ORIGINAL ARTICLE

Ligament reconstruction/advancement for managementof instability due to ligament insufficiency during total kneearthroplasty: a viable alternative to constrained implant

Jitesh Kumar Jain • Saurabh Agarwal •

Rajeev K. Sharma

Received: 26 September 2013 / Accepted: 26 March 2014

� The Japanese Orthopaedic Association 2014

Abstract

Background We aimed to assess the results of ligament

reconstruction/advancement for the management of liga-

ment insufficiency during total knee arthroplasty.

Method We retrospectively reviewed the results of liga-

ment reconstruction/advancement for management of insta-

bility due to ligament insufficiency during total knee

arthroplasty (TKA). Between January 2001 and January 2008

collateral ligament reconstruction/advancement was done in

15 patients. Wherever ligament advancement was not pos-

sible (mid-substance tear) ligament reconstruction was done

using the hamstring tendon. Knee society scores were cal-

culated and Kaplan–Meier survival analysis was done.

Results Average follow-up was 6.2 years. No patient

developed instability until the last follow-up, except one

patient who required revision due to instability at six years

after primary surgery.

Conclusion We concluded from this study that ligament

reconstruction/advancement during TKA is a viable option

to address instability due to ligament insufficiency.

Introduction

In challenging cases of ligament insufficiency in total knee

arthroplasty, instability is usually corrected by either con-

strained implant or by ligament reconstruction or advance-

ment. What is the optimal option is a matter of debate. In

many cases of severe deformity even with use of a con-

strained prosthesis, some sort of ligament balancing is

required. If the medial collateral ligament (MCL) is insuf-

ficient and not addressed at the time of total knee arthroplasty

(TKA), subsequent valgus instability will fail the TKA. On

the other hand some degree of varus instability due to a lax

lateral collateral ligament (LCL) is usually well tolerated

[1]. Although constrained implants improve coronal stabil-

ity, in primary TKA use of constrained implants has been

disfavored by many authors due to concern of increased

stress at implant–cement and cement–bone interfaces and

subsequent early loosening [2, 3]. Also due to their limited

survival, constrained implants are not favored in young

patients. Medial (valgus) instability is much more common

than lateral (varus) instability, and several repair techniques

and treatment options are described in the literature [4, 5].

Ligament insufficiency can be either preexisting or iat-

rogenically produced. Intraoperative collateral ligament

injuries are almost confined to the medial collateral liga-

ment and often go unnoticed. When one or both of the

collateral ligaments are deficient, a flexion extension gap

mismatch appears. There is either a large flexion gap that

cannot be corrected with ligament release, or an opening of

joint space in extension with varus or valgus stress.

Three main methods to correct preexisting soft tissue

insufficiency are the release of tight structures on the

concave side of the deformity, the use of constrained

implants, and ligament advancement or reconstruction on

the convex side of the deformity. Intraoperative loss of

ligament can also be managed with the same techniques,

along with direct repair.

Materials and methods

We retrospectively analyzed medical records of 2,210

knees in 1,770 patients who underwent total knee

J. K. Jain (&) � S. Agarwal � R. K. Sharma

Department of Orthopaedics, Indraprastha Apollo Hospital,

Sarita Vihar, Delhi-Mathura Road, New Delhi 110076, India

e-mail: dr.jiteshajmera@yahoo.com

123

J Orthop Sci

DOI 10.1007/s00776-014-0564-9

arthroplasty between January 2001 to January 2008 in our

hospital in New Delhi. We found 15 patients (Table 1) in

whom either ligament reconstruction or ligament

advancement was done for ligament insufficiency. The

mean age of patients was 61 years, and there were 10

females and 5 males. Patients were assessed with preop-

erative and postoperative weight-bearing anteroposterior,

lateral, and sky line radiographs of the knees. All patients

were assessed clinically and radiologically by a senior

surgeon (RKS) at their OPD follow-up. Knee society scores

(KSS) were calculated, and a Kaplan–Meier survival ana-

lysis was done at five years and at last follow-up. Institu-

tional review board approval and consent from all patients

was taken for the study and its publication.

All patients underwent the procedure in the supine

position under spinal/epidural anesthesia. A mid-line,

straight, longitudinal skin incision was used. A standard

medial parapatellar arthrotomy was done in all knees. All

the replacements were done using a cruciate substituting

implant. Our definition of ligament balancing was a

\2 mm difference in medial and lateral femoral condylar

lift-off in extension and 90� flexion. Before fixing the

advanced soft tissue sleeve, a proper center of rotation was

chosen which was usually in line 45� from the posterior

femoral cortex at the epicondylar area. Ligament balancing

with medio-lateral symmetry within 2 mm was obtained in

all cases. A range-of-motion knee brace, which can be

locked in different degrees of knee flexion to get a

desirable range of motion of the knee, was given for three

weeks in all cases. All patients were approved for full

weight-bearing walking with support for the first three

weeks. Proximal advancement was used when the ligament

was avulsed or injured near the femoral attachment. When

it was difficult to do ligament advancement as in mid-

substance tear, reconstruction using a hamstring tendon

was done. Direct repair was not done in any case. All

patients were followed up at two weeks and at one, three

and six months, and then at yearly intervals. We specially

called all the patients between July and December 2012 for

the final evaluation.

