Evaluation of Therapeutic Outcomes for Intraoperative MCL Injury in Subjects Undergoing Total Knee Arthroplasty: a Cohort Study

Evaluation of Therapeutic Outcomes for Intraoperative MCL Injury in Subjects Undergoing Total Knee Arthroplasty: a Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Therapeutic Outcomes for Intraoperative MCL Injury in Subjects Undergoing Total Knee Arthroplasty: a Cohort Study Sepehr Shirouei, Mehdi Karimi, Gholamreza Ghorbani-Amjad, Morteza Majidi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4654486/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Total knee arthroplasty (TKA) is an effective procedure for replacing damaged knee joints, recommended when conservative treatments fail. Intraoperative medial collateral ligament (MCL) injuries are a known complication of TKA, potentially impacting patient recovery and overall surgical outcomes. Effective management of these injuries is crucial to ensuring optimal function and stability of the knee postoperatively. This study aims to evaluate the therapeutic outcomes for patients who sustained intraoperative MCL injuries during TKA, focusing on recovery, stability, and the need for additional interventions. Material and Methods In this prospective cohort study, over 2 years, 553 patients with advanced severe knee arthritis underwent TKA, and only 13 patients had intraoperative MCL injury. After surgery, patients followed a partial weight-bearing protocol with a locked knee brace for two weeks, followed by physiotherapy to restore motion over six weeks gradually. The patients were followed up for 12 months. The International Knee Documentation Committee (IKDC) score was used to evaluate patients before and after surgery, and collected data was analyzed. Results None of the patients who experienced intraoperative MCL injury showed any knee instability during the 12-month follow-up period. The statistical analysis revealed no significant relationship between MCL injury and gender (P = 0.786). The mean pain score decreased from 90 preoperatively to 3.8 postoperatively, indicating a statistically significant improvement in knee pain (P < 0.001). No significant association was found between the IKDC score in intraoperative MCL injury and patient gender (P = 0.806). A comparison of the mean IKDC scores post-surgery between individuals who had intraoperative MCL injury (77.78) and received treatment and the control group without intraoperative MCL injury (80.00) revealed that MCL injury, when treated, had no significant effect on the IKDC score (P = 0.141). The mean IKDC score increased from 28.2 preoperatively to 77.8 postoperatively, indicating a statistically significant improvement in knee function (p-value < 0.001). Conclusion When MCL injury is treated intraoperatively, it has no significant effect on the IKDC score and significantly improves knee function. MCL injury during TKA, managed with primary repair and reinforcement with hamstring autograft or reattachment to the bone using pull-out techniques followed by six weeks of knee brace use postoperatively, is associated with favorable and treatable outcomes. total knee arthroplasty knee joint replacement medial collateral ligament MCL injury joint instability Orthopedic surgery Figures Figure 1 Figure 2 1. Introduction Total knee arthroplasty (TKA), also known as total replacement (TKR), is a surgical procedure that resurfaces the damaged knee joint with artificial metal and plastic components ( 1 ). TKA is one of the most cost-effective and consistently successful surgeries performed in orthopedics ( 2 ). TKA is recommended as a viable treatment option when conservative treatments fail to provide relief ( 3 ). It is a standard treatment for advanced severe knee arthritis or other degenerative joint diseases at the end stage of advanced knee arthritis, particularly in cases where patients suffer from severe pain, restricted mobility, and knee instability, typically ( 2 , 4 – 6 ). The primary goals are to relieve pain, improve mobility, and restore knee function. Studies have shown that TKA can significantly improve quality of life, reduce pain, and enhance functional abilities in most patients. However, a small percentage of patients may remain dissatisfied or experience persistent pain after the procedure, which can be associated with factors like depression or surgical complications ( 2 ). Despite TKA success, intra-operative complications during TKA are rare but can occur ( 5 ). In general, the most common reported complications following TKA include bleeding, wound-related complications such as wound infection, deep joint infection, periprosthetic fracture, nerve injuries, stiffness, medial collateral ligament (MCL) injury, extensor mechanism disruption, limb length discrepancy, heterotopic ossification, instability and dislocation, thromboembolic diseases, and vascular injuries ( 7 – 9 ). Intraoperative complications, such as MCL injuries, are a significant concern for surgeons. The MCL plays a crucial role in maintaining the stability of the knee joint, and its injury during TKA can complicate the postoperative recovery and overall outcome. An experienced specialist with high skill levels should perform the surgical process to ensure precise and appropriate alignment of prosthesis components and achieve ligamentous balance to minimize complications ( 4 ). Treatment options for MCL injuries during TKA vary depending on the type and severity. They range from conservative approaches, such as bracing and physiotherapy, to more invasive procedures, including ligament repair or reconstruction. The severity of the injury influences the choice of treatment, the patient's overall health, and the surgeon's expertise and preferences ( 10 – 13 ). The insufficient number of studies in this field, the presence of conflicting opinions among surgeons regarding managing this issue, and the fact that most existing studies have been conducted on CR9 prostheses prompted us to undertake this study. Therefore, using PCLS prostheses, our study strives to evaluate the clinical outcomes of MCL repair or reconstruction after iatrogenic injury during TKA surgeries. In addition, we aim to prospectively compare various therapeutic modalities based on the type and extent of MCL injury in conjunction with each other in PS10 prostheses for the first time in Iran. 2. Methods Methods and study designs This prospective cohort study was conducted between April 2017 and March 2018 at the Knee Clinics of Be'sat Hospital and the affiliated knee clinic at Hamadan University of Medical Sciences and Health Services (UMSHA). The study focused on patients with intraoperative MCL injury during TKA and examined repair and augmentation methods with initial pull-out or augmentation. In this study, 553 patients with severe advanced knee arthritis were recruited for knee treatment with TKA. only 13 patients experienced MCL injuries during surgery. Eligible Criteria Due to the limited availability of qualified samples, 13 eligible patients with severe knee arthritis who experienced MCL injuries during TKA were included via a census method and subjected to investigation. Exclusion criteria included patients requiring revision surgery, those with MCL inefficiency identified during preoperative assessments (e.g., severe valgus), individuals undergoing specific systems such as Legacy Constrained Condylar Knee (LCCK) ( 14 ) and Rotating Hinged Knee (RHK) ( 15 ), and those lacking accessibility for early and late surgical complication follow-up. Pre-surgery evaluation of the patients Initially, patients with complaints of knee pain and arthritis visited the hospital's orthopedic clinic and were examined by an orthopedic surgeon and a knee fellowship-trained specialist. They were evaluated based on predefined criteria and enrolled in the study as candidates for TKA. Preoperative stages included conducting radiographic examinations such as anteroposterior, lateral, patella, and skyline views, performing routine laboratory tests including complete blood count, electrolyte assessment, urinalysis, and, if indicated, coagulation tests and blood glucose level assessment, as well as necessary consultations such as cardiology, internal medicine, anesthesia, etc., depending on the patient's condition, which was carried out for all patients. Data collection For data collection, a questionnaire was used containing information such as age, gender, type of MCL injury, and the technique used for ligament repair or reconstruction. Information regarding the latter two was extracted based on intraoperative events recorded in the surgical report of the patient's file and documented in the questionnaire. The subjective International Knee Documentation Committee (IKDC) questionnaire ( 16 ) was used to evaluate knee pain and function in patients before and after surgery. The IKDC is a patient-completed questionnaire comprising seven items related to knee symptom assessment, two items for knee functional evaluation, and two for assessing the level of sports