1
|
Klasan A, Maerz A, Putnis SE, Ernat JJ, Ollier E, Neri T. Outcomes after multiligament knee injury worsen over time: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39194423 DOI: 10.1002/ksa.12442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/04/2024] [Accepted: 08/04/2024] [Indexed: 08/29/2024]
Abstract
PURPOSE Multiligament knee injuries (MLKIs) are devastating injuries that can have life-long consequences. A management plan requires the decision to perform surgery or not, timing of surgery, consideration of repair versus reconstruction, reconstruction technique and reconstruction graft choice. The purpose of this study was to analyze development of clinical outcomes of MLKIs over time at a minimum of 2 years of follow-up. METHODS Four databases were queried for surgical outcome-based studies of MLKIs published from 01/2000 through 09/2022 with a minimum 2-year follow-up. Technique articles, nonoperative treatment, arthroplasty, pediatric and review articles were excluded. Study characteristics including design, number of patients, age, follow-up period, anatomical region and posterior-cruciate ligament (PCL)-based injury were collected. Primary outcomes were Lysholm, International Knee Documentation Committee (IKDC) outcome scores and Tegner activity score. Random-effects model analysis was performed. RESULTS After the application of inclusion and exclusion criteria, 3571 patients in 79 studies were included in the analysis. The mean age at surgery was 35.6 years. The mean follow-up was 4.06 years (range 2-12.7). The mean Lysholm score at 2-year follow-up was 86.09 [95% confidence interval [CI]: 82.90-89.28], with a yearly decrease of -0.80 [95% CI: -1.47 -0.13], (p = 0.0199). The mean IKDC at 2 years was 81.35 [95% CI: 76.56-86.14], with a yearly decrease of -1.99 [95% CI: -3.14 -0.84] (p < 0.001). Non-PCL-based injuries had a higher IKDC 83.69 [75.55-91.82] vs. 75.00 [70.75-79.26] (p = 0.03) and Lysholm score 90.84 [87.10-94.58] versus 84.35 [82.18-86.52] (p < 0.01) than PCL-based injuries, respectively. CONCLUSION According to the present systematic review and meta-analysis of MLKIs with minimum 2-year follow-ups, the patients who suffered an MLKI can expect to retain around 80-85% of knee function at 2 years and can expect a yearly deterioration of knee function, depending on the score used. Inferior outcomes can be expected for PCL-based injuries at 2 years postoperative. LEVEL OF EVIDENCE Level IV meta-analysis.
Collapse
Affiliation(s)
- Antonio Klasan
- AUVA UKH Steiermark, Graz, Austria
- Johannes Kepler University Linz, Linz, Austria
| | - Anne Maerz
- Johannes Kepler University Linz, Linz, Austria
| | - Sven E Putnis
- Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Justin J Ernat
- Department of Orthopedic Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Edouard Ollier
- University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Thomas Neri
- University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
- Laboratory of Human Movement Biology (LIBM EA 7424), University of Lyon - Jean Monnet, Saint-Étienne, France
| |
Collapse
|
2
|
Blaber OK, DeFoor MT, Aman ZA, McDermott ER, DePhillipo NN, Dickens JF, Dekker TJ. Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis. JBJS Rev 2024; 12:01874474-202406000-00007. [PMID: 38913807 DOI: 10.2106/jbjs.rvw.24.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.
Collapse
Affiliation(s)
- Olivia K Blaber
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Zachary A Aman
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Emily R McDermott
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | | | | | - Travis J Dekker
- Department of Orthopaedics Surgery, 10th Medical Group, US Air Force Academy, Colorado Springs, Colorado
| |
Collapse
|
3
|
Shultz CL, Poehlein E, Morriss NJ, Green CL, Hu J, Lander S, Amoo-Achampong K, Lau BC. Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries-Which Is Best? A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:522-534. [PMID: 36960920 DOI: 10.1177/03635465231153157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries. PURPOSE To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach. RESULTS In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength. CONCLUSION Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.