MCL is the most commonly injured ligament in total

knee arthroplasty. We encountered four cases of MCL

transection injury near the femoral attachment and three

cases of MCL mid-substance transection injury. In three

cases MCL was detached from the femoral end, with a

bony fragment, and in another three cases, it was attenuated

and lax due to severe deformity. Wherever possible MCL

was advanced and fixed proximally with a 3.5 mm screw

(Fig. 1a–e) or by using suture anchors. An entire sleeve of

soft tissue including capsule and ligament was freed from

the bone, elevated, and advanced in a proximal and anterior

direction. The advanced tissue sleeve was attached to the

epicondylar region of the femur with a screw. Screws were

inserted after the final implant insertion. Tightness of soft

tissues was assessed on the medial and lateral sides for any

joint opening.

Table 1 Patient data in which

ligament advancement or

reconstruction was done

SN Age

(years)

Preoperative

findings

Intraoperative

findings

Follow-up

(months)

KSS

(pain)

KSS

(function)

1 57 10� varus deformity MCL injury 84 77 70

2 56 30� valgus deformity LCL injury 74 82 80

3 46 30� valgus deformity Attenuated

MCL

62 81 85

4 55 15� varus, 10� flexion deformity MCL injury 60 84 95

5 78 35� varus deformity Attenuated

MCL

84 89 80

6 68 40� varus, 15� flexion deformity Attenuated LCL 68 79 80

7 68 15� valgus deformity MCL injury 90 74 75

8 49 20� varus deformity MCL injury 100 85 85

9 68 10� varus deformity MCL

detachment

72 82 75

10 60 10� varus, 10� flexion deformity MCL

detachment

60 81 55

11 70 35� varus deformity Attenuated MCL 75 81 70

12 48 50� flexion deformity 15� varus

deformity

MCL detachment 80 82 70

13 59 20� varus deformity MCL injury 60 83 65

14 72 10� varus deformity MCL injury 75 82 85

15 70 20� varus deformity MCL injury 74 81 85

J. K. Jain et al.

123

In three cases, iatrogenic mid-substance injury to the

MCL was the cause of excessive and sudden medial

opening during surgery. This type of injury was not ame-

nable to advancement, so MCL reconstruction was done

using a semitendinosus tendon graft. The tendon was

identified, looped, and pulled into view with a curved

clamp. After getting it freed from its peripheral attachment

it was cut at the musculo-tendinous junction. Keeping its

tibial attachment intact, the tendon was attached on the

femur at the proper epicenter of rotation using staples and

screws (Fig. 2a–e).

In one case of severe varus deformity, lateral structures

were severely stretched, and medially soft tissues were

contracted. Only medial release was not sufficient to pro-

vide for a balanced knee, so a lateral epicondylar osteot-

omy was done. A sufficiently large block was osteotomised

and advanced proximally. It was fixed with multiple

screws. Block of bone should not be too large to create a

bony defect (Fig. 3a–d).

Injury to the lateral collateral ligament is rare in primary

TKA. In 3,210 knees operated on by the senior author

(RKS), iatrogenic LCL injury near the femoral attachment

was found in only two cases (one patient was managed

with a constrained implant and so not included in the

study). In another patient, a tissue sleeve consisting of a

capsule and LCL was freed, elevated, and advanced

proximally and anteriorly and fixed to the femur at the

epicondylar region, in similar way as in MCL advancement

(Fig. 4a, b).

Results

Average age of patients was 61.6 years, and the average

follow-up was 74.53 (60–100) months (6.2 years). Average

KSS for pain and function at last follow-up were 81.53 and

77. Average postoperative flexion was 95� (90�–125�). One

patient had an extension lag of 10� which did not improve

with physiotherapy at the one-year follow-up. No patient

had instability to the valgus, varus, and anteroposterior

stress testing. A constrained prosthesis was not required

after ligament advancement in any patient. All patients

Fig. 1 Figure showing MCL avulsion from the femoral attachment (a), opening of joint medially (b), and after advancement and fixation, a well

balanced joint (c). Preoperative and postoperative photographs (d, e)

Collateral ligament reconstruction in TKA

123

were subjectively satisfied with results at three months and

further follow-ups. One patient developed instability with

excessive medial opening at 2 years and required revision

surgery. In this patient a constrained implant was used in

the primary surgery to provide stability for the MCL injury.

In revision surgery, a bone patellar tendon bone graft was

used for MCL reconstruction for collateral balancing

(Fig. 5a, b). This patient was doing well till last follow-up

2 years after the second surgery. Five-year survival prob-

ability was 93.33 %.

Discussion

The goal of TKA is to reproduce normal knee kinematics.

