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Vaishya R, Patralekh MK, Vaish A, Tollefson LV, LaPrade RF. Effect of Timing of Surgery on the Outcomes and Complications in Multi-ligament Knee Injuries: An Overview of Systematic Reviews and A Meta-analysis. Indian J Orthop 2024; 58:1175-1187. [PMID: 39170656 PMCID: PMC11333784 DOI: 10.1007/s43465-024-01224-1] [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: 06/23/2024] [Accepted: 07/05/2024] [Indexed: 08/23/2024]
Abstract
Background and Aims Multi-ligament knee injuries (MLKI) are serious and challenging to manage. This study aimed to elucidate the impact of surgical timing on both early and long-term outcomes following an MLKI. Methods A comprehensive search strategy was employed across PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were identified using a combination of relevant keywords encompassing "multi-ligament knee injury," "knee dislocation," "reconstruction," "repair," "surgery," and "timing," and their synonyms, along with appropriate Boolean operators. Selection of articles (systematic reviews and meta-analyses) adhered to predefined inclusion and exclusion criteria. Furthermore, a meta-analysis was conducted utilizing data extracted from primary studies. Results Early surgery for MLKI demonstrated a significant advantage over delayed surgery, reflected by significantly higher Lysholm scores (Mean Difference [MD] 3.51; 95% Confidence Interval [CI] 1.79, 5.22), IKDC objective scores (Mantel-Haenszel Odds Ratio [MH-OR] 2.95; 95% CI 1.30, 6.69), Tegner activity scores (MD 0.38; 95% CI 0.08, 0.69), and Mayer's ratings (MH-OR 5.47; 95% CI 1.27, 23.56). In addition, we found a significantly reduced risk of secondary chondral lesions (MH-OR 0.33; 95% CI 0.23, 0.48), lower instrumented anterior tibial translation in the early surgery group (MD -0.92; 95% CI -1.83, -0.01), but no significant difference was observed in the secondary meniscal tears, between the two groups. However, the early surgery group also exhibited a significantly increased risk of knee stiffness (MH-OR 2.47; 95% CI 1.22, 5.01) and a greater likelihood of requiring manipulation under anaesthesia (MH-OR 3.91; 95% CI 1.10, 13.87). Conclusion Early surgery for MLKI improves function, and stability, and reduces further articular cartilage damage, but increases the risk of stiffness. Level of Evidence IV. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-024-01224-1.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
| | | | - Abhishek Vaish
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076 India
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Hoit G, Chahal J, Khan R, Rubacha M, Nauth A, Whelan DB. Early Compared with Delayed Reconstruction in Multiligament Knee Injury: A Retrospective Propensity Analysis. J Bone Joint Surg Am 2024:00004623-990000000-01177. [PMID: 39172809 DOI: 10.2106/jbjs.23.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The purpose of this study was to compare outcomes following early compared with delayed reconstruction in patients with multiligament knee injury (MLKI). METHODS A retrospective cohort analysis of patients with MLKI from 2007 to 2019 was conducted. Patients who underwent a reconstructive surgical procedure with ≥12 months of postoperative follow-up were included. Patients were stratified into early reconstruction (<6 weeks after the injury) and delayed reconstruction (12 weeks to 2 years after the injury). Multivariable regression models with inverse probability of treatment weighting (IPTW) were utilized to compare the timing of the surgical procedure with the primary outcome (the Multiligament Quality of Life questionnaire [MLQOL]) and the secondary outcomes (manipulation under anesthesia [MUA], Kellgren-Lawrence [KL] osteoarthritis grade, knee laxity, and range of motion). RESULTS A total of 131 patients met our inclusion criteria, with 75 patients in the early reconstruction group and 56 patients in the delayed reconstruction group. The mean time to the surgical procedure was 17.6 days in the early reconstruction group compared with 280 days in the delayed reconstruction group. The mean postoperative follow-up was 58 months. The early reconstruction group, compared with the delayed reconstruction group, included more lateral-sided injuries (49 patients [65%] compared with 23 [41%]; standardized mean difference [SMD], 0.44) and nerve injuries (36 patients [48%] compared with 9 patients [16%]; SMD, 0.72), and