Pie-crusting Technique Research Articles

Comparative analysis of medial pivot vs. posterior stabilized total knee arthroplasty in patients with valgus deformed osteoarthritic knees: a retrospective cohort study.

Total knee arthroplasty (TKA) is highly effective for end-stage knee osteoarthritis, providing long-term benefits and anticipated increased prevalence. The study compares Medial Pivot TKA's (MP-TKA) historical success for varus deformities with recent findings suggesting comparable outcomes for valgus deformities. Despite prevalent use of Posterior Stabilized TKA (PS-TKA) for valgus deformities, this research explores the unexplored comparative efficacy of MP-TKA vs. PS-TKA in knee osteoarthritis patients with valgus deformity. This single-centrecohort study focused on 57 knees in 53 patients undergoing TKA for knee osteoarthritis with valgus deformity. Conducted between January 2013 and April 2021, the study compared MP-TKA and PS-TKA. Surgeries adhered to a medial parapatellar approach and modified gap technique, with perioperative interventions for pain, bleeding, and swelling. Outcome measurements included knee joint range of motion, radiographic evaluation, patients-reported outcomes, operative time, blood laboratory tests, estimated blood loss, and postoperative adverse events, and analyzed between the two groups. Postoperative hip-knee-ankle angles showed no significant difference between MP-TKA and PS-TKA. The pie crust technique was similarly used in both groups, and deformity correction showed no significant difference. Range of motion and clinical outcomes, measured by WOMAC and JOA scores, were comparable postoperatively. MP-TKA had a shorter surgical duration (p = 0.01), and PS-TKA exhibited higher estimated blood loss (p = 0.01) without significant complications in either group. This pioneering study compares the outcomes of MP TKA and PS TKA in patients with valgus-deformed osteoarthritic knees. Compared to PS TKA, MP TKA shows a prolonged operative duration and increased blood loss, likely due to the requirement for patellar replacement. However, postoperative range of motion and clinical outcomes are similar. Both groups exhibit favorable midterm clinical results, supporting the viability of MP TKA for valgus deformed knees. The study, consistent in surgical approach, highlights MP TKA's effectiveness for valgus deformities.

The pie-crusting release of the medial collateral ligament in arthroscopic partial meniscectomy is associated with improved clinical outcomes without altering radiological measurements.

The aim of this study was to evaluate how the pie-crusting technique affects clinical and radiological outcomes in patients undergoing arthroscopic partial meniscectomy. A total of 68 patients with Kellgren-Lawrence (K-L) grade 2 who underwent arthroscopic partial meniscectomy between 2015 and 2021 were evaluated and divided into two groups as arthroscopic partial meniscectomy (36 patients) and arthroscopic partial meniscectomy with pie-crusting (32 patients) according to whether the pie-crusting technique was applied or not. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity score, International Knee Documentation Committee (IKDC) score and Visual Analogue Scale (VAS) score. To assess the impact of the pie-crusting technique, radiological measurements were conducted using radiographs taken before and after pie-crusting, as well as postoperative radiographs. Lysholm, Tegner, IKDC and VAS scores exhibited statistically significant differences after surgery compared to preoperative evaluations in both groups (p < 0.05). Furthermore, these scores were significantly superior in the arthroscopic partial meniscectomy with pie-crusting group compared to the arthroscopic partial meniscectomy group at 24 months postoperatively (p < 0.05). While the radiological measurements in the arthroscopic partial meniscectomy with pie-crusting group showed statistically significant differences before and after pie-crusting (p < 0.05), no significant difference was observed between before pie-crusting and 12 and 24 months postoperatively (n.s.). The current study is the first to demonstrate the true effectiveness of the pie-crusting technique. The application of the pie-crusting technique when necessary results in a statistically significant improvement in clinical scores without affecting radiological measurements for patients undergoing arthroscopic partial meniscectomy compared to not utilising it. Level III.

Precision soft tissue balancing: grid-assisted pie-crusting in total knee arthroplasty.

