Pie‐crusting the medial collateral ligament is a safe and effective technique for improving visualisation and access in arthroscopic meniscal surgery: A systematic review

Purpose: To assess the safety, effectiveness, and postoperative outcomes of medial collateral ligament (MCL) pie‐crusting (PC) in arthroscopic meniscus surgery. Methods: This systematic review was conducted in accordance with PRISMA guidelines. Three databases (PubMed, EMBASE and MEDLINE) were searched from inception to 21 January 2025, for studies evaluating the use of MCL PC during arthroscopic meniscus or anterior cruciate ligament (ACL) surgery. Data on patient demographics, medial joint space measurements, postoperative instability, patient reported outcome measures (PROMs), and complications were extracted. Results: Fifteen studies comprising 1009 patients were included, with 723 undergoing PC. PC significantly increased medial joint space width by a mean of 5.7mm intraoperatively (p < 0.05), with no residual laxity reported at mean final follow‐up of 16.5 months. The most common complications of PC were transient medial knee pain (12.7%) and ecchymosis (12.9%). There were five reports of saphenous nerve irritation (0.8%), all resolved by final follow‐up of 31.6 months. In contrast, iatrogenic chondral injury was reported in 9.0% of patients undergoing meniscal repair without PC. Conclusion: MCL PC is a safe and effective technique to improve visualisation and outcomes in arthroscopic meniscus surgery. It is associated with improved joint access and low complication rates without long‐term instability. While current evidence supports its use, further high‐quality, long‐term comparative studies are needed to validate its safety and efficacy, as this study primarily used retrospective data without long‐term follow‐up