had a higher mean Schenck class (SMD, 0.57). After propensity adjustment, we found no difference between early and delayed reconstruction across the 4 MLQOL domains (p > 0.05). Patients in the early reconstruction group had higher odds of requiring MUA compared with the delayed reconstruction group (24 [32%] compared with 8 [14%]; IPTW-adjusted odds ratio [OR], 3.85 [95% confidence interval (CI), 2.04 to 7.69]; p < 0.001) and had less knee flexion at the most recent follow-up (β, 6.34° [95% CI, 0.91° to 11.77°]; p = 0.023). Patients undergoing early reconstruction had lower KL osteoarthritis grades compared with patients in the delayed reconstruction group (OR, 0.46 [95% CI, 0.29 to 0.72]; p < 0.001). There were no differences in clinical laxity between groups. CONCLUSIONS Early reconstruction of MLKIs likely increases the likelihood of postoperative arthrofibrosis compared with delayed reconstruction, but it may be protective against the development of osteoarthritis. When considering the timing of MLKI reconstruction, surgeons should consider the benefit that early reconstruction may convey on long-term outcomes but should caution patients regarding the possibility of requiring an MUA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graeme Hoit
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
| | - Jaskarndip Chahal
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
| | - Ryan Khan
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Matthew Rubacha
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Nauth
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Daniel B Whelan
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
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Schneebeli V, Philippe V, Laurent A, Applegate LA, Martin R. Prognostic Factors for Multiligament Knee Injury Treated With Multiligament Reconstruction: Functional and Radiological Outcomes at 2 to 8 Years Postoperatively. Orthop J Sports Med 2024; 12:23259671241261103. [PMID: 39143988 PMCID: PMC11322938 DOI: 10.1177/23259671241261103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 08/16/2024] Open
Abstract
Background Multiligament reconstruction (MLR) has become the standard surgical approach for treating multiligament knee injuries (MLKIs). Purpose To identify prognostic factors for patient-reported outcome measures, return to work (RTW), return to sports, and radiographic osteoarthritis (OA) (Kellgren-Lawrence grade ≥2) after MLR for MLKI. Study Design Case-control study; Level of evidence 3. Methods Included were 52 consecutive patients (age, 35.5 ± 11 years; 75% men), with MLKI sustained between 2013 and 2019 and treated with MLR. At a mean follow-up of 3.8 ± 1.6 years, patient-reported outcome measure scores-including the International Knee Documentation Committee (IKDC), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), and the 12-Item Short-Form Health Survey-RTW, return to sports, and weightbearing radiographs were obtained. A total of 20 determinants were hypothesized and tested by univariate logistic regression for binary variables or linear regression for continuous variables. Only factors identified as significant (P < .10) were entered into a multivariate logistic regression model. Results The prevalence of injury severity according to the Schenck knee dislocation (KD) classification was as follows: KD I (44%), KD III (36%), KD IV (10%), and KD V (10%). Increased KD grades resulted in decreased IKDC (P = .002) and all 5 KOOS subscales (P≤ .007 for all) scores. Medial meniscectomy (23%) was associated with a worse ACL-RSI score (P = .007) and RTW failure (odds ratio [OR], 36.8; P = .035). Peroneal nerve palsy (6%) was associated with a worse ACL-RSI score (P≤ .001). Radiographic OA was observed in 38%, with distribution predominantly patellofemoral (80%) and medial tibiofemoral (45%). Traumatic cartilage damage (Outerbridge grade >2 [37%]) was associated with secondary patellofemoral (OR, 10; P = .012) and medial tibiofemoral (OR, 10; P = .019) OA. Anterior cruciate ligament reconstruction failure (7%) was a risk factor for medial tibiofemoral OA (OR, 25.8; P = .006). Conclusion Increased Schenck KD grade, permanent peroneal nerve palsy, and irreparable medial meniscus lesions were prognostic factors for worse functional outcomes 3.8 years after MLKI was treated with MLR. Traumatic cartilage damage and anterior cruciate ligament failure were associated with the development of early OA.