activities. Scores range from 0 points (highest level of symptoms or lowest level of function) to 100 points (lowest level of symptoms and highest level of function) ( 17 , 18 ). Surgery method Patients received anesthesia in the operating room and underwent knee arthroscopy in sterile conditions with tourniquet control. The classic midline incision was made. Limited bone cuts were made following synovectomy, and ligament balancing was performed. The PCLS prosthesis ( 19 , 20 ) prosthesis from the Zimmer NexGen or PFC SIGMA DePuy cemented system was used for all patients. Any unintended events, including MCL injury, were recorded. Intraoperative MCL injuries were classified into two groups and treated. First, Ligament laxity from the femoral or tibial side was re-fixed to its anatomical location on the same bone using the pullout method with Ethibond 5 sutures. second, if partial, injuries at the ligament mid-substance were initially repaired with Ethibond 2 sutures, and if complete, primary repair with augmentation of the semitendinosus tendon was performed. If intraoperative instability was observed on the medial side after ligament repair or reconstruction using the methods above, the prosthesis type was changed to an LCCK (Low Contact Stress) prosthesis with increased constraint to achieve stability on the medial side. Once stability on the medial side was confirmed throughout the full knee range of motion (RoM) and ligament balancing was completed, the capsule and skin were repaired. Post-surgery follow-up of the patients After the surgery, the patients followed a partial weight-bearing (PWB) protocol starting the day after the surgery ( 21 , 22 ). They were given knee braces to wear for six weeks after the operation. The knee brace was locked in full extension for the first two weeks. At the end of the second week, physiotherapy started ( 23 ). During physiotherapy, the patients' knees increased by 30 degrees of motion per week until a full range of motion was achieved by the end of six weeks. At the end of six weeks, stress radiographs, including anteroposterior, lateral, and varus-valgus views, were performed. The knee brace was discontinued if examinations indicated sufficient stability on the medial side. Patients were then followed up at intervals of 3 months, six months, and one year, and at the end of one year, IKDC questionnaires were completed again. The data obtained from clinical examinations, current status descriptions, and paraclinical findings in the researcher-designed checklist were collected and subjected to statistical analysis. Ethical considerations All study participants were provided with necessary explanations and sufficiently informed about the research procedures. Patients entered the study voluntarily, with full awareness and consent. All data obtained from the study participants, whether through questionnaires or examinations, will remain confidential. Patients' names and surnames will not be included in the research under any circumstances; only a unique identification code was used for data analysis. Participants were assured that their decision to participate or withdraw from the study at any time would not disrupt their care and treatment process. All patients gave written and informed consent to participate in the study, which was approved by the ethics committee of Hamadan University of Medical Sciences (IR.umsha.rec.1399.616). Data analysis method The collected data were analyzed using SPSS version 21 software. Descriptive statistical indices such as percentages, frequencies, means, and standard deviations were employed to describe the data. The analytical section used a paired t-test to compare patients' mean IKDC scores before and after arthroplasty. The Pearson correlation coefficient was also used to examine the relationship between injury and gender. Furthermore, the Pearson correlation coefficient was employed to determine the correlation between the IKDC score and age. A significance level of 0.05 was considered for all analyses. 3. Results 3.1. Follow-up of patients Over two years, 553 patients underwent TKA. Only 13 (2.2%) experienced intraoperative MCL injuries, while 540 (97.8%) had TKA without MCL injuries. The duration of patient follow-up was 12 months. Based on examinations and stress radiographs, none of the patients exhibited knee instability during the scheduled visits and final follow-up after one year. None required assistive devices for walking, and no complications were observed in the patients. 3.2. Prevalence of MCL injury The prevalence of MCL injury in the study population was 85% ( 11 ) in women and 15% ( 2 ) in men, as determined by the chi-square test. The statistical analysis revealed no significant relationship between MCL injury and gender (p-value = 0.786) (see Table 1 ). Table 1 Prevalence of TKA with and without MCL injury Prevalence of TKA Gender Frequency Total Patients underwent TKA Male 109 (19.7) Female 444 (80.3%) without MCL injury Male 107 (98.2%) Female 433 (97.7%) with MCL injury Male 2 (15%) Female 11 (85%) 3.3. Basic characteristics of participants Of 553 patients who underwent TKA over two years, 13 (2.4%) experienced MCL injury. Among these, two were male, and 11 were female, with one female patient being excluded from the study due to passing away. Among the 12 patients with MCL injury, the injury site was mid-substance in 2 patients (16.7%) and avulsion from the tibia or femur in 10 patients (83.3%). The mean age of individuals with MCL injury was 72.5, with the youngest being 64 and the oldest being 84. (see Table 2 ) Table 2 Basic characteristics of participants Variables Frequency TKA without MCL injury 540 (97.8%) with MCL injury 13 (2.2%) Gender Male 2 (15%) Female 11 (85%) Age 68 (± 4) (64 − 72.5) Site of the MCL injury Mid-substance 2 (16.7%) Avulsion (from the tibia or femur) 10 (83.3%). 3.4. Analysis of IKDC score and pain score The mean pain score decreased from 90 preoperatively to 3.8 postoperatively, indicating a statistically significant improvement in knee pain (p-value < 0.001), as determined by paired t-test. The mean IKDC score increased from 28.2 preoperatively to 77.8 postoperatively, indicating a statistically significant improvement in knee function (p-value < 0.001), as determined by paired t-test. Using One Way ANOVA, no significant association was found between the IKDC score in intraoperative MCL injury and patient gender (p-value = 0.806) (see Table 3 ). The correlation coefficient between the mean IKDC score and patient age was 0.001 (p-value = 0.998), indicating no statistically significant relationship between these variables. (see Fig. 1 ). Table 3 Evaluation of the IKDC and pain scores based on before and after TKA, age, and sex Scores Study group Mean Standard Deviation Minimum Maximum P-value Pain score Before surgery 90 ± 9.5 70 100 < 0.001 After surgery 8.3 ± 7.1 0 20 < 0.001 IKDC score Before surgery 28.8 ± 3.4 24.8 34.6 < 0.001 After surgery 78.7 ± 3.4 70.3 83 < 0.001 IKDC score Male 77.2 ± 1.69 76 78.4 0.806 Female 77.9 ± 3.72 70.3 83 0.806 A comparison of the mean IKDC scores post-surgery between individuals who had intraoperative MCL injury (77.78) and received treatment, and the control group without intraoperative MCL injury (80.00) revealed, through an independent samples T-test, that MCL injury, when treated, had no significant effect on the IKDC score (P-value = 0.141) ( see Fig. 2 ). 4. Discussion The study compared the treatment outcomes of individuals who experienced MCL injury during TKA to a control group of individuals who did not suffer such injuries during the procedure. Specifically, the study focused on MCL injuries in PCLS. The study's primary finding was that repairing or reconstructing MCL injuries during TKA resulted in acceptable functional outcomes. MCL injury during primary knee arthroplasty poses a significant challenge. It leads to coronal plane instability, affecting knee function and reducing prosthesis longevity, thus potentially necessitating revision with more constrained prostheses. ( 24 , 25 ). Many orthopedic surgeons recommend and practice using such prostheses with increased constraint ( 26 – 29 ). While prostheses may initially appear attractive to surgeons, they have significant limitations and challenges. These include increased stress at the prosthesis-cement and cement-bone interfaces, leading to wear and tear in the polyethylene and joint capsule. Additionally, the need for more extensive bone resection can weaken prosthesis fixation and the femoral bone, complicating future revision surgeries. Other issues include higher costs and limited availability, particularly in certain regions. Consequently, most surgeons hesitate to convert prostheses to more constrained types directly. ( 30 ). Given these factors, and based on positive experiences with MCL reconstruction, knee valgus deformities, and the ligament's high healing potential, a clinical trial focusing on direct ligament repair and augmentation was decided to pursue. Previous research on MCL injuries during TKA