The varus and valgus knee deformities result from imbalance in tension between medial and lateral soft tissue compartments. These conditions need to be addressed during total knee arthroplasty (TKA). However, there is no consensus on optimal soft-tissue release techniques for correcting varus and valgus deformities during TKA. We assessed the efficacy of a novel grid-based pie-crusting technique on soft-tissue release. Cadaver knees were dissected, leaving only the femur and tibia connected by an isolated MCL or the femur and fibula connected by an isolated LCL. Bone cuts were made as performed during primary TKA. Mechanical testing was performed using an MTS machine. A 3D-printed 12-hole grid was placed directly over the MCL and LCL. Using an 18-gauge needle, horizontal in-out perforations were made 3 mm apart. Deformation and stiffness of the ligaments were collected after every 2 perforations. Means were calculated, and regression analyses were performed. A total of 7 MCL and 6 LCL knees were included in our analysis. The mean medial femorotibial (MFT) space increased from 6.018 ± 1.4 mm-7.078 ± 1.414 mm (R2 = 0.937) following 12 perforations. The mean MCL stiffness decreased from 32.15 N/mm-26.57 N/mm (R2 = 0.965). For the LCL group, the mean gap between the femur and fibula increased from 4.287 mm-4.550 mm following 8 perforations. The mean LCL stiffness decreased from 29.955 N/mm-25.851 N/mm. LCL stiffness displayed a strong inverse relationship with the number of holes performed (R2 = 0.988). Our results suggest that using this novel grid for pie-crusting of the MCL and LCL allows for gradual lengthening of the ligaments without sacrificing their structural integrity. Our proposed technique may serve as a valuable piece in the soft-tissue release toolkit for orthopaedic surgeons performing TKA in varus and valgus deformed knees.

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases.

The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis. This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release. The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case. Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

Effectivity of the Outside-In Pie-Crusting Technique and an All-Inside Meniscal Repair Device in the Repair of Ramp Lesions

Ramp lesions are characteristic medial meniscus injuries seen in anterior cruciate ligament–injured knees. Anterior cruciate ligament injuries combined with ramp lesions increase the amount of anterior tibial translation and tibial external rotation. Therefore, the diagnosis and treatment of ramp lesions have received increasing attention. However, ramp lesions can be difficult to diagnose on preoperative magnetic resonance imaging. Additionally, ramp lesions are difficult to observe and treat intraoperatively in the posteromedial compartment. Although good results have been reported with the use of a suture hook through the posteromedial portal in the treatment of ramp lesions, the complexity and difficulty of the technique are further problems. The outside-in pie-crusting technique is a simple procedure that can enlarge the medial compartment and facilitate the observation and repair of ramp lesions. After this technique, ramp lesions can be properly sutured, using an all-inside meniscal repair device, without damaging the surrounding cartilage. A combination of the outside-in pie-crusting technique and an all-inside meniscal repair device (with only anterior portals) is effective in the repair of ramp lesions. This Technical Note aims to report in detail the flow of a series of techniques, including our diagnostic and therapeutic methods.

Abnormal patellar loading may lead to femoral trochlear dysplasia: an experimental study of patellar hypermobility and patellar dislocation in growing rats

BackgroundThis animal study aimed to explore the effects of patellar hypermobility and patellar dislocation on the developing femoral trochlea.MethodsSeventy-two 3-week-old Wistar rats were randomly divided into three groups. The sham group (SG) underwent simple incision and suture of the skin and subcutaneous tissue; the patellar hypermobility group (PHG) underwent medial and lateral retinacular release and pie-crusting technique for the patellar ligament; the patellar dislocation group (PDG) underwent plication of the medial patellofemoral retinaculum. Twelve rats in each group were euthanized at 3 and 6 weeks postoperatively, respectively, and specimens were collected. The bony sulcus angle (BSA), cartilaginous sulcus angle (CSA), trochlear sulcus depth (TSD), and thickness of the cartilage on the lateral facet (CTL), medial facet (CTM), and center (CTC) of the trochlea were measured on hematoxylin and eosin-stained sections.ResultsIn the PHG and PDG, the femoral condyles became blunt, the trochlear groove became shallower, and cartilage became thicker compared with the SG. Compared with the SG, the PHG and PDG had significantly larger BSA and CSA values at 3 (p < 0.05) and 6 weeks (p < 0.005), and a significantly shallower TSD (p < 0.05). At 3 weeks, all cartilage thicknesses in the PHG and the CTC and CTM in the PDG were significantly thinner than in the SG (PHG vs. SG: p = 0.009 for CTL, p < 0.001 for CTM, p = 0.003 for CTC; PDG vs. SG: p = 0.028 for CTC, p = 0.048 for CTM). At 6 weeks, the CTC was thicker in the PHG and PDG than the SG (PHG vs. SG: p = 0.044; PDG vs. SG: p = 0.027), and the CTL was thinner in the PDG than the SG (p = 0.044).ConclusionPatellar hypermobility and patellar dislocation may result in trochlear dysplasia that worsens with age. Excessive or insufficient loading leads to trochlear dysplasia.