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Affiliation(s)
- Valentine Schneebeli
- Orthopedics Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Virginie Philippe
- Orthopedics Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, Épalinges, Switzerland
| | - Alexis Laurent
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, Épalinges, Switzerland
| | - Lee Ann Applegate
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, Épalinges, Switzerland
| | - Robin Martin
- Orthopedics Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Fortier LM, Knapik DM, Condon JJ, DeWald D, Khan Z, Kerzner B, Matava MJ, LaPrade R, Chahla J. Higher success rate observed in reconstruction techniques of acute posterolateral corner knee injuries as compared to repair: an updated systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:5565-5578. [PMID: 37848567 DOI: 10.1007/s00167-023-07582-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE There remains controversy regarding the optimal surgical treatment for acute complete (grade III) posterolateral corner (PLC) injuries. The purpose of this article is to systematically review the contemporary literature regarding surgical options and subsequent outcomes of acute grade III PLC injuries. METHODS A systematic review was performed using the following search terms: posterolateral corner knee, posterolateral knee, posterolateral instability, multi-ligament knee, and knee dislocation. Inclusion criteria consisted of studies with level I-IV evidence, reporting on human patients with acute grade III PLC injuries undergoing operative management within 4 weeks from injury, with subjective and/or objective outcomes (including varus stress examinations or varus stress radiographs) reported at a minimum 2-year follow-up. Two investigators independently performed the search by sequentially screening articles. Accepted definitions of varus stability on examination or stress radiographs and revision surgery were used to determine success and failure of treatment. RESULTS A total of 12 studies, consisting of 288 patients were included. Ten studies reported primary repair, while reconstruction techniques were reported in seven studies. Overall, 43% (n = 125/288) of injuries involved the PLC, ACL and PCL. Staged reconstruction was reported in 25% (n = 3/12) of studies. The Lysholm score was the most commonly reported outcome measure. An overall failure rate of 12.4% (n = 35/282) was observed. Surgical failure was significantly higher in patients undergoing repair (21.9%; n = 21/96) compared to reconstruction (7.1%; n = 6/84) (p = 0.0058). Return to sport was greater in patients undergoing reconstruction (100%; n = 22/22) compared to repair (94%; n = 48/51) (n.s). The most common post-operative complication was arthrofibrosis requiring manipulation under anesthesia (8.7%; n = 25/288). A total of 3.8% (n = 11/288) of patients underwent revision PLC reconstruction. CONCLUSION There remains substantial heterogeneity in the surgical techniques of acute, grade III PLC injuries with an overall failure rate of 12.4%. Failure rates were significantly lower, and return to sport rates higher in patients undergoing PLC reconstruction compared to repair. The most common postoperative complication was arthrofibrosis requiring manipulation under anesthesia. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Luc M Fortier
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, 14532 South Outer Forty Drive, Chesterfield, MO, 63017, USA
| | - Josh J Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA
| | - Daniel DeWald
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - Zeeshan Khan
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, 14532 South Outer Forty Drive, Chesterfield, MO, 63017, USA
| | - Robert LaPrade
- Twin Cities Orthopaedics, 4010 W 65th St., Edina, MN, 55435, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA.
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA.
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Holuba K, Rilk S, Vermeijden HD, O’Brien R, van der List JP, DiFelice GS. Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness. Arthrosc Sports Med Rehabil 2023; 5:100799. [PMID: 37822672 PMCID: PMC10562670 DOI: 10.1016/j.asmr.2023.100799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/15/2023] [Indexed: 10/13/2023] Open
Abstract
Purpose To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up. Methods A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR). Results A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0). Conclusions In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Kurt Holuba
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Sebastian Rilk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
- Medical University of Vienna, Vienna, Austria
| | - Harmen D. Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
- Department of Orthopaedic Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Sports, Amsterdam, the Netherlands
| | - Robert O’Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jelle P. van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
- Department of Orthopaedic Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Sports, Amsterdam, the Netherlands
| | - Gregory S. DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A
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Anies EP, Sheppard SG, McDonald LS, Bailey JR. Bilateral Knee Dislocations in an Active Duty Service Member: A Case Report. Mil Med 2023; 188:3236-3241. [PMID: 35916477 DOI: 10.1093/milmed/usac222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/26/2022] [Accepted: 07/10/2022] [Indexed: 11/13/2022] Open
Abstract
This case highlights a staged operative approach for a patient who sustained bilateral knee dislocations and subsequent staged operative treatment and rehabilitation. This patient underwent bilateral multiligamentous knee reconstructions and left-sided peroneal nerve allografting because of complete peroneal nerve palsy. The initial treatment was bilateral medial collateral ligament reconstructions, posterolateral corner reconstructions, and capsular repairs with left leg peroneal nerve allografting and repair of avulsed biceps femoris tendon. The patient underwent physical therapy following the first stage procedure until he regained appropriate motion and soft tissue healing occurred. Subsequently, combined anterior cruciate and posterior cruciate ligament reconstructions were performed in a staged fashion to allow one leg to fully bear weight for rehabilitation purposes. With the help of a multidisciplinary surgical and rehabilitation team, the patient has regained the stability of his knees and achieved acceptable functional outcomes. A staged systematic approach to multiligamentous bilateral knee reconstruction can provide optimal pain management, obtain initial joint stability, minimize complications, and achieve acceptable functional outcomes. Surgical techniques to first restore medial and lateral structures can be utilized to provide initial valgus and varus stability while allowing for knee mobilization and, eventually, in-line ambulation, before staged anterior and posterior cruciate ligament reconstructions. This case demonstrates a multistaged approach to bilateral knee dislocations with favorable outcomes in a 23-year-old active duty patient.