has primarily focused on cruciate-retaining (CR) prostheses ( 31 , 32 ). For example, studies by Leopold et al. ( 31 ) and Wang et al. ( 32 ) highlighted that the PCL serves as a secondary medial stabilizer in the coronal plane, potentially affecting the outcomes with such prostheses. Only one study by Lee & Lotke in 2018 ( 33 ) reported superior functional results in the MCL repair group compared to those using prostheses with canisters. The prevalence of MCL injury in TKA in the present study was 2.2%, whereas the prevalence of MCL injury in knee arthroplasty in various studies has been reported to range from 0.2–7.2% ( 31 , 32 , 34 – 36 ). In our study, although 10 out of the 12 patients (83.3%) who experienced injury were female, statistically, no significant difference was observed compared to the control group. Therefore, we did not obtain sufficient evidence to confirm a relationship between gender and MCL injury in this study, despite this result aligning with other studies in the field ( 31 – 33 , 35 , 37 ). However, Bohl et al. ( 36 ) reported a statistically significant higher frequency of MCL injury among females in their study. In the present study, the technique of tendon pull-out in bone tunnels was used for fixing the graft or MCL to the bone, which imposes no additional cost burden on the patient and yields acceptable functional outcomes; however, in a study by Wang et al. ( 32 ), it was noted that although the cost of reconstruction with autograft hamstring is much lower than that of more constrained prostheses, using screws for graft fixation in bone incurs a fee of $ 1000, and if allograft is used, the cost increases by up to $ 2000 due to the need for fixation. In our study, most MCL injuries (83.3%) occurred at the osseous avulsion site, with only a minority (16.7%) being mid-substance injuries. This contrasts sharply with the findings of Wang et al. ( 32 ), who reported that 70.6% of their MCL injuries were mid-substance, attributing these to direct contact with oscillating saw blades during tibial cuts or the use of sharp instruments while elevating the medial side of the proximal tibia. Leopold et al. ( 31 ) also observed a predominance of mid-substance injuries and explained the causes similarly. The discrepancy in injury patterns between our study and others highlights the impact of surgical techniques and protective measures. For instance, Bohl et al. ( 36 ) reported a nearly equal distribution of mid-substance (53%) and avulsion injuries (47%). This balanced distribution further underscores the variability in MCL injury patterns based on different operative practices. In this study, we utilized the subjective IKDC index to assess the Knee function in the study and control groups. The mean IKDC index of patients with MCL injury before surgery was 28.8, which increased to 77.8 after surgery. Although these results were lower than the control group (80.1), there was no statistically significant difference. In previous studies, all reported significant improvement in knee functional scores. For instance, Leopold et al. reported an improvement from 47 to 93 in the functional index, although they did not compare it with a control group. Wang et al. ( 32 ) also reported an improvement in knee functional index (84.7). They indicated this index score is lower than the control group's (87.9). The difference is considerable but not statistically significant (p-value = 0.08). Therefore, it can be stated that the results of their study are consistent with the present study. In this study, no cases of knee joint stiffness were observed contrary to the use of braces for six weeks postoperatively. However, Bohun et al. ( 36 ) reported joint stiffness in over 10% of patients, defining it as flexion less than 90 degrees. They assumed that this reduction in flexion was due to the use of knee braces for six weeks post-surgery. Leopold et al. ( 31 ) similarly their study, used braces for rehabilitation for six weeks postoperatively and reported one case of joint stiffness. It is worth mentioning, however, that some researchers, such as Dragosloveanu et al. ( 35 ), state that successful MCL repair or reconstruction requires rigid ligament fixation and a less constrained PS prosthesis with polyethylene. In such cases, there is no need for brace use in postoperative rehabilitation stages, and they have also reported excellent study outcomes. Whiteside et al. ( 38 ) demonstrated that releasing different bands of the MCL during knee surgery affects the medial joint gap at various degrees of knee flexion. This release is typically performed using techniques like pie crusting or tendon punctures. Excessive release can lead to complete disruption of the superficial MCL. Even without pie crusting, high pressure during ligament balancing may cause MCL tears, especially at its tibial attachment, a known complication in TKA surgeries. Loss of MCL tension due to tears increases the gap between the femoral condyles and tibial surface during knee movement, promoting more rotational movement around the lateral axis ( 38 ). Surgeons and researchers have proposed various methods, including repair with sutures and screws, ligament reconstruction, and prosthetic replacement with more constrained models, to address MCL injuries during TKA surgery ( 37 ). Despite the MCL's potential for self-healing when torn from the bone, some studies suggest lower healing potential and reduced strength after recovery in ligamentous injuries ( 32 ). PCL-retaining prostheses are commonly used in studies investigating conservative treatment during knee arthroplasty for MCL injury. However, this approach may introduce confounding effects due to the PCL's role as a secondary stabilizer against valgus forces ( 39 ). The study had a few limitations. Firstly, the sample size was small due to the low rate of complications during TKA operations. However, our sample size is similar to other studies in this field. Secondly, we did not examine clinical results in subgroups of MCL injury based on the location of the injury due to the limited number of cases in these subgroups. Lastly, the follow-up period for the patients was only one year, and it was impossible to follow up with the patients to check the stability of the results in the future, considering that the study started in 2016. 5. Conclusion Injuries to the MCL during TKA can be treated using primary repair and augmentation with a hamstring autograft or by reattaching it to the bone using a pull-out technique (depending on the location of the ligament injury). A brace can manage post-operative recovery, which helps avoid using more constrained prostheses. The current preferred treatment method for repairing or reconstructing the MCL involves prostheses with a canister. However, it is essential to conduct further research to compare this method with MCL repair. A prospective and random study is necessary to investigate these two methods in a statistical population. Abbreviations OA: Osteoarthritis TKA: Total Knee Arthroplasty MCL: Medial Collateral Ligament PCLS: Posterior cruciate ligament substitution IKDC: International Knee Documentation Committee LCCK: Legacy Constrained Condylar Knee RHK: Rotating Hinge Knee Declarations Ethical Approval: This study was approved by the Ethics Committee of Hamadan University of Medical Sciences (UMSHA), with the number IR.umsha.rec.1399.616. It was performed according to the ethical standards in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent to participate: Returning informed consent was obtained from the participants of this study. All participants participated in the survey knowingly and with consent. Conflict of interest: The authors declare that there are no conflicts of interest regarding the publication of this study. The research was conducted independently, and no financial or personal relationships with other people or organizations could have inappropriately influenced the study. Funding: This study did not receive a specific grant from any public, commercial, or not-for-profit funding agency. Availability of data: data is available upon request from corresponding authors. Author Contribution: "SS and GG conceived and developed the theory. SS, NS, and MK collected the data, and AM conducted the statistical analysis. MK, NS, and SS wrote the main manuscript. MK edited and supervised the manuscript, and GG helped supervise the project. All authors provided critical feedback and contributed to shaping the research, discussing the results, and finalizing the manuscript." Acknowledgments: We would like to express our sincere gratitude to my advisor, Dr. Amir Human Hoveidaei , for their invaluable guidance and support and to the staff and patients at Be'sat Hospital, Hamadan, for their essential assistance during my research. Additionally, we are deeply thankful for the encouragement and support from our family, colleagues, and friends. References Affatato S. 1 - The history of total knee arthroplasty (TKA). In: Affatato S, editor. Surgical Techniques in Total Knee Arthroplasty and Alternative Procedures. Oxford: Woodhead Publishing; 2015. p. 3-16. Schwabe MT, Hannon CP. The Evolution, Current Indications and Outcomes of Cementless Total Knee Arthroplasty. J Clin Med. 2022;11(22). Hirschmann MT, Testa E, Amsler F, Friederich NF. The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2405-11. 