Collapse
Affiliation(s)
- Christopher L Shultz
- Department of Orthopaedic Surgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicholas J Morriss
- Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica Hu
- Department of Orthopaedic Surgery, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah Lander
- Department of Orthopaedic Surgery, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelms Amoo-Achampong
- Department of Orthopaedic Surgery, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian C Lau
- Department of Orthopaedic Surgery, Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
4
|
Mowers C, Jackson GR, Condon JJ, Dhillon N, Brusalis CM, Khan ZA, Batra A, Jawanda H, Mameri ES, Kaplan DJ, Knapik DM, Verma NN, Chahla J. Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review. Arthroscopy 2023; 39:2231-2240. [PMID: 36898592 DOI: 10.1016/j.arthro.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
Collapse
Affiliation(s)
- Colton Mowers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joshua J Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nireet Dhillon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Christopher M Brusalis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Anjay Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Enzo S Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Instituto Brasil de Tecnologia da Saúde, Rio de Janeiro, Brazil; Department of Orthopedics and Traumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Daniel J Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
| |
Collapse
|
5
|
Rao R, Bhattacharyya R, Andrews B, Varma R, Chen A. The management of combined ACL and MCL injuries: A systematic review. J Orthop 2022; 34:21-30. [PMID: 35992613 PMCID: PMC9382135 DOI: 10.1016/j.jor.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 10/31/2022] Open
Abstract
Background The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies. Methods A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score. Results 52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury. Conclusions Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.
Collapse
Affiliation(s)
- Raunak Rao
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Rahul Bhattacharyya
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Barry Andrews
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Rajat Varma
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| | - Alvin Chen
- Orthopaedics and Trauma, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
| |
Collapse
|
6
|
Marom N, Xiang W, Wolfe I, Jivanelli B, Williams RJ, Marx RG. High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:1369-1379. [PMID: 33978778 DOI: 10.1007/s00167-021-06594-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/26/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data. METHODS Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS. RESULTS One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery. CONCLUSION This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Niv Marom
- Department of Orthopaedic Surgery, Meir Medical Center, 59 Tcharnihovsky St., 4428164, Kfar Saba, Israel. .,The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Isabel Wolfe
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Bridget Jivanelli
- Hospital for Special Surgery, Kim Barrett Memorial Library, New York, NY, USA
| | - Riley J Williams
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Robert G Marx
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| |
Collapse
|
7
|
Lutz PM, Höher LS, Feucht MJ, Neumann J, Junker D, Wörtler K, Imhoff AB, Achtnich A. Ultrasound-based evaluation revealed reliable postoperative knee stability after combined acute ACL and MCL injuries. J Exp Orthop 2021; 8:76. [PMID: 34524557 PMCID: PMC8443730 DOI: 10.1186/s40634-021-00401-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose
Anterior cruciate ligament (ACL) injuries are often combined with lesions of the medial collateral ligament (MCL). The aim of this study was to evaluate treatment outcome of combined acute ACL and MCL lesions using functional US and clinical examination. Methods Patients aged > 18 years undergoing primary ACL reconstruction with concomitant operative (group 1) or non-operative treatment of the MCL (group 2) between 2014 and 2019 were included after a minimum follow-up of 12 months. Grade II MCL injuries with dislocated tibial or femoral avulsions and grade III MCL ruptures underwent ligament repair whereas grade II injuries without dislocated avulsions were treated non-operatively. Radiological outcome was assessed with functional US examinations. Medial knee joint width was determined in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton) conditions using a fixation device. Clinical examination was performed and patient-reported outcomes were assessed by the use of the subjective knee form (IKDC), Lysholm score, and the Tegner activity scale. Results A total of 40 patients (20 per group) met inclusion criteria. Mean age of group 1 was 40 ± 12 years (60% female) with a mean follow-up of 33 ± 17 months. Group 2 showed a mean age of 33 ± 8 years (20% female) with a mean follow-up of 34 ± 15 months. Side-to-side differences in US examinations were 0.4 ± 1.5 mm (mm) in 0° and 0.4 ± 1.5 mm in 30° knee flexion in group 1, and 0.9 ± 1.1 mm in 0° and 0.5 ± 1.4 mm in 30° knee flexion in group 2, with no statistically significant differences between both groups. MCL repair resulted in lower Lysholm scores (75 ± 19 versus 86 ± 15; p < 0.05). No significant differences could be found for subjective IKDC or Tegner activity scores among the two groups. Conclusion A differentiated treatment concept in combined ACL and MCL injuries based on injury patterns leads to reliable postoperative ligamentous knee stability in US-based and clinical examinations. However, grade II and III MCL lesions with subsequent operative MCL repair (group 1) result in slightly poorer subjective outcome scores. Level of evidence Retrospective cohort study; Level III
Collapse
Affiliation(s)
- Patricia M Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Louisa S Höher
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Matthias J Feucht
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany.,Orthopädische Klinik Paulinenhilfe, Diakonie-Klinikum Stuttgart, Rosenbergstraße 38, 70176, Stuttgart, Germany
| | - Jan Neumann
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Daniela Junker
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Klaus Wörtler
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany.