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Affiliation(s)
- Ervin P Anies
- Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, MD 20814, USA
| | - Sean G Sheppard
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Lucas S McDonald
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - James R Bailey
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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Crandall C, Richards Z, Seely KD, Mortensen S, Quinn Z, Gibbs D. Lateral Meniscal Root Displacement into the Popliteal Hiatus in a Multiligamentous Knee Injury: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00009. [PMID: 37437073 DOI: 10.2106/jbjs.cc.22.00743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
CASE A 45-year-old female patient presented with left knee pain after a ski accident. Magnetic Resonance Imaging (MRI) showed complete rupture of the anterior cruciate ligament, posterior cruciate ligament, proximal Medial Collateral Ligament (MCL), and medial patellofemoral ligament. The lateral meniscal root was torn with the posterior horn incarcerated superiorly into the popliteal hiatus, rendering high risk of plastic deformation. An unconventional 2-staged surgical approach was performed. CONCLUSION Where risk of meniscal plastic deformation is high in the setting of multiligamentous knee injury (MLKI), diagnosis and careful surgical planning are central to a successful outcome. Treatment of intra-articular structures in operative stage 1 in MLKI is possible and was necessary in this case.
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Affiliation(s)
- Cody Crandall
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Zeke Richards
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Kevin D Seely
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Shad Mortensen
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
| | - Zachary Quinn
- Rocky Vista University College of Osteopathic Medicine, Ivins, Utah
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Makaram NS, Murray IR, Geeslin AG, Chahla J, Moatshe G, LaPrade RF. Diagnosis and treatment strategies of the multiligament injured knee: a scoping review. Br J Sports Med 2023; 57:543-550. [PMID: 36822842 DOI: 10.1136/bjsports-2022-106425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs). DESIGN Scoping review. DATA SOURCES Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary. RESULTS Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups. CONCLUSIONS There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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Watrinet J, von Rüden C, Regenbogen S, Brand A, Bormann M, Stuby FM, Fürmetz J. Mid-Term Results following Traumatic Knee Joint Dislocation. J Clin Med 2022; 12:jcm12010266. [PMID: 36615066 PMCID: PMC9821045 DOI: 10.3390/jcm12010266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Although treatment strategies of knee joint dislocations have evolved, there is still no consensus on the best method and timing. New therapeutic concepts suggest that early one-stage treatment, including suturing and bracing of the cruciate ligaments in acute knee joint dislocation, are leading to improved functional results. This study aimed to evaluate the midterm functional outcome following traumatic knee joint dislocation and to determine whether the outcome is influenced by the surgical management, patient habitus or concomitant injuries. METHODS In this retrospective single center study, 38 patients with acute Schenck type II to IV knee dislocations were treated over an eight-year period in a level I trauma center. At follow-up, various clinical scores, such as the International Knee Documentation Committee (IKDC) Score, Lysholm Score, and Tegner Activity Scale (TAS), and individual questions about rehabilitation and activity levels of 38 patients were evaluated. RESULTS Mean follow-up was 5.5 ± 2.7 years. The mean IKDC Score was 65.6 ± 15.7 points, the average Lysholm Score was 70.5 ± 16.4 points and the median TAS was 4 (0-7), resulting in a loss of activity of 2 (range 0-6) points. There was no significant difference between a one-stage treatment compared to a two-stage approach. Ligament reconstruction of the ACL in a two-stage approach was required in only 33.3%. Further operations (early and late) were performed in 37% of cases. Being overweight was associated with more complications and worse outcomes, and external fixation with arthrofibrosis. CONCLUSIONS Knee dislocation is a severe trauma that often leads to a prolonged loss of function and increased knee pain over years, affecting the patient's activity. Clinical outcome is influenced significantly by concomitant injuries. Severe cases with initial external fixation are associated with a higher risk of knee stiffness and should be considered during rehabilitation. Obese patients present a challenge due to higher complication rates and lower postoperative knee function. LEVEL OF EVIDENCE Retrospective single center study, level III.
