The Journal of Arthroplasty , Volume 33 , Issue 8 , 2636 - 2639

Variability in Elongation and Failure of the Medial Collateral Ligament After Pie-Crusting With 16- and 18-Gauge Needles

Amundsen, Spencer H. et al.


In knee arthroplasty with preoperative varus deformity, medial collateral ligament (MCL) release may be needed to achieve balance. Pie-crusting allows for controlled release, but questions remain regarding its ability to obtain predictable results. We compared 16- vs18-gauge needle punctures and determined the number of punctures required to (1) lengthen the MCL by 1 mm and (2) cause ligament failure.


Thirteen knees were dissected, leaving the femur and tibia with an isolated MCL, and randomly assigned to 16- or 18-gauge groups. Initial stiffness was assessed by cycling the ligament to 300 N for 5 cycles. The selected needle was used to make 10 punctures centered over the area of greatest tension. Cyclic testing was repeated after each set of punctures. Changes in MCL length and stiffness were measured. This process was repeated until failure.


No differences occurred between the 16- and 18-gauge groups in cross-sectional area, initial stiffness, number of punctures to lengthen the MCL by 1 mm, or number of punctures to failure. As the number of punctures increased, a linear increase in elongation and decrease in stiffness occurred.


Needle size was not the influencing factor. Variability in number of punctures, regardless of needle size, to elongate or fail the MCL shows the difficulty in developing a reproducible pie-crusting technique. This suggests that a standard number of punctures do not achieve controlled MCL lengthening for all patients, but that the number of punctures needed can be calculated for an individual knee based on the initial elongation after 10 punctures.

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