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| |
Collapse
|
8
|
Irfan A, Kerr S, Hopper G, Wilson W, Wilson L, Mackay G. A Criterion Based Rehabilitation Protocol for ACL Repair with Internal Brace Augmentation. Int J Sports Phys Ther 2021; 16:870-878. [PMID: 34123539 PMCID: PMC8169034 DOI: 10.26603/001c.22217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
The anterior cruciate ligament (ACL) is one of the main stabilizing structures of the knee and its rupture is a common injury in young active adults. ACL reconstruction has been the preferred operative management of an ACL rupture for several decades; however, success rates are variable. Recently, interest in arthroscopic primary repair of the ligament has increased. The repair is augmented with an Internal Brace (IB), which is an ultra-high strength suture tape that bridges the ligament. This technique protects the ligament during the healing and the ligament is encouraged to heal naturally, whilst not requiring any external braces. It acts as a stabiliser to permit early mobilization and optimise rehabilitation. As understanding of rehabilitation has progressed, there has been an increased focus on early weight-bearing and achieving full range of movement. While detailed criterion-based rehabilitation protocols exist for ACL reconstruction, this is not the case for ACL repair. The purpose of this commentary is to present a novel criterion-based rehabilitation protocol following ACL repair surgery augmented with an IB. LEVEL OF EVIDENCE V.
Collapse
|
9
|
Huang H, Li J, Tang X. [Classification, diagnosis, and treatment system of posteromedial structure and posterolateral corner injury in knee dislocation]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:614-619. [PMID: 29798553 PMCID: PMC8498247 DOI: 10.7507/1002-1892.201611139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/30/2017] [Indexed: 02/05/2023]
Abstract
Objective To review the research progress of diagnosis and treatment system for knee dislocation (KD) based on the stage and classification of posteromedial structure and posterolateral corner injury, so as to provide guidance for clinical work. Methods The relevant literature on the classification, diagnosis and treatment was extensively reviewed. Results At present, the criterion of the stage and classification of KD mainly include classification based on the size of the injury energy, Kennedy classification, and the improved Schenck classification, but they are not perfect because of no stage and classification of multiple ligament injury and no standardized treatment of different injuries. Hua Xi Knee Dislocation and Multiple Ligament Injury (HX-KDMLI) has optimum plan for injury treatment of posteromedial structure and posterolateral corner injury in KD based on stage and classification. Conclusion At present, there is no unified opinion on stages and classifications of the posteromedial structure and posterolateral corner injury in KD as well as on diagnosis and treatment. HX-KDMLI has certain feasibility for the stage and classification of the posteromedial structure and posterolateral corner injury in KD, to a certain extent, it can be used as reference for the diagnosis and treatment of KD.