A novel instrument for ligament balancing: a biomechanical study in human cadaveric knees

PurposeLigament balancing is a prerequisite for good function and survival in total knee arthroplasty (TKA). Various balancing techniques exist, but none have shown superior results. The pie-crusting technique by Bellemans of the medial collateral ligament is commonly utilized; however, it can be difficult to achieve repeatable ligament lengthening with this technique. Therefore, we invented a novel instrument to standardize the pie-crusting technique of the superficial and deep medial collateral ligament (hereafter MCL). The purpose was to examine if pie-crusting with the instrument could produce repeatable ligament lengthening.MethodsThe MCL was isolated in 16 human cadaveric knees, and subjected to axial tension. The instrument was composed of a specific grid of holes in rows, used to guide sequential pie-crusting puncturing of the MCL with a Ø1.6 mm end-cutting cannula. Ligament lengthening was measured after each row of punctures. Regression analysis was performed on the results.ResultsMean lengthening ± SD in human cadaveric MCL for puncturing of row 1 in the instrument was 0.06 ± 0.09 mm, 0.06 ± 0.04 mm for row 2, 0.09 ± 0.08 mm for row 3, 0.06 ± 0.05 mm for row 4 and 0.06 ± 0.04 mm for row 5, giving a mean total lengthening of 0.33 ± 0.20 mm. Linear regression revealed that MCLs were repeatably lengthened by 0.07 mm per row when punctured using the instrument.ConclusionsMCLs showed linear lengthening in human cadavers for subsequent use of the instrument. Our instrument shows promising results for repeatable ligament lengthening.

Pie-Crusting Technique of Medial Collateral Ligament for Total Knee Arthroplasty in Varus Deformity: A Systematic Review.

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. 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. 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. 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.

Role of Pie Crusting Technique on Soft Tissues in Preventing Soft Tissue Complications Compared to Conventional Closure of Wound in Fractures of Distal Tibia (PILON) and Fibula

Objective: To demonstrate the effect of performing pie crusting on skin bridging two incisions used for open reduction and fixation to reduce wound complications compared to conventional wound closure.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Orthopedics and Trauma, Combined Military Hospital Rawalpindi from Jan to Nov 2020.&#x0D; Methodology: Forty-seven patients, managed primarily with open reduction and internal fixation for type-43 fractures per AO/OTA classification, were studied. Group-1 comprised patients in whom the pie crusting technique was used during the closure of the wound. Group-2 included patients in whom conventional closure of the wound was performed. Evaluation of complications in the presence or absence of superficial and deep infection and necrosis was done. The time from injury to surgery was 6 hours to 72 hours. Patients were followed for an average of 12 weeks. &#x0D; Results: In group-1 (pie-crust technique), there were 23 patients, whereas group-2 (classic wound closure) comprised 24 patients. In group-1, only 1 (4%) patient had a superficial infection, and no deep infection was reported. Whereas in group-2, six patients (25%) had superficial infection, and two patients (8%) had the deep infection.&#x0D; Conclusion: Results indicated that pie-crust technique significantly reduces the risk of superficial and deep wound complications compared to classic wound closure because it reduces skin tension and allows the drainage of subcutaneous fluids.

Which Fibers of the Medial Collateral Ligament (MCL) Should Be Released in the Pie Crust Technique Applied During Knee Arthroscopy: Superficial MCL or Deep MCL?

BackgroundKnee arthroscopy is the most common surgery performed to treat meniscal injuries. The pie crust (PC) technique is applied during knee arthroscopy to increase joint vision of the medial femorotibial compartment and reduce the risk of iatrogenic damage. Medial collateral ligament (MCL) release is applied in the PC technique. Currently, there are no studies directly comparing the release of the superficial MCL (sMCL) or deep MCL (dMCL) when applied during the PC technique. In this study, we compared the clinical and functional results of the release of the deep and proximal tibial attachment of the superficial fibers of the MCL.MethodologyWe evaluated the results of 67 (27 women and 40 men) patients who underwent the PC technique during knee arthroscopy due to a medial meniscal tear. The patients who underwent the PC technique were divided into two groups according to the release of the deep and superficial fibers of the MCL. All patients were evaluated for pain, functional capacity, and laxity using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Oxford Knee scores. All patients were evaluated with radiographic examinations such as valgus laxity angle and medial tibiofemoral compartment opening height.ResultsThe KOOS and Oxford Knee Scores in both groups showed a statistically significant increase at 12 months postoperatively compared with the preoperative values (p = 0.005, 0.002, 0.002, and 0.01, respectively). No statistically significant difference was found between the groups (p > 0.05). When the valgus laxity angle before the PC technique was compared with the 12-month result after the procedure, no statistically significant difference was noted (p > 0.05). There was no evidence of complications such as chondral injury and saphenous nerve or vein injury among patients in either group.ConclusionsIn this study, we did not observe laxity in the long-term follow-up of the groups in which the superficial or deep fibers of the MCL were released. In our view, the PC technique has similar effects on surgical outcomes regardless of sMCL and dMCL release techniques.

