[Intraoperative damage to the medial collateral ligament (MCL) - what is to be done?]

Intraoperative damage to the medial collateral ligament is a rather rare condition given only scant attention in the literature. Observing international medical journals (over the recent years), one finds very few case histories. What is more, these case histories vary significantly with regards to their approaches to the problem at hand.

This survey lists essential publications and case histories in question and - following their analysis and in light of the fairly low number of respective cases - attempts to create a 'treatment algorithm'.

Approaches to treatment vary considerably throughout the medical literature. Reasons are the localisation of the actual damage, pertaining to the medial collateral ligament as well as surgeons' aptitudes and preferences with regards to hinged or constraint implants. Eventually, there are five different treatment options: (i) solely conservative treatment by means of an orthesis; (ii) primary reconstruction of the medial collateral ligament; (iii) medial collateral ligament augmentation; (iv) inlay elevation and lateral release procedure; and (v) a higher degree of coupling regarding the TKA.

It is strongly advised to refrain from conducting a release at the femoral origin of the medial collateral ligament. In stages, a tibial release should be carried out strictly subperiostally. A high expenditure of energy during tension examination needs to be utterly avoided. Reconstruction of the femoral origin/insertion can be carried out rather safely, while reconstruction of the tibial origin/insertion is more complicated due to the more complex anatomic line-up/constellation. Likewise, the reconstruction of the median ligament portion is considerably more difficult; in this case, the application of a primary suture or augmentation by use of the semitendinosus or quadriceps tendon are recommended. In addition, the temporary application of an orthesis is recommended regardless. In any case, a higher degree of coupling should be considered as a fallback. Introduced is an algorithm which differentiates the ligament damage location.