Collapse
Affiliation(s)
- Huaqiang Huang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Xin Tang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
| |
Collapse
|
10
|
Chan TWK, Kong CC, Del Buono A, Maffulli N. Acute augmentation for interstitial insufficiency of the posterior cruciate ligament. A two to five year clinical and radiographic study. Muscles Ligaments Tendons J 2016; 6:58-63. [PMID: 27331032 DOI: 10.11138/mltj/2016.6.1.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND there is need to ascertain clinical and imaging outcomes after posterior cruciate ligament (PCL) augmentation. METHODS we performed a retrospective analysis of clinical, imaging and functional data on 21 physically active males who underwent arthroscopic trans-tibial augmentation of the PCL for symptomatic grade III PCL insufficiency. The average follow-up time was 50 months (24-60 months). The Lysholm knee score was administered to all the patients, ligament laxity was evaluated with the posterior drawer test, the KT-1000 arthrometer, and the anteromedial tibial step-off. Standing antero-posterior, lateral and Merchant's view radiographs were taken preoperatively and at annual follow-up. RESULTS post-operatively, ligament laxity and Lysholm knee scores were significantly improved than at baseline. Sixteen patients (73%) returned to pre-injury sport activity level, 3 patients (14%) returned to a lower level, 2 had to stop. We found radiographic degenerative changes in 5 of 22 affected knees (23%), with evidence of a statistically significant association between the occurrence of degenerative changes and the interval time from injury to surgery and duration of the follow up. CONCLUSIONS arthroscopic transtibial single bundle autograft hamstring augmentation significantly improves the function of the knee, with an overall satisfactory outcome of 82% at 2-5 years from surgery.
Collapse
Affiliation(s)
| | | | - Angelo Del Buono
- Department of Orthopaedic and Trauma Surgery, Hospital Vaio, Fidenza, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Salerno, Italy; Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK
| |
Collapse
|
11
|
DeLong JM, Waterman BR. Surgical Techniques for the Reconstruction of Medial Collateral Ligament and Posteromedial Corner Injuries of the Knee: A Systematic Review. Arthroscopy 2015. [PMID: 26194939 DOI: 10.1016/j.arthro.2015.05.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review reconstruction techniques of the medial collateral ligament (MCL) and associated medial structures of the knee (e.g., posterior oblique ligament). METHODS A systematic review of Medline/PubMed Database (1966 to November 2013), reference list scanning and citation searches of included articles, and manual searches of high-impact journals (2000 to July 2013) and conference proceedings (2009 to July 2013) were performed to identify publications describing MCL reconstruction techniques of the knee. Exclusion criteria included (1) MCL primary repair techniques or advancement procedures, (2) lack of clear description of MCL reconstruction technique, (3) animal models, (4) nonrelevant study design, (5) and foreign language articles without available translation. RESULTS After review of 4,600 references, 25 publications with 359 of 388 patients (92.5%) were isolated for analysis, including 18 single-bundle MCL and 10 double-bundle reconstruction techniques. Only 2 techniques were classified as anatomic reconstructions, and clinical and objective outcomes (n = 28; 100% <3 mm side-to-side difference [SSD]) were superior to those with nonanatomic reconstruction (n = 182; 79.1% <3 mm SSD) and tendon transfer techniques (n = 114; 52.6% <3 mm SSD). CONCLUSIONS This systematic review demonstrated that numerous medial reconstruction techniques have been used in the treatment of isolated and combined medial knee injuries in the existent literature. Many variations exist among reconstruction techniques and may differ by graft choices, method of fixation, number of bundles, tensioning protocol, and degree of anatomic restoration of medial and posteromedial corner knee restraints. Further studies are required to better ascertain the comparative clinical outcomes with anatomic, non-anatomic, and tendon transfer techniques for medial knee reconstruction. LEVEL OF EVIDENCE Level IV, systematic review of level IV studies and surgical techniques.
Collapse
Affiliation(s)
- Jeffrey M DeLong
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, U.S.A..