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Medicine (Baltimore). 2017;96(30):e7617. Lee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res. 2011;469(1):64-8. Siqueira MB, Haller K, Mulder A, Goldblum AS, Klika AK, Barsoum WK. Outcomes of Medial Collateral Ligament Injuries during Total Knee Arthroplasty. J Knee Surg. 2016;29(1):68-73. 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(8):1499-503. Bohl DD, Wetters NG, Del Gaizo DJ, Jacobs JJ, Rosenberg AG, Della Valle CJ. Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty. J Bone Joint Surg Am. 2016;98(1):35-9. Koo MH, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty. 2009;24(8):1249-53. Whiteside LA, Saeki K, Mihalko WM. Functional medical ligament balancing in total knee arthroplasty. Clin Orthop Relat Res. 2000(380):45-57. Saeki K, Mihalko WM, Patel V, Conway J, Naito M, Thrum H, et al. Stability after medial collateral ligament release in total knee arthroplasty. Clin Orthop Relat Res. 2001(392):184-9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4654486","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331885915,"identity":"e41beb99-77bc-4f9c-84c7-25da1f15b180","order_by":0,"name":"Sepehr Shirouei","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Hamadan University of Medical Sciences (UMSHA)","correspondingAuthor":false,"prefix":"","firstName":"Sepehr","middleName":"","lastName":"Shirouei","suffix":""},{"id":331885916,"identity":"eedfe3ae-075d-41e3-a18d-32b373a87bc2","order_by":1,"name":"Mehdi Karimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACgwMMDAcYDGx42JiZgUwGCRmCWgwbwFrS5PjY2xJAWngIajGGUIeN5XjOGIBYhLWYsZ99eOhGweHENomcz69u1FjwMLAfProBnxYbnnSDwzkG6UAtudusc44BHcaTlnYDrxaGNAagFmuwFuMcNqAWCR4zvFrM+J+BtDCDHPbMOOcfEVqMJcC2OBuz8ZxhfpzbRoQWwxlgW9Lk2NjbzJhz+yR42Aj5xeB8GvPnnD82PPLNzI8/53yrk+NnP3wMrxZkwCYBJolVDgLMH0hRPQpGwSgYBSMHAABxsUSpin1xWwAAAABJRU5ErkJggg==","orcid":"","institution":"Bogomolets National Medical University (NMU)","correspondingAuthor":true,"prefix":"","firstName":"Mehdi","middleName":"","lastName":"Karimi","suffix":""},{"id":331885917,"identity":"7fa7b536-5c79-4c7a-b852-5399d1d2ff1c","order_by":2,"name":"Gholamreza Ghorbani-Amjad","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Hamadan University of Medical Sciences (UMSHA)","correspondingAuthor":false,"prefix":"","firstName":"Gholamreza","middleName":"","lastName":"Ghorbani-Amjad","suffix":""},{"id":331885918,"identity":"c927a13d-3521-4d26-9ebd-12975e6b0658","order_by":3,"name":"Morteza Majidi","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Hamadan University of Medical Sciences (UMSHA)","correspondingAuthor":false,"prefix":"","firstName":"Morteza","middleName":"","lastName":"Majidi","suffix":""},{"id":331885919,"identity":"ed3d9c79-38be-41db-a328-e461c560a20a","order_by":4,"name":"Niyousha Shirsalimi","email":"","orcid":"","institution":"Hamadan University of Medical Sciences (UMSHA)","correspondingAuthor":false,"prefix":"","firstName":"Niyousha","middleName":"","lastName":"Shirsalimi","suffix":""},{"id":331885920,"identity":"7b7a6f6a-2f36-4394-910c-d32e64a69cc6","order_by":5,"name":"Abbas Moradi","email":"","orcid":"","institution":"Department of Community Medicine. Hamadan University of Medical Science (UMSHA)","correspondingAuthor":false,"prefix":"","firstName":"Abbas","middleName":"","lastName":"Moradi","suffix":""}],"badges":[],"createdAt":"2024-06-28 11:32:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4654486/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4654486/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62124945,"identity":"ace90849-5e01-493f-b15d-a10d649bd8b6","added_by":"auto","created_at":"2024-08-09 14:32:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85734,"visible":true,"origin":"","legend":"\u003cp\u003eIKDC score scatter diagram according to age\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4654486/v1/20cdf5e2e2d3249ec8071c75.png"},{"id":62124947,"identity":"7b005ca8-252c-4b6c-bdf4-2d4a6bc69af0","added_by":"auto","created_at":"2024-08-09 14:32:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1108326,"visible":true,"origin":"","legend":"\u003cp\u003eComparison chart of IKDC score before and after TKA in patients with and without MCL injury.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4654486/v1/ba0cf0d14c703be4b929cbc3.png"},{"id":76789775,"identity":"2c6a35e8-a0cb-453c-9bb5-1c83ca6b8573","added_by":"auto","created_at":"2025-02-20 19:48:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2200250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4654486/v1/aae69f95-9f7b-4e79-a960-f111de62b784.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Therapeutic Outcomes for Intraoperative MCL Injury in Subjects Undergoing Total Knee Arthroplasty: a Cohort Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA), also known as total replacement (TKR), is a surgical procedure that resurfaces the damaged knee joint with artificial metal and plastic components (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). TKA is one of the most cost-effective and consistently successful surgeries performed in orthopedics (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). TKA is recommended as a viable treatment option when conservative treatments fail to provide relief (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is a standard treatment for advanced severe knee arthritis or other degenerative joint diseases at the end stage of advanced knee arthritis, particularly in cases where patients suffer from severe pain, restricted mobility, and knee instability, typically (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The primary goals are to relieve pain, improve mobility, and restore knee function. Studies have shown that TKA can significantly improve quality of life, reduce pain, and enhance functional abilities in most patients. However, a small percentage of patients may remain dissatisfied or experience persistent pain after the procedure, which can be associated with factors like depression or surgical complications (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite TKA success, intra-operative complications during TKA are rare but can occur (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In general, the most common reported complications following TKA include bleeding, wound-related complications such as wound infection, deep joint infection, periprosthetic fracture, nerve injuries, stiffness, medial collateral ligament (MCL) injury, extensor mechanism disruption, limb length discrepancy, heterotopic ossification, instability and dislocation, thromboembolic diseases, and vascular injuries (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Intraoperative complications, such as MCL injuries, are a significant concern for surgeons. The MCL plays a crucial role in maintaining the stability of the knee joint, and its injury during TKA can complicate the postoperative recovery and overall outcome.\u003c/p\u003e \u003cp\u003eAn experienced specialist with high skill levels should perform the surgical process to ensure precise and appropriate alignment of prosthesis components and achieve ligamentous balance to minimize complications (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Treatment options for MCL injuries during TKA vary depending on the type and severity. They range from conservative approaches, such as bracing and physiotherapy, to more invasive procedures, including ligament repair or reconstruction. The severity of the injury influences the choice of treatment, the patient's overall health, and the surgeon's expertise and preferences (\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe insufficient number of studies in this field, the presence of conflicting opinions among surgeons regarding managing this issue, and the fact that most existing studies have been conducted on CR9 prostheses prompted us to undertake this study. Therefore, using PCLS prostheses, our study strives to evaluate the clinical outcomes of MCL repair or reconstruction after iatrogenic injury during TKA surgeries. In addition, we aim to prospectively compare various therapeutic modalities based on the type and extent of MCL injury in conjunction with each other in PS10 prostheses for the first time in Iran.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eMethods and study designs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis prospective cohort study was conducted between April 2017 and March 2018 at the Knee Clinics of Be'sat Hospital and the affiliated knee clinic at Hamadan University of Medical Sciences and Health Services (UMSHA). The study focused on patients with intraoperative MCL injury during TKA and examined repair and augmentation methods with initial pull-out or augmentation.