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Affiliation(s)
- Julius Watrinet
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian von Rüden
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Stephan Regenbogen
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute of Biomechanics, BG Trauma Center Murnau, 82418 Murnau, Germany
| | - Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | - Fabian M. Stuby
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Julian Fürmetz
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
- Correspondence:
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Fahlbusch H, Krivec L, Müller S, Reiter A, Frosch KH, Krause M. Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: a systematic review. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04730-9. [PMID: 36520199 PMCID: PMC10374851 DOI: 10.1007/s00402-022-04730-9] [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: 08/21/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose of this study is to systematically review multiligament knee injury (MLKI) outcome studies to determine definitions of arthrofibrosis (AF) and provide information about incidence, management as well as potential risk factors. METHODS A systematic literature search was performed (PubMed and Cochrane library) following the PRISMA guidelines of operatively treated MLKI (Schenck II-IV) studies reporting the incidence of AF. Twenty-five studies met the inclusion criteria. Injury pattern, timing of surgery, surgical technique, treatment of AF, rehabilitation programs and PROMS were inquired. Risk of bias and quality of evidence were assessed using the Coleman methodological score. RESULTS Twenty-five studies with a total of 709 patients with a mean age of 33.6 ± 4.8 years were included and followed 47.2 ± 32.0 months. The majority of studies (22/25) used imprecise and subjective definitions of AF. A total of 86 patients were treated for AF, resulting in an overall prevalence of 12.1% (range 2.8-57.1). Higher-grade injuries (Schenck III-IV), acute treatment and ROM (range of motion) limiting rehabilitation programs were potential risk factors for AF. The time from index surgery to manipulation anesthesia (MUA) and arthroscopic lysis of adhesions (LOA) averaged at 14.3 ± 8.8 and 27.7 ± 12.8 weeks. Prior to MUA and LOA, the ROM was 51.7° ± 23.5 and 80.2° ± 17.0, resulting in a total ROM gain after intervention of 65.0° ± 19.7 and 48.0° ± 10.6, respectively; with no reports of any complication within the follow-up. The overall methodological quality of the studies was poor as measured by the Coleman score with average 56.3 ± 12.5 (range 31-84) points. CONCLUSIONS AF is a common but poorly defined complication particularly in high-grade MLKI. Early postoperative and intensified physiotherapy is important to reduce the risk of AF. MUA and LOA are very effective treatment options and result in good clinical outcome. Prospective studies with bigger study population are needed to optimize treatment algorithms of further patients after MLKI. The protocol of this systematic review has been prospectively registered with PROSPERO (CRD42021229187, January 4th, 2021).
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Affiliation(s)
- Hendrik Fahlbusch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Krivec
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Müller
- Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
| | - Alonja Reiter
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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11
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Li C, Liu Y, Zheng R, Sun J, Peng W, Deng X, Huang X. One-Stage Arthroscopic Multiple Ligament Reconstruction for Schenck IV Knee Dislocation. Orthop Surg 2022; 15:502-509. [PMID: 36513497 PMCID: PMC9891907 DOI: 10.1111/os.13611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/09/2022] [Accepted: 11/06/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Schenck IV knee dislocation patients have dissatisfactory knee function and return-to-sport rate with the existing treatment methods. The purpose of this study was to illustrate a one-stage arthroscopic multiple ligament reconstruction method for treating Schenck IV knee dislocations. METHODS A retrospective case series study was performed. All patients with a history of Schenck IV knee dislocation who underwent one-stage arthroscopic multi-ligament reconstruction from 2010 to 2018 were followed for 24 months. The outcomes, including general patient data, Lysholm scores, International Knee Documentation Committee (IKDC) scores, visual analog scale (VAS) pain scores, knee active range of motion, and complications, were reviewed. The data was analyzed with paired-samples t-test. RESULTS A total of 12 patients, comprising nine males and three females, were followed up and reviewed. The mean age at the time of the surgical procedure was 40.3 ± 9.0 (22-57) years. The mean body mass index (BMI) was 24.6 ± 4.9 (15.2-32.5) kg/m2 . The mean IKDC score and Lysholm score before surgery were 30.4 ± 6.1 (21-42) and 28.2 ± 6.2 (22-39), respectively. The average operation time was 121.8 minutes. The mean IKDC score and Lysholm score at the 24-month follow-up were 80.6 ± 6.5 (68-92) and 82.0 ± 7.5 (72-95), respectively. There were significant differences in the IKDC and Lysholm scores between the preoperative and 24-month postoperative time points (p < 0.01). The mean knee range of motion was 124.6° ± 6.6° (115°-135°) at the 24-month follow-up. No major complications occurred. CONCLUSIONS The results of this retrospective study suggest that the new arthroscopic one-stage multi-ligament reconstruction technique is an effective way to treat Schenck IV knee dislocation with satisfactory postoperative knee function.