| |
Collapse
|
12
|
DeLong JM, Waterman BR. Surgical Repair of Medial Collateral Ligament and Posteromedial Corner Injuries of the Knee: A Systematic Review. Arthroscopy 2015; 31:2249-55.e5. [PMID: 26163306 DOI: 10.1016/j.arthro.2015.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/20/2015] [Accepted: 05/19/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically evaluate surgical techniques and objective clinical outcomes of primary repair of the medial collateral ligament (MCL) and posteromedial corner of the knee. METHODS A systematic review of the PubMed/Medline Database (1966 to August 2014) was performed to identify all clinical studies describing MCL and other medial-based repairs of the knee. Exclusion criteria were applied to reconstruction techniques, animal models, and non-English publications. Descriptive analysis identified surgical technique, International Knee Documentation Committee (IKDC) objective form valgus stability subscore, functional outcome measures, and laxity on valgus stress. RESULTS After exclusion of 165 references, 16 publications with 355 knees were included in the final analysis. Fixation construct included suture-only repair (49.5%), staples (12.1%), suture anchors (11.2%), and mixed or unknown fixation (27.0%). When isolating knees with available relative valgus stress opening (n = 223), 75.8% had side-to-side difference of <3 mm or <1+ (n = 169; 10 studies; range, 36% to 100%). Similarly, an IKDC valgus stability grade of A or B was identified in 126 of 140 knees (90.0%; 6 studies; range, 60% to 100%). Of 93 knees with quantified values, the mean side-to-side difference in medial joint space opening was 1.25 mm (SD ± 0.85) after primary repair. Thirteen of 212 knees (6.1%) met the criteria for failure, and the average Lysholm score was 91.6 (n = 210; range, 85.5 to 98.5). CONCLUSIONS This systematic review demonstrated that repair of the MCL and posteromedial corner of the knee may be an effective and reliable treatment for medial-sided knee injuries, resulting in improved valgus stability and patient-reported functional scores with low rates of secondary failure. However, repair techniques may vary significantly depending on the chronicity and extent of medial ligamentous knee injuries, and appropriate patient selection is critical in determining ultimate clinical outcomes. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Jeffrey M DeLong
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Brian R Waterman
- The Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, Texas, U.S.A..
| |
Collapse
|
13
|
Zhang H, Sun Y, Han X, Wang Y, Wang L, Alquhali A, Bai X. Simultaneous Reconstruction of the Anterior Cruciate Ligament and Medial Collateral Ligament in Patients With Chronic ACL-MCL Lesions: A Minimum 2-Year Follow-up Study. Am J Sports Med 2014; 42:1675-81. [PMID: 24769410 DOI: 10.1177/0363546514531394] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In cases of chronic anterior cruciate ligament (ACL)-medial collateral ligament (MCL) lesions, nonoperative treatment of the MCL lesion may lead to chronic valgus instability and rotatory instability. The optimal management for patients who have combined ACL-MCL injuries remains controversial. PURPOSE To present a case series of 21 patients who underwent simultaneous ACL-MCL reconstruction with a 2- to 5-year follow-up. STUDY DESIGN Case series; Level of evidence, 4. METHODS From October 2007 to December 2010, a total of 21 patients with chronic ACL-MCL injuries, for which the 2 ligaments were reconstructed during the same surgical procedure, were studied. All patients were available for follow-up for at least 2 years. The International Knee Documentation Committee (IKDC) subjective knee scores, valgus and sagittal stability, anteromedial rotatory stability, range of motion, and complications were assessed both preoperatively and postoperatively. RESULTS At follow-up, valgus and sagittal laxity were not observed in any of the patients. The mean medial knee opening was significantly reduced to 0.80 ± 0.96 mm (range, -1.2 to 2.6 mm) postoperatively compared with 8.0 ± 1.3 mm (range, 6.1 to 10.7 mm) preoperatively (P < .01). The mean postoperative side-to-side difference measured with the KT-1000 arthrometer was reduced to 0.8 ± 0.9 mm (range, -1.2 to 2.3 mm) compared with 8.4 ± 1.6 mm (range, 6.2 to 13.2 mm) preoperatively (P < .01). Preoperative anteromedial instability was seen in 71% of patients (15/21), whereas none of the patients had anteromedial rotatory instability at the last follow-up. The mean IKDC subjective score improved overall from 45.3 ± 12.0 (range, 28.7-69.0) preoperatively to 87.7 ± 8.2 (range, 65.5-100.0) at the last follow-up (P < .01). Most patients (20/21) had normal or nearly normal range of motion of the knee joint; only 1 patient (5%) had a limitation of flexion of 15° compared with the contralateral knee at the last follow-up. CONCLUSION In patients with chronic ACL-MCL lesions, simultaneous reconstruction of the ACL and MCL can significantly improve the medial, sagittal, and rotatory stability of the knee at short-term follow-up.