\u003c/p\u003e \u003cp\u003eIn this study, 553 patients with severe advanced knee arthritis were recruited for knee treatment with TKA. only 13 patients experienced MCL injuries during surgery.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEligible Criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDue to the limited availability of qualified samples, 13 eligible patients with severe knee arthritis who experienced MCL injuries during TKA were included via a census method and subjected to investigation.\u003c/p\u003e \u003cp\u003eExclusion criteria included patients requiring revision surgery, those with MCL inefficiency identified during preoperative assessments (e.g., severe valgus), individuals undergoing specific systems such as Legacy Constrained Condylar Knee (LCCK) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and Rotating Hinged Knee (RHK) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and those lacking accessibility for early and late surgical complication follow-up.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003ePre-surgery evaluation of the patients\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInitially, patients with complaints of knee pain and arthritis visited the hospital's orthopedic clinic and were examined by an orthopedic surgeon and a knee fellowship-trained specialist. They were evaluated based on predefined criteria and enrolled in the study as candidates for TKA.\u003c/p\u003e \u003cp\u003ePreoperative stages included conducting radiographic examinations such as anteroposterior, lateral, patella, and skyline views, performing routine laboratory tests including complete blood count, electrolyte assessment, urinalysis, and, if indicated, coagulation tests and blood glucose level assessment, as well as necessary consultations such as cardiology, internal medicine, anesthesia, etc., depending on the patient's condition, which was carried out for all patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eData collection\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor data collection, a questionnaire was used containing information such as age, gender, type of MCL injury, and the technique used for ligament repair or reconstruction. Information regarding the latter two was extracted based on intraoperative events recorded in the surgical report of the patient's file and documented in the questionnaire.\u003c/p\u003e \u003cp\u003eThe subjective International Knee Documentation Committee (IKDC) questionnaire (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) was used to evaluate knee pain and function in patients before and after surgery. The IKDC is a patient-completed questionnaire comprising seven items related to knee symptom assessment, two items for knee functional evaluation, and two for assessing the level of sports activities. Scores range from 0 points (highest level of symptoms or lowest level of function) to 100 points (lowest level of symptoms and highest level of function) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eSurgery method\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients received anesthesia in the operating room and underwent knee arthroscopy in sterile conditions with tourniquet control. The classic midline incision was made. Limited bone cuts were made following synovectomy, and ligament balancing was performed. The PCLS prosthesis (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) prosthesis from the Zimmer NexGen or PFC SIGMA DePuy cemented system was used for all patients. Any unintended events, including MCL injury, were recorded.\u003c/p\u003e \u003cp\u003eIntraoperative MCL injuries were classified into two groups and treated. First, Ligament laxity from the femoral or tibial side was re-fixed to its anatomical location on the same bone using the pullout method with Ethibond 5 sutures. second, if partial, injuries at the ligament mid-substance were initially repaired with Ethibond 2 sutures, and if complete, primary repair with augmentation of the semitendinosus tendon was performed.\u003c/p\u003e \u003cp\u003eIf intraoperative instability was observed on the medial side after ligament repair or reconstruction using the methods above, the prosthesis type was changed to an LCCK (Low Contact Stress) prosthesis with increased constraint to achieve stability on the medial side. Once stability on the medial side was confirmed throughout the full knee range of motion (RoM) and ligament balancing was completed, the capsule and skin were repaired.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003ePost-surgery follow-up of the patients\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAfter the surgery, the patients followed a partial weight-bearing (PWB) protocol starting the day after the surgery (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). They were given knee braces to wear for six weeks after the operation. The knee brace was locked in full extension for the first two weeks. At the end of the second week, physiotherapy started (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). During physiotherapy, the patients' knees increased by 30 degrees of motion per week until a full range of motion was achieved by the end of six weeks. At the end of six weeks, stress radiographs, including anteroposterior, lateral, and varus-valgus views, were performed. The knee brace was discontinued if examinations indicated sufficient stability on the medial side. Patients were then followed up at intervals of 3 months, six months, and one year, and at the end of one year, IKDC questionnaires were completed again. The data obtained from clinical examinations, current status descriptions, and paraclinical findings in the researcher-designed checklist were collected and subjected to statistical analysis.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eEthical considerations\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll study participants were provided with necessary explanations and sufficiently informed about the research procedures. Patients entered the study voluntarily, with full awareness and consent. All data obtained from the study participants, whether through questionnaires or examinations, will remain confidential. Patients' names and surnames will not be included in the research under any circumstances; only a unique identification code was used for data analysis. Participants were assured that their decision to participate or withdraw from the study at any time would not disrupt their care and treatment process.\u003c/p\u003e \u003cp\u003e All patients gave written and informed consent to participate in the study, which was approved by the ethics committee of Hamadan University of Medical Sciences (IR.umsha.rec.1399.616).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eData analysis method\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe collected data were analyzed using SPSS version 21 software. Descriptive statistical indices such as percentages, frequencies, means, and standard deviations were employed to describe the data. The analytical section used a paired t-test to compare patients' mean IKDC scores before and after arthroplasty. The Pearson correlation coefficient was also used to examine the relationship between injury and gender. Furthermore, the Pearson correlation coefficient was employed to determine the correlation between the IKDC score and age. A significance level of 0.05 was considered for all analyses.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Follow-up of patients\u003c/h2\u003e \u003cp\u003eOver two years, 553 patients underwent TKA. Only 13 (2.2%) experienced intraoperative MCL injuries, while 540 (97.8%) had TKA without MCL injuries. The duration of patient follow-up was 12 months. Based on examinations and stress radiographs, none of the patients exhibited knee instability during the scheduled visits and final follow-up after one year. None required assistive devices for walking, and no complications were observed in the patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Prevalence of MCL injury\u003c/h2\u003e \u003cp\u003eThe prevalence of MCL injury in the study population was 85% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) in women and 15% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) in men, as determined by the chi-square test. The statistical analysis revealed no significant relationship between MCL injury and gender (p-value\u0026thinsp;=\u0026thinsp;0.786) (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of TKA with and without MCL injury\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevalence of TKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal Patients underwent TKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e444 (80.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ewithout MCL injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (98.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e433 (97.