 13]
Some literature recommended the use of more constrained implants to restore coronal plane stability if the MCL was deemed incompetent or disrupted.[3] However, increasing the level of constraint can result in various concerns that a surgeon must take into consideration before selecting this type of implant. Also increasing level of constraint is not going to give varus and valgus stability. Condylar constrained prosthetic designs increase the stresses on implant fixation, which can play a role in aseptic loosening. [3]. If these methods don’t work we may have to revise it using Hinge knee. In the presence of a disrupted MCL, the PCL substituting implant provided no valgus stability in any degree of flexion [8, 12, 13].
Proper TKA balancing relies on appropriate soft tissue tension provided by intact collateral ligaments. Loss of the medial soft tissue structures such as the MCL can result in instability and accelerated wear, necessitating the need for a revision. Currently, no specific recommendations have been universally agreed on for this situation.
The case discussed in this article is unique as it describes a traumatic bilateral MCL avulsion following TKR after sustaining a fall from stairs. This diagnosis should be considered when presented with a swollen and painful knee with limited range of motion with valgus stress test positive in a patient who previously underwent total knee arthroplasty. Recognition of this injury and proper surgical intervention is imperative for the outcome of TKR.The treatment recommendation is immediate immobilization of the knee joint and a careful physical examination to assess neurovascular status often requiring advanced imaging such as computed tomography.
Based on our experience with this patient, we recommend immediate immobilization and protection of the injured knee followed by surgical exploration. It’s important to assess the stability of implant and size of bone attached with MCL. If there is Bony avulsion of MCL which is fixable and implant is not loose then it should be fixed with screw and buttress plate. However if there is implant loosening its advisable to revise it with hinge knee.
Post operatively the limb should be immobilised for at least 3 weeks if repair or fixation has been done. Gentle physiotherapy; ROM exercises with protected delayed weight bearing is advisable subsequently.
Summary
A bilateral traumatic avulsion of the MCL after a total knee arthroplasty is a very rare injury. Our case report describes a patient who sustained this injury after fall from stairs. This injury can be associated with suboptimal outcome of a TKR. Therefore, it is important to perform a thorough clinical and radiological assessment of the injury and exploration of the joint. Most important is to assess the stability of implant. If implant is stable we can try repair with augmentation or fixation if good amount of bone left. However if implant is loose there is no point retaining it and it should be revised with hinge knee. Also the surgeon needs to be guarded about the prognosis with gentle physiotherapy and protected delayed weight bearing as well as regular clinical and radiological examinations subsequently.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