Ligament and soft-tissue balance play critical roles in

obtaining optimal kinematic behavior. Instability after total

knee arthroplasty is a cause of failure and a reason for

10–22 % revisions [6]. There is scarce literature available

describing ligament advancement. We face two types of

situations. One is severe angular deformity where collateral

ligaments are already stretched and attenuated, and the

second is when ligaments are cut or avulsed intraopera-

tively. In the first situation, excessive medial or lateral

release is required to achieve a balanced knee, but this can

produce instability on the side of release. A medial or

lateral release to balance the knee is not indicated in the

setting of a completely torn collateral ligament. LCL injury

is very rare as to literature regarding its management dur-

ing TKA. LCL reconstruction has only been reported in

trauma cases [7, 8]. Intraoperative MCL injuries are treated

by various options like reconstruction [9], direct repair [4,

10], augmentation, and nonconstrained implants [11],

conservative management using thicker polyethylene [12],

and with the use of constrained implants, etc [13]. Preop-

erative attenuated MCL is usually managed by constrained

total knee arthroplasty. A hinged prosthesis provides

intrinsic varus-valgus stability, but it does not obviate the

Fig. 2 Figure showing MCL reconstruction using semitendinosus tendon (a, b), postoperative X-ray (c) and excellent functional results at 5-year

follow-up (d, e)

J. K. Jain et al.

123

need for soft tissue release. The constrained nature of the

implant increases stress and load across the joint, so early

aseptic loosening occurs as compared to condylar pros-

thesis. So these implants cannot meet the demands of

highly demanding young patients. High cost and patellar

instability are other issues of consideration in the use of

constrained implants. Constrained implants for ligament

balancing in total knee arthroplasty have enjoyed both

reports of good success [13, 16] as well as reports of high

failure and revision rate [14]. Pour et al. [14] reported a

68.2 % survival rate of the hinged prosthesis at 5 years

with revision or re-operation as the end point. Healy et al.

[9] produced excellent results with proximal medial col-

lateral advancement for severe valgus deformity of knee.

Peters et al. [15] presented management of two cases of

MCL deficiency with a deficient medial condyle of the

Fig. 3 Figure showing severe varus deformity (a). Lateral epicondylar osteotomy, advancement, and fixation with screws were done. Post-

operative anteroposterior (b), lateral (c) and skyline view (d)

Fig. 4 Intraoperative X-ray showing gross lateral opening (a) and a

well balanced knee after LCL advancement (b)

Collateral ligament reconstruction in TKA

123

femur using a tendoachilles allograft with calcaneal bone

block. Clearly there is no consensus for management of

collateral injury or excessive collateral laxity during TKA.

So we focused our study on ligament reconstruction or

advancement for management of ligament deficiency dur-

ing TKA. Sekia et al. [1] concluded from their study that

lateral ligamentous laxity decreases markedly three months

after surgery. This may be due to relaxation of the stretched

ligament after correction of a deformity, but we cannot

close the joint unbalanced in hopes of a spontaneous cor-

rection. Pritsch et al. [5] concluded from their case series

that ligament reconstruction alone cannot stabilize a knee

unbalanced due to MCL deficiency. He presented seven

cases, all of which failed. They addressed ligament insuf-

ficiency with both proximal and distal advancement. In our

series we only did proximal advancement because MCL

has a focal point of attachment at the medial epicondyle,

whereas distally the MCL and entire soft tissue sleeve are

attached to a relatively large area on the proximal poster-

omedial tibia. Failure of all cases in the series of Pritsch

et al. [5] may be due to failure to address important tech-

nical aspects.

In a similar series, Lee and Lotke [13] reported better

KSS for both pain and function for the constrained group

(88 and 83) compared to the MCL repair (direct suture

repair and staples) group (81 and 74). Leopold et al. [4]

produced excellent results (mean KSS of 93 with no failure

in 16 knees) of treatment of intraoperative MCL injuries

with repair and nonconstrained prosthesis.

We attribute our results to better methods of ligament

reconstruction/advancement. The proper epicenter of rota-

tion was chosen in all cases before ligament fixation, and

no direct repair was done. We could not find any study on

LCL advancement during TKR in English literature. We

had two cases in our series in which LCL advancement was

done to address lateral laxity. Functional KSS for both of

these patients was 80 (excellent) at the five-year follow-up.

Drawbacks of this case series are the small sample size

(n = 15) and relatively short follow-up. Still our results are

reliable because a constrained implant was not used in any

case (except in one revision), and all surgeries were done

by a senior author (RKS). Our results showed that in

experienced hands with proper surgical technique, ligament

reconstruction/advancement to address instability during

total knee arthroplasty gives excellent results. Surgeons

who deal with difficult cases of total knee replacement

should be familiar with these techniques, as these are a big

relief when one is not prepared with a constrained implant

and ligament insufficiency occurs either due to over-release

or iatrogenic injury.

Conflict of interest The authors declare that they have no conflict

of interest.

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