During Arthroscopic Repair of Medial Meniscal Tears: Do Not Be Afraid to Perform "Pie Crust" Technique.

In the absence of effective long-term repair of meniscal injuries, damage to the knee may lead to the development of osteoarthritis. Recent reports have recommended meniscal repair to be undertaken in all cases of meniscal tears. However, the most common complication encountered during repair of the medial meniscus is iatrogenic cartilage and meniscal injury due to its unclear visualization. The aim of this study is to evaluate the long-term clinical and radiological results of the pie-crust (PC) technique performed during the repair of medial meniscal tears. This retrospective study included 86 patients who underwent arthroscopic medial meniscus repair. PC technique was performed if the medial joint width was less than 5 mm. The patient population was divided into two groups as who underwent meniscus repair with PC technique (PC + repair group) or not (repair group). All patients were evaluated clinically (Kujala score, International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score) and radiologically (medial joint width and valgus laxity angle). When the medial joint width measurements before the PC technique and at the postoperative first and sixth months were compared, it was found to be statistically significant (p < 0.05). However, there was no significant difference between the preoperative and 12-month postoperative joint width measurements (p > 0.05). At the 12-month follow-up, no statistically significant difference was determined for the valgus laxity angle in the PC group compared with preoperative values (p > 0.05). The follow-up Kujala score, IKDC subjective score, Lysholm score, and Tegner activity score were similar between the groups. The clinical scores in both groups were determined to have statistically significant increase at 12-month postoperatively compared with the preoperative values (p < 0.05). The results of this study showed that performing the PC technique prior to medial meniscal tear repair increase the medial joint visualization safely and effectively without permanent valgus laxity.

Primary Repair of Intraoperative Medial Collateral Ligament Tear during Medial Pie-Crusting Technique in Total Knee Arthroplasty with Varus Deformity

The article's abstract is not available.

Pie-Crusting Capsulotomy Provides Similar Visualization With Increased Repair Stiffness Compared With a T-Capsulotomy: A Biomechanical Study

To compare the area of visualization, capsular stiffness, and strength between the pie-crusting capsulotomy technique and the T-capsulotomy technique following repair. Eight matched pairs of fresh-frozen cadaveric hips (n= 16) were divided to either T-capsulotomy or pie-crusting capsulotomy followed by subsequent repair. The area of visualization was measured for all capsulotomy states using a digitizing probe. Hips were then distracted along the iliofemoral ligament in the intact, extended capsulotomy, and repair states. Afterwards, specimens were externally rotated to failure. An average force of 250.1 ± 16.1 N was required to distract intact hips to 6 mm. Both extended capsulotomy techniques reduced the force required to distract the hip 6 mm with no statistical difference between the two (T-capsulotomy [T-cap]= 114.3 ± 63.4 N vs pie-capsulotomy [Pie-cap]= 170.1 ± 38.8 N), P= .07. Subsequent repair of the extended capsulotomies demonstrated the pie-crust capsulotomy required significantly greater force to reach 6 mm of distraction than those with a repaired T-capsulotomy (T-cap= 165.04 ± 40.43N vs Pie-cap= 204.43 ± 10.13N), P= .03. There was no significant difference in ultimate torque to failure between the 2 techniques (T-cap= 22.0 ± 7.41 N·m vs Pie-cap= 27.01 ± 11.13 N·m), P= .28. Visualization significantly increased with each extended capsulotomy, with an average increase of 62% (P < .001) and 48% (P < .001) for the pie- and T-capsulotomies, respectively. The pie-crusting technique maintained similar strength and increased stiffness to the T-capsulotomy following repair while using less suture. Both techniques provided similar visualization. Clinically, the pie-crusting technique provides an alternative to the T-capsulotomy with similar biomechanical and visual outcomes. Visualization during hip arthroscopy can be difficult with large cam morphology. Techniques to improve visualization while restoring the native biomechanics of the hip as best as possible are important.