Collapse
Affiliation(s)
- Hangzhou Zhang
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yu Sun
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaorui Han
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yanfeng Wang
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Lin Wang
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ali Alquhali
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xizhuang Bai
- Department of Sports Medicine and Joint Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| |
Collapse
|
14
|
Zhang H, Bai X, Sun Y, Han X. Tibial inlay reconstruction of the medial collateral ligament using Achilles tendon allograft for the treatment of medial instability of the knee. Knee Surg Sports Traumatol Arthrosc 2014; 22:279-84. [PMID: 23361650 DOI: 10.1007/s00167-013-2382-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 01/04/2013] [Indexed: 02/06/2023]
Abstract
Although various surgical procedures have been described for the medical collateral ligament (MCL) reconstruction, none can accurately reestablish its original anatomy and orientation. The purpose of this study was to present a technique restoring the anatomy and stability of the medial knee with an Achilles tendon allograft using a tibial inlay technique. The bone block was fixed into a cancellous trough created on the medial surface of the tibia with a cancellous screw and washer, while the tendinous portion was fixed into the femoral insertion site of the superficial MCL with a bioabsorbable interference screw. This technique can successfully reproduce the native anatomy and orientation of the MCL.
Collapse
Affiliation(s)
- Hangzhou Zhang
- Department of Orthopaedics, The First Affiliated Hospital of China Medical University, 155 Nanjing North Street, Shenyang, 110001, Liaoning Province, People's Republic of China
| | | | | | | |
Collapse
|
15
|
Franceschi F, Papalia R, Rizzello G, Del Buono A, Maffulli N, Denaro V. Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study. Arthroscopy 2013; 29:1330-7. [PMID: 23906273 DOI: 10.1016/j.arthro.2013.05.020] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 05/11/2013] [Accepted: 05/17/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to undertake a retrospective analysis of prospectively collected data comparing, at a minimum follow-up of 5 years (78.1 ± 5.3 months v 75.6 ± 4.8 months), the clinical, functional, and radiographic outcomes of 2 homogeneous groups of athletes who had undergone arthroscopic single-bundle autologous hamstring reconstruction of the anterior cruciate ligament (ACL) using a transtibial (TT) or an anteromedial portal (AMP) approach to drill the femoral tunnel. METHODS Ninety-four patients were operated on in 2005 and 2006, and 88 (93.6%) (73 men, 15 women) were evaluated subjectively and objectively, using the Lysholm and International Knee Documentation Committee (IKDC) scores, manual maximum displacement test with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and the Lachman test, and rotational instability with the pivot shift test. Degenerative changes were assessed on radiographs according to the Fairbank classification. RESULTS The median age at operation was 29 years (20 to 43 years; SD, 5.4) in the TT group 1 and 28 years (19 to 45 years; SD, 6.1) in the AMP group 2. At the last appointment, the 2 groups had similar results for the Lysholm and IKDC scores (primary outcome). Patients who underwent the AMP approach had less glide pivot shift (P = .42) and Lachman (P = .47) phenomena, with no statistically significant intergroup difference. Radiography showed fewer, but not significantly different, degenerative changes in the AMP ACL reconstruction group at final follow-up (P = .47). CONCLUSIONS In our series, ACL reconstruction using a femoral tunnel drilled through an AMP provided better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique. This difference likely is not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of development of degenerative changes seen radiographically at a minimum follow-up of 5 years. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Francesco Franceschi
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome, Italy
| | | | | | | | | | | |
Collapse
|
16
|
Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. INTERNATIONAL ORTHOPAEDICS 2013; 37:1369-74. [PMID: 23624910 DOI: 10.1007/s00264-013-1886-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 03/25/2013] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of this study was to show that this two-stage procedure for ACL (anterior cruciate ligament) revision surgery could be straight-forward and provide satisfactory clinical and functional outcomes. MATERIALS This is a five-year prospective analysis of clinical and functional data on 30 patients (19 men and 11 women; average age 29.1 ± 5.4) who underwent a two-stage ACL revision procedure after traumatic re-rupture of the ACL. Diagnosis was on Lachman and pivot-shift tests, arthrometer 30-lb KT-1000 side-to-side findings, and on MRI and arthroscopic assessments. RESULTS Postoperative IKDC and Lysholm scores were significantly improved compared to baseline values (P < 0.001). At the last follow up, 20 of 30 patients (66.7%) had returned to preoperative sport activity level (nine elite athletes, 11 county level), seven had changed to lower sport levels, and three had given up any sport activity. At the same appointment, 11 patients had degenerative changes. All these patients reported significantly lower Lysholm scores compared to patients without any degenerative change (p < 0.001). CONCLUSIONS In ACL revision surgery, when the first femoral tunnel has been correctly placed, this procedure allows safe filling of large bony defects, with no donor site comorbidities. It provides comfortable clinical, functional and imaging outcomes.