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Affiliation(s)
- Chao Li
- Senior Department of OrthopaedicsThe Fourth Medical Center of PLA General HospitalBeijingChina,National Clinical Research Center for OrthopaedicsSports Medicine & RehabilitationBeijingChina
| | - Yubo Liu
- Senior Department of OrthopaedicsThe Fourth Medical Center of PLA General HospitalBeijingChina,National Clinical Research Center for OrthopaedicsSports Medicine & RehabilitationBeijingChina,School of MedicineNankai UniversityTianjinChina
| | - Runlong Zheng
- Department of Orthopaedic SurgeryPLA Strategic Support Force Characteristic Medical CenterBeijingChina
| | - Jitong Sun
- Senior Department of OrthopaedicsThe Fourth Medical Center of PLA General HospitalBeijingChina,National Clinical Research Center for OrthopaedicsSports Medicine & RehabilitationBeijingChina
| | - Wei Peng
- Senior Department of OrthopaedicsThe Fourth Medical Center of PLA General HospitalBeijingChina,National Clinical Research Center for OrthopaedicsSports Medicine & RehabilitationBeijingChina
| | - Xiang‐Hua Deng
- Sports Medicine and Shoulder ServiceHospital for Special SurgeryNew YorkUSA,Orthopaedic Soft Tissue Research ProgramHospital for Special SurgeryNew YorkUSA
| | - Xunwu Huang
- Senior Department of OrthopaedicsThe Fourth Medical Center of PLA General HospitalBeijingChina,National Clinical Research Center for OrthopaedicsSports Medicine & RehabilitationBeijingChina
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12
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Smith JRH, Belk JW, Friedman JL, Dragoo JL, Frank RM, Bravman JT, Wolcott ML, McCarty EC. Predictors of Mid- to Long-Term Outcomes in Patients Experiencing a Knee Dislocation: A Systematic Review of Clinical Studies. J Knee Surg 2022; 35:1333-1341. [PMID: 33545729 DOI: 10.1055/s-0041-1723762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m2 are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m2, concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.
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Affiliation(s)
- John-Rudolph H Smith
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jamie L Friedman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jason L Dragoo
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Rachel M Frank
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan T Bravman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michelle L Wolcott
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
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13
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Complex Repair and Cruciate Ligament Reconstruction in KDs III and IV Multiligamentous Knee Injuries-Results of Mid-Term Follow-up. J Knee Surg 2022. [PMID: 35649432 DOI: 10.1055/s-0042-1748172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of the present study was to describe the longitudinal outcomes of acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament for knee dislocations (KDs) III and IV multiligamentous knee injuries. Forty-seven patients with an acute KD III or IV were treated with one-stage management within 9.2 days. Forty-five KDs III and IV with a follow-up at a mean of 53.2 months were evaluated. The mean International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were 81.5 ± 0.7, 89.6 ± 1.2, and 6.8 ± 0.5, respectively. Comparing preoperative data with those at the latest follow-up, significant improvements in IKDC score (p < 0.01), Lysholm score (p < 0.01), and Tegner score (p < 0.01) were noted in all groups. Comparing contralateral knee stability, no statistical differences were found including the varus/valgus (0 degree/30 degrees) and Telos stress radiography. So, acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament resulted in satisfactory outcomes for KDs III and IV multiligamentous knee injuries.
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14
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Cui S, Yi H, Zhu X, Fan J, Ding Y, Liu W. The Efficacy and Outcome of a Two-Staged Operation for Irreducible Knee Dislocation: A Prospective Short-Term Follow-Up. Front Bioeng Biotechnol 2022; 10:861788. [PMID: 35547163 PMCID: PMC9081522 DOI: 10.3389/fbioe.2022.861788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Irreducible knee dislocation (IKD) is a very rare but serious type of knee dislocation; it can lead to soft tissue necrosis due to incarceration of the medial structures and faces great difficulty in the postoperative rehabilitation, too. IKD needs careful pre-operative planning. There is no universal agreement about the appropriate surgical strategy for IKD. The purpose of this study was to investigate the clinical efficacy, safety, and outcome of the two-staged operation in treatment of IKD. Methods: IKD patients were included from June 1, 2016 to May 31, 2020. In the stage-1 surgery, acute reduction and extra-articular structure repair were performed. Following an intermediate rehabilitation, delayed cruciate ligament reconstructions were performed in stage-2. Physical examination, CT, MRI, and X-ray were performed during the pre-operative period. Knee function, joint stability, ligament laxity, knee range of motion (ROM), and alignment were accessed at follow-ups. The minimum and maximum follow-up times were 0.5 years and 1 year, respectively. Results: In total, 17 IKD patients were included. There were three subjects (17.65%) missing at the 1 year follow-up and the average follow-up was 11.18 ± 2.53 months. After stage-1, normal alignment and superior valgus/varus stability were restored in most subjects; however, a notable anterior-posterior instability still existed in most patients. The intermediate rehabilitation processed smoothly (6.94 ± 1.20 weeks), and all patients achieved knee ROM of 0-120° finally. At 0.5 years and 1 year follow-up after stage-2, all subjects had achieved normal knee stability, ROM, and satisfying joint function. No infection or DVT was observed. Conclusions: The two-staged operation for IKD has superior efficacy on knee stability and function, and it can facilitate the rehabilitation and achieve satisfactory short-term outcome.