Medial Meniscal Ramp Lesion Repair Through Anterior Portals Using a Medial Collateral Ligament Pie-Crusting Technique

Ramp injury, that is, injury to the peripheral attachment of the posterior horn of the medial meniscus, often requires additional surgery during anterior cruciate ligament (ACL) reconstruction. Diagnosis and treatment of ramp lesions are important because unrepaired ramp lesions could cause risk to the reconstructed ACL because of anteroposterior and external rotation laxity, whereas acute rupture or chronic deficiency of the ACL could also cause ramp lesions because of instability. Ramp lesions are difficult to diagnose and treat from the anterior compartment during arthroscopy. Typically, this repair requires technically demanding skills and is performed from the posterior portal using a suture hook under visualization with the arthroscope through the intercondylar notch. Inexperienced surgeons often struggle with using the posterior portal and the suture hook. Our all-inside repair technique using the FasT-Fix system (Smith & Nephew, Andover, MA) under direct visualization from the anterior compartment accompanied by a medial collateral ligament pie-crusting technique facilitates repair of ramp lesions without causing medial instability.

The Role of the Pie-Crusting Technique of the Medial Collateral Ligament in the Arthroscopic Inside-out Technique for Medial Meniscal Repair With or Without Anterior Cruciate Ligament Reconstruction: A Satisfactory Repair Technique

PurposeTo assess the results of a technique for pie crusting of the medial collateral ligament (MCL) and inside-out medial meniscal repair and perform a comparison with the literature.MethodsThis retrospective study consisted of electronic data collection between 2012 and 2017 with a minimum of 2 years’ follow-up. The inclusion criteria were the presence of difficult medial meniscal tears with joint tightness requiring pie crusting and the presence of acute or chronic tears of zone I or II with or without anterior cruciate ligament reconstruction (ACLR) using hamstring autograft during the same session. The primary outcome of the study was the achievement of good results with the aforementioned technique. There was no control group. All patients underwent assessments at 1, 2, and 6 months in outpatient clinics. At 6 months, the Lysholm knee score was calculated. For statistical analysis, the Social Science Statistics online program was used to perform descriptive analysis and assess any associations between the variables.ResultsThis study included 53 patients from a single surgeon’s practice; of these patients, 31 underwent additional ACLR using hamstring autograft during the same session. The mean age was 29.43 years (range, 14-49 years), and the mean increase in the medial joint space width was 3.21 mm (range, 2-5 mm) with pie crusting. At 6 months, the average Lysholm score was 93 (range, 67-100) and the average visual analog scale score was 0.8 (range, 0-4). There was no meaningful association between age, tear pattern, chronicity of tear, joint space width obtained after pie crusting, and associated anterior cruciate ligament tear. Patients returned to their daily activity level at 4.5 months on average and returned to sporting activities at 7.4 months on average. Saphenous nerve symptoms were observed in 5 patients, but no infection or instability was documented in the follow-up period.ConclusionsIn this study, we obtained good outcomes using arthroscopic inside-out medial meniscal repair combined with pie crusting for the release of the MCL, with or without ACLR.Level of EvidenceLevel IV, therapeutic case series.

Strain release assessment of the iliotibial band (ITB) when using a pie-crusting technique: a preliminary ex vivo study

Possible lack of length or over-stiffness of soft tissues may explain some musculo-skeletal disorders. Certain extra length of soft tissues can be recovered by releasing some strain with pie-crusti...

Intraoperative repair for iatrogenic MCL tear due to medial pie-crusting in TKA yields satisfactory mid-term outcomes.