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ewith MCL injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Basic characteristics of participants\u003c/h2\u003e \u003cp\u003eOf 553 patients who underwent TKA over two years, 13 (2.4%) experienced MCL injury. Among these, two were male, and 11 were female, with one female patient being excluded from the study due to passing away. Among the 12 patients with MCL injury, the injury site was mid-substance in 2 patients (16.7%) and avulsion from the tibia or femur in 10 patients (83.3%). The mean age of individuals with MCL injury was 72.5, with the youngest being 64 and the oldest being 84. (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBasic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ewithout MCL injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e540 (97.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ewith MCL injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (85%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (\u0026plusmn;\u0026thinsp;4) (64 \u0026minus;\u0026thinsp;72.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of the MCL injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMid-substance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvulsion (from the tibia or femur)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (83.3%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Analysis of IKDC score and pain score\u003c/h2\u003e \u003cp\u003eThe mean pain score decreased from 90 preoperatively to 3.8 postoperatively, indicating a statistically significant improvement in knee pain (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as determined by paired t-test. The mean IKDC score increased from 28.2 preoperatively to 77.8 postoperatively, indicating a statistically significant improvement in knee function (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as determined by paired t-test. Using One Way ANOVA, no significant association was found between the IKDC score in intraoperative MCL injury and patient gender (p-value\u0026thinsp;=\u0026thinsp;0.806) (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe correlation coefficient between the mean IKDC score and patient age was 0.001 (p-value\u0026thinsp;=\u0026thinsp;0.998), indicating no statistically significant relationship between these variables. (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of the IKDC and pain scores based on before and after TKA, age, and sex\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePain score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIKDC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIKDC score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;3.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA comparison of the mean IKDC scores post-surgery between individuals who had intraoperative MCL injury (77.78) and received treatment, and the control group without intraoperative MCL injury (80.00) revealed, through an independent samples T-test, that MCL injury, when treated, had no significant effect on the IKDC score (P-value\u0026thinsp;=\u0026thinsp;0.141) (\u003cb\u003esee\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe study compared the treatment outcomes of individuals who experienced MCL injury during TKA to a control group of individuals who did not suffer such injuries during the procedure. Specifically, the study focused on MCL injuries in PCLS. The study's primary finding was that repairing or reconstructing MCL injuries during TKA resulted in acceptable functional outcomes.\u003c/p\u003e \u003cp\u003eMCL injury during primary knee arthroplasty poses a significant challenge. It leads to coronal plane instability, affecting knee function and reducing prosthesis longevity, thus potentially necessitating revision with more constrained prostheses. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Many orthopedic surgeons recommend and practice using such prostheses with increased constraint (\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). While prostheses may initially appear attractive to surgeons, they have significant limitations and challenges. These include increased stress at the prosthesis-cement and cement-bone interfaces, leading to wear and tear in the polyethylene and joint capsule. Additionally, the need for more extensive bone resection can weaken prosthesis fixation and the femoral bone, complicating future revision surgeries. Other issues include higher costs and limited availability, particularly in certain regions. Consequently, most surgeons hesitate to convert prostheses to more constrained types directly. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Given these factors, and based on positive experiences with MCL reconstruction, knee valgus deformities, and the ligament's high healing potential, a clinical trial focusing on direct ligament repair and augmentation was decided to pursue.\u003c/p\u003e \u003cp\u003ePrevious research on MCL injuries during TKA has primarily focused on cruciate-retaining (CR) prostheses (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). For example, studies by Leopold et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and Wang et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) highlighted that the PCL serves as a secondary medial stabilizer in the coronal plane, potentially affecting the outcomes with such prostheses. Only one study by Lee \u0026amp; Lotke in 2018 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) reported superior functional results in the MCL repair group compared to those using prostheses with canisters.\u003c/p\u003e \u003cp\u003eThe prevalence of MCL injury in TKA in the present study was 2.2%, whereas the prevalence of MCL injury in knee arthroplasty in various studies has been reported to range from 0.2\u0026ndash;7.2% (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, although 10 out of the 12 patients (83.3%) who experienced injury were female, statistically, no significant difference was observed compared to the control group. Therefore, we did not obtain sufficient evidence to confirm a relationship between gender and MCL injury in this study, despite this result aligning with other studies in the field (\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, Bohl et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) reported a statistically significant higher frequency of MCL injury among females in their study.\u003c/p\u003e \u003cp\u003eIn the present study, the technique of tendon pull-out in bone tunnels was used for fixing the graft or MCL to the bone, which imposes no additional cost burden on the patient and yields acceptable functional outcomes; however, in a study by Wang et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), it was noted that although the cost of reconstruction with autograft hamstring is much lower than that of more constrained prostheses, using screws for graft fixation in bone incurs a fee of \u003cspan\u003e$\u003c/span\u003e1000, and if allograft is used, the cost increases by up to \u003cspan\u003e$\u003c/span\u003e2000 due to the need for fixation.\u003c/p\u003e \u003cp\u003eIn our study, most MCL injuries (83.3%) occurred at the osseous avulsion site, with only a minority (16.7%) being mid-substance injuries. This contrasts sharply with the findings of Wang et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), who reported that 70.6% of their MCL injuries were mid-substance, attributing these to direct contact with oscillating saw blades during tibial cuts or the use of sharp instruments while elevating the medial side of the proximal tibia. Leopold et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) also observed a predominance of mid-substance injuries and explained the causes similarly. The discrepancy in injury patterns between our study and others highlights the impact of surgical techniques and protective measures. For instance, Bohl et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) reported a nearly equal distribution of mid-substance (53%) and avulsion injuries (47%). This balanced distribution further underscores the variability in MCL injury patterns based on different operative practices.\u003c/p\u003e \u003cp\u003eIn this study, we utilized the subjective IKDC index to assess the Knee function in the study and control groups. The mean IKDC index of patients with MCL injury before surgery was 28.8, which increased to 77.8 after surgery. Although these results were lower than the control group (80.1), there was no statistically significant difference. In previous studies, all reported significant improvement in knee functional scores. For instance, Leopold et al. reported an improvement from 47 to 93 in the functional index, although they did not compare it with a control group. Wang et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) also reported an improvement in knee functional index (84.7). They indicated this index score is lower than the control group's (87.9). The difference is considerable but not statistically significant (p-value\u0026thinsp;=\u0026thinsp;0.08). Therefore, it can be stated that the results of their study are consistent with the present study.