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Affiliation(s)
- Shengyu Cui
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China
- Nantong First Peoples Hospital, Nantong, China
| | - Hong Yi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China
- Nantong First Peoples Hospital, Nantong, China
| | - Xinhui Zhu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China
- Nantong First Peoples Hospital, Nantong, China
| | - Jianbo Fan
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China
- Nantong First Peoples Hospital, Nantong, China
| | - Yi Ding
- Rehabilitation Hospital Affiliated to National Research Center for Rehabilitation Technical Aids, Beijing, China
| | - Wei Liu
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Nantong University, Nantong, China
- Nantong First Peoples Hospital, Nantong, China
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15
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Scheepers W, Khanduja V, Held M. Current concepts in the assessment and management of multiligament injuries of the knee. SICOT J 2021; 7:62. [PMID: 34870591 PMCID: PMC8647687 DOI: 10.1051/sicotj/2021058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.
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Affiliation(s)
- Waldo Scheepers
- Department of Orthopedic Surgery, Groote Schuur Hospital, Orthopedic Research Unit, University of Cape Town, 7925 Cape Town, South Africa
| | - Vikas Khanduja
- Consultant Orthopedic Surgeon, Addenbrooke's - Cambridge University Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Michael Held
- Department of Orthopedic Surgery, Groote Schuur Hospital, Orthopedic Research Unit, University of Cape Town, 7925 Cape Town, South Africa
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16
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Harris BT, Eichman EA, Burrus MT. Traumatic Simultaneous Bilateral Knee Dislocation: A Case Report. Cureus 2021; 13:e18989. [PMID: 34853734 PMCID: PMC8607962 DOI: 10.7759/cureus.18989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/05/2022] Open
Abstract
Bilateral knee dislocation is an extremely rare and devastating injury to the knee joint. This injury is a true emergency as concomitant injuries may threaten life and limb. Here, we report the case of a 26-year-old male patient who sustained bilateral knee dislocation due to a high-velocity motor vehicle accident. In this case, the patient suffered a feared complication associated with knee dislocation, popliteal artery disruption with peroneal nerve damage. Abdominal and skeletal injuries were also discovered and treated appropriately by a multidisciplinary team. A staged surgical approach to ligament reconstruction was used without any postoperative complication. Postoperatively, the patient successfully returned to his preoperative activity level.
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Affiliation(s)
- Benjamin T Harris
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Elizabeth A Eichman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Matthew T Burrus
- Orthopedic Surgery, Orthopedic Associates of Central Texas, Austin, USA
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17
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Kilicoglu OI, Pehlivanoglu T, Demirel M, Chodza M, Balcı HI, Asık M. The Impact of the Ligamentous Injury Pattern and Associated Neurovascular Injury on Ultimate Knee Function in Patients with Traumatic Knee Dislocations. J Knee Surg 2021; 34:1495-1502. [PMID: 32462644 DOI: 10.1055/s-0040-1710368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The present study aims to investigate whether there is a relationship between the ligamentous injury pattern and concomitant neurovascular injury with long-term functional outcomes in patients with traumatic knee dislocations (TKDs). A total of 42 patients with TKDs were categorized according to the Schenck's classification based on the pattern of ligamentous injury. Concomitant vascular and neural injuries were recorded. Long-term functional outcomes were assessed using several objective and subjective outcome measures. This retrospective study was conducted in two phases: (1) to analyze the impact of ligamentous injury pattern on functional outcomes of patients with TKDs in the overall study population, by comparing all the variables among Schenck's grades; (2) to determine the impact of concomitant vascular and neural injury on ultimate knee function based on the subgroup analyses. In the overall study statistical differences were determined among each pattern of ligamentous injury in the total range of motion (ROM) and scoring systems (chi-squared test, p = 0.254). The overall rates of vascular and neural injury were 26 and 28%, respectively. In subgroup analyses, 40 patients were divided into three subgroups: group A (isolated concomitant neural injury), group B (isolated concomitant vascular injury), group C (without concomitant major vascular or neural injury). The analysis revealed a significant difference in the total ROM (p = 0.005), flexion measurements (p = 0.004), and the loss of extension (p = 0.003). Group A had the lowest total knee ROM and the mean flexion degrees, as well as the highest loss of extension. Concerning functional scoring systems including the combined Knee Society Score (knee score + function score), Lysholm knee scoring scale, and International Knee Documentation Committee score, subgroup analyses revealed significant differences among the groups (p = 0.001, p < 0.01 for all scores). All the scores were found to be lowest in group A. Evidence from the current study showed that the ligamentous pattern and concomitant neurovascular injury both may have a significant impact on ultimate knee function in patients with TKDs. This is a Level III-retrospective comparative study.