This study aimed to assess the rate of iatrogenic mid-substance superficial medial collateral ligament (sMCL) tear due to the medial pie-crusting technique during varus deformity total knee arthroplasty and compare the knee society score (KSS), range of motion (ROM), and instability rate of the repaired group to the control group with intact sMCL. For this retrospective series of prospectively collected data, the multiple needle puncturing technique was performed for 653 out of the 1768 knees during algorithmic medial soft-tissue release. Iatrogenic tear was observed in 35 knees (5%); hence, repair with running locking nonabsorbable braided suture was performed. Patients were visited and reviewed both clinically and radiographically at 6weeks, 3months, 6months, 12months, and annually thereafter. Chi-square, ANOVA, Mann-Whitney, independent and paired t test were used to analyze the variables. P value < 0.05 was considered statistically significant. 85% of the repaired sMCL had stable joints with a mean KSS of 88 ± 3 and a mean ROM of 103 ± 11 degrees (°). The other five patients (15%) with mean KSS of 40 ± 8 and mean ROM of 81° ± 5° had an instability and needed to undergo a revision surgery. The control group had a mean KSS of 86 ± 15 and mean ROM of 107° ± 8°; however, 7 knees had an instability and needed a revision surgery. No significant difference was observed in terms of KSS (P = 0.86) and ROM (P = 0.64) between the control and repaired groups. The mid-substance sMCL tear is an important intraoperative complication of medial pie-crusting. Repairing this iatrogenic tear with nonabsorbable suture had satisfying clinical outcomes regarding the postoperative knee ROM and KSS in comparison to the control group. However, there is a chance of failure, which should be perceived by the surgeons. Therapeutic studies, investigating the results of treatment, Level III.

Relâchement sélectif par “pie crusting” du ligament collatéral médial superficiel au cours des ostéotomies tibiales proximales d’ouverture

Various techniques to release the superficial MCL (sMCL) during medial open-wedge high tibial osteotomy (MOWHTO) has been introduced. However, there have been debates regarding the extent of sMCL release in MOWHTO. The authors present a pie-crust technique that involves selective and gradual release of sMCL from inside using a small, round-tip blade after opening the gap. The aims were to introduce our novel technique regarding sMCL release and evaluate the clinical and radiologic outcomes. One-hundred sixty-six knees underwent this procedure. With a mean 60.3 months’ follow-up, clinical scores were significantly improved after index operation (p<0.001). Hip-knee-ankle angle, medial joint opening, joint line convergence angle, and weight-bearing line ratio significantly improved after MOWHTO (p<0.05) and there were no significant changes during the follow-up period. No cases of valgus progression were observed. This technique would be a safe and effective method for selective and adequate release of sMCL in MOWHTO.

Selective pie-crust release of superficial medial collateral ligament in medial open-wedge high tibial osteotomy

Various techniques to release the superficial MCL (sMCL) during medial open-wedge high tibial osteotomy (MOWHTO) has been introduced. However, there have been debates regarding the extent of sMCL release in MOWHTO. The authors present a pie-crust technique that involves selective and gradual release of sMCL from inside using a small, round-tip blade after opening the gap. The aims were to introduce our novel technique regarding sMCL release and evaluate the clinical and radiologic outcomes. One-hundred sixty-six knees underwent this procedure. With a mean 60.3 months’ follow-up, clinical scores were significantly improved after index operation (p<0.001). Hip-knee-ankle angle, medial joint opening, joint line convergence angle, and weight-bearing line ratio significantly improved after MOWHTO (p<0.05) and there were no significant changes during the follow-up period. No cases of valgus progression were observed. This technique would be a safe and effective method for selective and adequate release of sMCL in MOWHTO.

Preoperative Clinical Correctability and Prediction of the Prosthesis Type in Total Knee Arthroplasty for ‌Severe Osteoarthritic Varus Deformity

Background: The preoperative identification of patients who might need constrained condylar knee (CCK) prosthesis in total knee arthroplasty (TKA), is essential to ensure the availability of equipment and to address the patients’ expectations accurately. Objectives: In this study, we aimed at investigating if the preoperative features of the patients can provide this data. Methods: A total of 30 patients who underwent primary TKA for severe osteoarthritic genu varum deformity (varus angle ≥20º) were evaluated in this retrospective study. Prosthesis selection was based on preoperative and intraoperative information. Demographic data, preoperative correctability of the deformity, and intraoperative information, including the reduction osteotomy, soft-tissue release, and pie-crust technique, were retrospectively collected. Soft-tissue release was performed in a sequential manner in 3 steps. Results: The study population included 4 males and 26 females with a mean±SD age of 64.6±8.7 years. A CCK prosthesis was used in 11 (36.7%) cases. A significant association was found between the preoperative correctability and the type of prosthesis. In other words, all CCK prostheses were used in patients who were preoperatively non-correctable (P&lt;0.001). Also, the step of release was significantly associated with the type of prosthesis, and CCK prosthesis was used in all patients with step 3 release (P&lt;0.001). Preoperative correctability was significantly related to the step of release, as well. It means that all deformities with step 3 release were preoperatively non-correctable (P=0.008). Conclusion: The preoperative clinical evaluation of correctability could be used in the identification of patients who might need a CCK prosthesis.