Collapse
|
17
|
Anterior cruciate ligament tears in children. Surgeon 2013; 11:59-62. [DOI: 10.1016/j.surge.2012.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 02/13/2012] [Accepted: 02/14/2012] [Indexed: 01/13/2023]
|
18
|
Anoka N, Nyland J, McGinnis M, Lee D, Doral MN, Caborn DNM. Consideration of growth factors and bio-scaffolds for treatment of combined grade II MCL and ACL injury. Knee Surg Sports Traumatol Arthrosc 2012; 20:878-88. [PMID: 21830112 DOI: 10.1007/s00167-011-1641-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 07/26/2011] [Indexed: 01/14/2023]
Abstract
The literature suggests that a Grade II medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury will heal naturally and not compromise patient outcome following ACL reconstruction. Evidence based on bone-patella tendon-bone autograft use is stronger than evidence supporting anatomically placed soft tissue graft use. Current ACL reconstruction practices make greater use of soft tissue grafts, differing fixation methods, and anatomically lower placement on the inner wall of the lateral femoral condyle. Anatomical graft placement aligns the femoral bone tunnel more directly with valgus knee loading forces. Differences in the soft tissue graft-bone tunnel integration and ligamentization timetable following ACL reconstruction also increase concerns regarding residual Grade II MCL laxity and functional deficiency during accelerated functional rehabilitation. MCL dysfunction may increase susceptibility to early ACL graft slippage, elongation, outright failure, and medial femoral condyle lift-off with valgus knee loading. This concept paper discusses the potential role of growth factors and bio-scaffolds for improving Grade II MCL injury healing and mechanical integrity when the injury occurs in combination with an ACL injury that is reconstructed with a soft tissue graft and an anatomical surgical approach.
Collapse
Affiliation(s)
- Natasha Anoka
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, 210 East Gray St., Suite 1003, Louisville, KY 40202, USA
| | | | | | | | | | | |
Collapse
|
19
|
Canata GL, Chiey A, Leoni T. Surgical technique: does mini-invasive medial collateral ligament and posterior oblique ligament repair restore knee stability in combined chronic medial and ACL injuries? Clin Orthop Relat Res 2012; 470:791-7. [PMID: 21842298 PMCID: PMC3270172 DOI: 10.1007/s11999-011-2018-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Residual laxity remains after ACL reconstruction in patients with combined chronic ACL and medial instability. The question arises whether to correct medial capsular and ligament injuries when Grade II and III medial laxity is present. DESCRIPTION OF TECHNIQUE We developed a mini-invasive medial ligament plasty to repair the medial collateral ligament to correct residual medial valgus and rotatory laxity after ACL reconstruction. PATIENTS AND METHODS We prospectively followed 36 patients with an ACL deficiency combined with chronic Grade II or III valgus and rotatory medial instability. The mean age was 37 years (range, 15-70 years). For all patients, we obtained preoperative and postoperative Knee Injury and Osteoarthritis Outcome, International Knee Documentation Committee, Lysholm, and Tegner Activity Level Scores. The minimum followup was 2 years (median, 3 years; range, 2-7 years). RESULTS The mean subjective International Knee Documentation Committee score improved from 36 preoperatively to 94 at the last followup. While all patients had an International Knee Documentation Committee score of Grade C or D preoperatively, no patient did postoperatively. The mean Knee Injury and Osteoarthritis Outcome Score improved from 45 preoperatively to 93 postoperatively. Valgus and external rotatory tests were negative in all patients. The mean Tegner activity level decreased from 7 preinjury to 6 postoperatively, and the mean Lysholm score improved from 40 preoperatively to 93 at last followup. CONCLUSIONS This simple technique restored medial stability and knee function to normal or nearly normal in all patients. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Gian Luigi Canata
- Centre of Sports Traumatology, Koelliker Hospital, Corso Duca degli Abruzzi, 30, 10129 Turin, Italy
| | - Alfredo Chiey