\u003c/p\u003e \u003cp\u003eIn this study, no cases of knee joint stiffness were observed contrary to the use of braces for six weeks postoperatively. However, Bohun et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) reported joint stiffness in over 10% of patients, defining it as flexion less than 90 degrees. They assumed that this reduction in flexion was due to the use of knee braces for six weeks post-surgery. Leopold et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) similarly their study, used braces for rehabilitation for six weeks postoperatively and reported one case of joint stiffness. It is worth mentioning, however, that some researchers, such as Dragosloveanu et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), state that successful MCL repair or reconstruction requires rigid ligament fixation and a less constrained PS prosthesis with polyethylene. In such cases, there is no need for brace use in postoperative rehabilitation stages, and they have also reported excellent study outcomes.\u003c/p\u003e \u003cp\u003eWhiteside et al. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) demonstrated that releasing different bands of the MCL during knee surgery affects the medial joint gap at various degrees of knee flexion. This release is typically performed using techniques like pie crusting or tendon punctures. Excessive release can lead to complete disruption of the superficial MCL. Even without pie crusting, high pressure during ligament balancing may cause MCL tears, especially at its tibial attachment, a known complication in TKA surgeries. Loss of MCL tension due to tears increases the gap between the femoral condyles and tibial surface during knee movement, promoting more rotational movement around the lateral axis (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgeons and researchers have proposed various methods, including repair with sutures and screws, ligament reconstruction, and prosthetic replacement with more constrained models, to address MCL injuries during TKA surgery (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Despite the MCL's potential for self-healing when torn from the bone, some studies suggest lower healing potential and reduced strength after recovery in ligamentous injuries (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). PCL-retaining prostheses are commonly used in studies investigating conservative treatment during knee arthroplasty for MCL injury. However, this approach may introduce confounding effects due to the PCL's role as a secondary stabilizer against valgus forces (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study had a few limitations. Firstly, the sample size was small due to the low rate of complications during TKA operations. However, our sample size is similar to other studies in this field. Secondly, we did not examine clinical results in subgroups of MCL injury based on the location of the injury due to the limited number of cases in these subgroups. Lastly, the follow-up period for the patients was only one year, and it was impossible to follow up with the patients to check the stability of the results in the future, considering that the study started in 2016.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eInjuries to the MCL during TKA can be treated using primary repair and augmentation with a hamstring autograft or by reattaching it to the bone using a pull-out technique (depending on the location of the ligament injury). A brace can manage post-operative recovery, which helps avoid using more constrained prostheses. The current preferred treatment method for repairing or reconstructing the MCL involves prostheses with a canister. However, it is essential to conduct further research to compare this method with MCL repair. A prospective and random study is necessary to investigate these two methods in a statistical population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eOA:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Osteoarthritis\u003c/li\u003e\n \u003cli\u003eTKA:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total Knee Arthroplasty\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMCL:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Medial Collateral Ligament\u003c/li\u003e\n \u003cli\u003ePCLS:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Posterior cruciate ligament substitution\u003c/li\u003e\n \u003cli\u003eIKDC:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Knee Documentation Committee\u003c/li\u003e\n \u003cli\u003eLCCK:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Legacy Constrained Condylar Knee\u003c/li\u003e\n \u003cli\u003eRHK:\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Rotating Hinge Knee\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of\u0026nbsp;Hamadan University of Medical Sciences (UMSHA), with the number IR.umsha.rec.1399.616. It was performed according to the ethical standards in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eReturning informed consent was obtained from the participants of this study. All participants participated in the survey knowingly and with consent.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors declare that there are no conflicts of interest regarding the publication of this study. The research was conducted independently, and no financial or personal relationships with other people or organizations could have inappropriately influenced the study.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study did not receive a specific grant from any public, commercial, or not-for-profit funding agency.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data:\u003c/strong\u003e data is available upon request from corresponding authors.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor Contribution:\u0026nbsp;\u003c/strong\u003e\u0026quot;SS and GG conceived and developed the theory. SS, NS, and MK collected the data, and AM conducted the statistical analysis. MK, NS, and SS wrote the main manuscript. MK edited and supervised the manuscript, and GG helped supervise the project. All authors provided critical feedback and contributed to shaping the research, discussing the results, and finalizing the manuscript.\u0026quot;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We would like to express our sincere gratitude to my advisor, \u003cem\u003eDr. Amir Human Hoveidaei\u003c/em\u003e, for their invaluable guidance and support and to the staff and patients at Be\u0026apos;sat Hospital, Hamadan, for their essential assistance during my research. Additionally, we are deeply thankful for the encouragement and support from our family, colleagues, and friends.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAffatato S. 1 - The history of total knee arthroplasty (TKA). In: Affatato S, editor. Surgical Techniques in Total Knee Arthroplasty and Alternative Procedures. Oxford: Woodhead Publishing; 2015. p. 3-16.\u003c/li\u003e\n\u003cli\u003eSchwabe MT, Hannon CP. The Evolution, Current Indications and Outcomes of Cementless Total Knee Arthroplasty. J Clin Med. 2022;11(22).\u003c/li\u003e\n\u003cli\u003eHirschmann MT, Testa E, Amsler F, Friederich NF. The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA. Knee Surg Sports Traumatol Arthrosc. 2013;21(10):2405-11.\u003c/li\u003e\n\u003cli\u003eAlshammari AO, Altamimi NA, Alshammari FF, Altamimi OA, Aljarboa AM, Alshebli AS, et al. Awareness About Total Knee Arthroplasty Among Hail Population. Cureus. 2023;15(1):e33260.\u003c/li\u003e\n\u003cli\u003eCromheecke M, Missinne M, Van Onsem S, Victor J, Arnout N. Efficacy of total knee arthroplasty (TKA) revision surgery depends upon the indication for revision : a systematic review. 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Clin Orthop Relat Res. 2014;472(1):194-205.\u003c/li\u003e\n\u003cli\u003eJacobs J, editor INTRA-OPERATIVE MCL INJURY DURING TKA: A BRACING SOLUTION. Orthopaedic Proceedings; 2016: Bone \u0026amp; Joint.\u003c/li\u003e\n\u003cli\u003eJacobs J, editor INTRA-OPERATIVE MCL INJURY REQUIRES CONSTRAINED COMPONENTS\u0026ndash;OPPOSES. Orthopaedic Proceedings; 2015: Bone \u0026amp; Joint.\u003c/li\u003e\n\u003cli\u003eHenstenburg JM, Kellish AS, Good RP, Freedman KB. Medial Collateral Ligament Reconstruction for Valgus Instability After Total Knee Arthroplasty: A Case Report. JBJS Case Connect. 2022;12(2).\u003c/li\u003e\n\u003cli\u003eZhang B, Du Y, Sun J, Shen J, Li T, Zhou Y. [Prevention and treatment of iatrogenic medial collateral ligament injuries in total knee arthroplasty]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2021;35(1):14-9.\u003c/li\u003e\n\u003cli\u003eLaudren A, Delacroix R, Huten D. Is hybrid fixation in revision TKA using LCCK prostheses reliable? Orthopaedics \u0026amp; Traumatology: Surgery \u0026amp; Research. 2023;109(5):103583.\u003c/li\u003e\n\u003cli\u003eKearns SM, Culp BM, Bohl DD, Sporer SM, Della Valle CJ, Levine BR. Rotating Hinge Implants for Complex Primary and Revision Total Knee Arthroplasty. J Arthroplasty. 2018;33(3):766-70.\u003c/li\u003e\n\u003cli\u003eAnderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ. The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data. Am J Sports Med. 2006;34(1):128-35.\u003c/li\u003e\n\u003cli\u003eEbrahimzadeh MH, Makhmalbaf H, Golhasani-Keshtan F, Rabani S, Birjandinejad A. The International Knee Documentation Committee (IKDC) Subjective Short Form: a validity and reliability study. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3163-7.\u003c/li\u003e\n\u003cli\u003eHiggins LD, Taylor MK, Park D, Ghodadra N, Marchant M, Pietrobon R, Cook C. Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine. 2007;74(6):594-9.\u003c/li\u003e\n\u003cli\u003eParsley BS, Conditt MA, Bertolusso R, Noble PC. Posterior cruciate ligament substitution is not essential for excellent postoperative outcomes in total knee arthroplasty. J Arthroplasty. 2006;21(6 Suppl 2):127-31.\u003c/li\u003e\n\u003cli\u003eSong SJ, Park CH, Bae DK. What to Know for Selecting Cruciate-Retaining or Posterior-Stabilized Total Knee Arthroplasty. Clin Orthop Surg. 2019;11(2):142-50.\u003c/li\u003e\n\u003cli\u003eWierer G, Runer A, Hoser C, Gf\u0026ouml;ller P, Fink C. Anatomical MCL reconstruction following TKA. The Knee. 2016;23(5):911-4.\u003c/li\u003e\n\u003cli\u003eAnderson PM, Heinz T, Scholmann E, Eidmann A, Arnholdt J, Rudert M, et al. Efficacy of postoperative partial weight-bearing after total knee arthroplasty - a prospective observational trial. Int Orthop. 2023;47(9):2189-95.\u003c/li\u003e\n\u003cli\u003eIwakiri K, Ohta Y, Shibata Y, Minoda Y, Kobayashi A, Nakamura H. Initiating range of motion exercises within 24 hours following total knee arthroplasty affects the reduction of postoperative pain: A randomized controlled trial. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2020;21:11-6.\u003c/li\u003e\n\u003cli\u003eAmiri S, Mirahmadi A, Parvandi A, Hosseini-Monfared P, Minaei Noshahr R, Hoseini SM, Kazemi SM. Management of Iatrogenic Medial Collateral Ligament Injury in Primary Total Knee Arthroplasty: A Systematic Review. Arch Bone Jt Surg. 2024;12(3):159-66.\u003c/li\u003e\n\u003cli\u003eJain JK, Agarwal S, Sharma RK. Ligament reconstruction/advancement for management of instability due to ligament insufficiency during total knee arthroplasty: a viable alternative to constrained implant. J Orthop Sci. 2014;19(4):564-70.\u003c/li\u003e\n\u003cli\u003eHartford JM, Goodman SB, Schurman DJ, Knoblick G. Complex primary and revision total knee arthroplasty using the condylar constrained prosthesis: an average 5-year follow-up. J Arthroplasty. 1998;13(4):380-7.\u003c/li\u003e\n\u003cli\u003eDonaldson WF, 3rd, Sculco TP, Insall JN, Ranawat CS. Total condylar III knee prosthesis. Long-term follow-up study. Clin Orthop Relat Res. 1988(226):21-8.\u003c/li\u003e\n\u003cli\u003eRosenberg AG, Verner JJ, Galante JO. Clinical results of total knee revision using the Total Condylar III prosthesis. Clin Orthop Relat Res. 1991(273):83-90.\u003c/li\u003e\n\u003cli\u003ePeters CL, Hennessey R, Barden RM, Galante JO, Rosenberg AG. Revision total knee arthroplasty with a cemented posterior-stabilized or constrained condylar prosthesis: a minimum 3-year and average 5-year follow-up study. The Journal of arthroplasty. 1997;12(8):896-903.\u003c/li\u003e\n\u003cli\u003eKoo M-H, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. The Journal of arthroplasty. 2009;24(8):1249-53.\u003c/li\u003e\n\u003cli\u003eLeopold SS, McStay C, Klafeta K, Jacobs JJ, Berger RA, Rosenberg AG. Primary repair of intraoperative disruption of the medical collateral ligament during total knee arthroplasty. J Bone Joint Surg Am. 2001;83(1):86-91.\u003c/li\u003e\n\u003cli\u003eWang X, Liu H, Cao P, Liu C, Dong Z, Qi J, Wang F. Clinical outcomes of medial collateral ligament injury in total knee arthroplasty. Medicine (Baltimore). 2017;96(30):e7617.\u003c/li\u003e\n\u003cli\u003eLee GC, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Relat Res. 2011;469(1):64-8.\u003c/li\u003e\n\u003cli\u003eSiqueira MB, Haller K, Mulder A, Goldblum AS, Klika AK, Barsoum WK. Outcomes of Medial Collateral Ligament Injuries during Total Knee Arthroplasty. J Knee Surg. 2016;29(1):68-73.\u003c/li\u003e\n\u003cli\u003eDragosloveanu S, Cristea S, Stoica C, Dragosloveanu C. Outcome of iatrogenic collateral ligaments injuries during total knee arthroplasty. Eur J Orthop Surg Traumatol. 2014;24(8):1499-503.\u003c/li\u003e\n\u003cli\u003eBohl DD, Wetters NG, Del Gaizo DJ, Jacobs JJ, Rosenberg AG, Della Valle CJ. Repair of Intraoperative Injury to the Medial Collateral Ligament During Primary Total Knee Arthroplasty. J Bone Joint Surg Am. 2016;98(1):35-9.\u003c/li\u003e\n\u003cli\u003eKoo MH, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty. 2009;24(8):1249-53.\u003c/li\u003e\n\u003cli\u003eWhiteside LA, Saeki K, Mihalko WM. Functional medical ligament balancing in total knee arthroplasty. Clin Orthop Relat Res. 2000(380):45-57.\u003c/li\u003e\n\u003cli\u003eSaeki K, Mihalko WM, Patel V, Conway J, Naito M, Thrum H, et al. Stability after medial collateral ligament release in total knee arthroplasty. Clin Orthop Relat Res. 2001(392):184-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"total knee arthroplasty, knee joint replacement, medial collateral ligament, MCL injury, joint instability, Orthopedic surgery","lastPublishedDoi":"10.21203/rs.3.rs-4654486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4654486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTotal knee arthroplasty (TKA) is an effective procedure for replacing damaged knee joints, recommended when conservative treatments fail. Intraoperative medial collateral ligament (MCL) injuries are a known complication of TKA, potentially impacting patient recovery and overall surgical outcomes. Effective management of these injuries is crucial to ensuring optimal function and stability of the knee postoperatively. This study aims to evaluate the therapeutic outcomes for patients who sustained intraoperative MCL injuries during TKA, focusing on recovery, stability, and the need for additional interventions.\u003c/p\u003e\u003ch2\u003eMaterial and Methods\u003c/h2\u003e \u003cp\u003eIn this prospective cohort study, over 2 years, 553 patients with advanced severe knee arthritis underwent TKA, and only 13 patients had intraoperative MCL injury. After surgery, patients followed a partial weight-bearing protocol with a locked knee brace for two weeks, followed by physiotherapy to restore motion over six weeks gradually. The patients were followed up for 12 months. The International Knee Documentation Committee (IKDC) score was used to evaluate patients before and after surgery, and collected data was analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNone of the patients who experienced intraoperative MCL injury showed any knee instability during the 12-month follow-up period. The statistical analysis revealed no significant relationship between MCL injury and gender (P\u0026thinsp;=\u0026thinsp;0.786). The mean pain score decreased from 90 preoperatively to 3.8 postoperatively, indicating a statistically significant improvement in knee pain (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant association was found between the IKDC score in intraoperative MCL injury and patient gender (P\u0026thinsp;=\u0026thinsp;0.806). A comparison of the mean IKDC scores post-surgery between individuals who had intraoperative MCL injury (77.78) and received treatment and the control group without intraoperative MCL injury (80.00) revealed that MCL injury, when treated, had no significant effect on the IKDC score (P\u0026thinsp;=\u0026thinsp;0.141). The mean IKDC score increased from 28.2 preoperatively to 77.8 postoperatively, indicating a statistically significant improvement in knee function (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhen MCL injury is treated intraoperatively, it has no significant effect on the IKDC score and significantly improves knee function. MCL injury during TKA, managed with primary repair and reinforcement with hamstring autograft or reattachment to the bone using pull-out techniques followed by six weeks of knee brace use postoperatively, is associated with favorable and treatable outcomes.\u003c/p\u003e","manuscriptTitle":"Evaluation of Therapeutic Outcomes for Intraoperative MCL Injury in Subjects Undergoing Total Knee Arthroplasty: a Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 14:32:23","doi":"10.21203/rs.3.rs-4654486/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e41c3e6-f886-44fc-8a9c-87ca3fec0081","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-20T19:39:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 14:32:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4654486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4654486","identity":"rs-4654486","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}