- Centre of Sports Traumatology, Koelliker Hospital, Corso Duca degli Abruzzi, 30, 10129 Turin, Italy
| | - Tommaso Leoni
- Centre of Sports Traumatology, Koelliker Hospital, Corso Duca degli Abruzzi, 30, 10129 Turin, Italy
| |
Collapse
|
20
|
Surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2012; 20:88-94. [PMID: 21556825 DOI: 10.1007/s00167-011-1541-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 05/02/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE Although various surgical procedures have attempted to restore valgus stability in medial knee injuries, so far none has achieved satisfactory results. The purpose of this study was to assess clinical outcome for patients with grade 3 valgus instability who were treated according to our surgical management strategy. METHODS Eighteen patients with both acute and chronic grade 3 medial knee injuries, all of which had combined cruciate ligament injuries, were treated with a proximal advancement of both the superficial medial collateral ligament (MCL) and posterior oblique ligament together with underlying deep MCL and joint capsule, in conjunction with cruciate ligament reconstructions in chronic phase. Augmentation with doubled semitendinosus tendon was added in 7 patients whose medial knee stability had been considered to be insufficient with only the proximal advancement procedure. They were evaluated preoperatively and at final follow-up. RESULTS Manual valgus laxities at 0° and 30°, as well as side-to-side difference in medial joint opening in stress radiograph, were significantly improved at final follow-up. The Lysholm knee scale was also significantly improved. Median values of the subjective evaluations of the patients' satisfaction, stability and sports performance level measured with visual analogue scale at final follow-up were 82 (60-100), 94 (71-100) and 88 (60-100), respectively. CONCLUSIONS Clinical outcomes of our surgical management strategy were reasonable in terms of restoring medial knee stability. This treatment protocol can help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries. LEVEL OF EVIDENCE Retrospective case series, Level IV.
Collapse
|
21
|
Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther 2012; 42:601-14. [PMID: 22402434 PMCID: PMC3576892 DOI: 10.2519/jospt.2012.3871] [Citation(s) in RCA: 331] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology. LEVEL OF EVIDENCE Therapy, level 5.
Collapse
|
22
|
A new diagnostic approach using regional analysis of anterior knee laxity in patients with anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc 2011; 19:760-7. [PMID: 21253707 DOI: 10.1007/s00167-010-1354-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 12/06/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE The first purpose of this study was to analyze the characteristics of the anterior knee laxity in the three regions of different stiffness in the force-displacement curve, which was obtained from a frequently used arthrometer for quantifying knee joint stability in the patients with anterior cruciate ligament (ACL) rupture and the healthy controls. The second purpose was to compare the characteristics from the regional analysis of the anterior knee laxity between the two subject groups in order to explore proper diagnosis criteria. METHODS Seventy-one patients with unilateral ACL tear and eighty healthy controls were enrolled and their anterior knee laxities were tested using the KT-2000 arthrometer. The displacements and stiffness of the three regions were extracted separately and compared between groups to further develop the diagnostic criteria. RESULTS The results indicated that the laxity behavior was mostly affected in Region 2 and Region 3 after ACL tear. Two good indicators for ACL tear were found in the receiver operating characteristic (ROC) curve analysis: Region 2 with the displacement larger than 3.7 mm and Region 3 with the stiffness smaller than 22 N/mm. These two criteria provided a better diagnostic accuracy with increased sensitivity. CONCLUSIONS The regional analysis method developed in this study could provide more information for understanding the characteristics of the anterior knee laxity and help increase the diagnostic accuracy for ACL rupture. LEVEL OF EVIDENCE II.
Collapse
|