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Affiliation(s)
- Onder I Kilicoglu
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
| | - Mehmet Demirel
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
| | - Mechmet Chodza
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
| | - Halil I Balcı
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
| | - Mehmet Asık
- Emsey Hospital, Department of Orthopedic Surgery and Traumatology, Yeni Yüzyıl University, Faculty of Health Sciences, Istanbul, Turkey
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18
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Marder RS, Poonawala H, Pincay JI, Nguyen F, Cleary PF, Persaud CS, Naziri Q, Zikria BA. Acute Versus Delayed Surgical Intervention in Multiligament Knee Injuries: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211027855. [PMID: 34671686 PMCID: PMC8521434 DOI: 10.1177/23259671211027855] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023] Open
Abstract
Background: The optimal timing of surgical intervention for multiligament knee injuries remains controversial. Purpose: To review the clinical and functional outcomes after acute and delayed surgical intervention for multiligament knee injuries. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a search of the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to September 2020. Eligible studies reported on knee dislocations, multiligament knee injuries, or bicruciate ligament injuries in adult patients (age, ≥18 years). In addition to comparing outcomes between acute and delayed surgical intervention groups, we conducted 3 subgroup analyses for outcomes within isolated knee injuries, knee injuries with concomitant polytrauma/fractures, and high-level (level 2) studies. Results: Included in the analysis were 31 studies, designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n = 20). These studies reported on 2594 multiligament knee injuries sustained by 2585 patients (mean age, 25.1-65.3 years; mean follow-up, 12-157.2 months). At the latest follow-up timepoint, the mean Lysholm (n = 375), International Knee Documentation Committee (IKDC) (n = 286), and Tegner (n = 129) scores for the acute surgical intervention group were 73.60, 67.61, and 5.06, respectively. For the delayed surgical intervention group, the mean Lysholm (n = 196), IKDC (n = 172), and Tegner (n = 74) scores were 85.23, 72.32, and 4.85, respectively. The mean Lysholm (n = 323), IKDC (n = 236), and Tegner (n = 143) scores for our isolated subgroup were 83.7, 74.8, and 5.0, respectively. By comparison, the mean Lysholm (n = 270), IKDC (n = 236), and Tegner (n = 206) scores for the polytrauma/fractures subgroup were 83.3, 64.5, and 5.0, respectively. Conclusion: The results of our systematic review did not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes. Although previous evidence has supported acute surgical intervention, future prospective randomized controlled trials and matched cohort studies must be completed to confirm these findings.
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Affiliation(s)
- Ryan S Marder
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Husain Poonawala
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Jorge I Pincay
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Frank Nguyen
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Patrick F Cleary
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Christine S Persaud
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Bashir A Zikria
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
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19
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Hoit G, Rubacha M, Chahal J, Khan R, Ravi B, Whelan DB. Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial. Clin Orthop Relat Res 2021; 479:1725-1736. [PMID: 33729214 PMCID: PMC8277250 DOI: 10.1097/corr.0000000000001729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. QUESTIONS/PURPOSES (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? METHODS Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. RESULTS With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. CONCLUSION With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Graeme Hoit
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | | | - Jaskarndip Chahal
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Women’s College Hospital, Toronto, ON, Canada
| | - Ryan Khan
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bheeshma Ravi
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | - Daniel B. Whelan
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, St. Michael’s Hospital, Unity Health, Toronto ON, Canada
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20
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Utilization and costs of postoperative physical therapy after multiligament knee surgery: a retrospective cross-sectional study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes. Knee Surg Sports Traumatol Arthrosc 2021; 29:4188-4197. [PMID: 33688978 PMCID: PMC8595154 DOI: 10.1007/s00167-021-06501-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 02/10/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD). METHODS The results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6-45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls. RESULTS The mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4-9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis. CONCLUSION Anatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial-temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics. LEVEL OF EVIDENCE Level III.
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22
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Ishibashi Y, Kimura Y, Sasaki E, Sasaki S, Yamamoto Y, Tsuda E. Acute primary repair of extraarticular ligaments and staged surgery in multiple ligament knee injuries. J Orthop Traumatol 2020; 21:18. [PMID: 33026549 PMCID: PMC7541803 DOI: 10.1186/s10195-020-00557-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study is to compare the outcomes of acute primary repair of extraarticular ligaments with staged surgery for acute knee dislocations (KDs) and multiligament knee injuries (MLKIs). Materials and methods Between January 2005 and May 2018, 61 consecutive patients diagnosed with MLKI or KD were referred to or visited our institution. Of these, 31 patients who underwent acute repair of extraarticular ligaments within 3 weeks of injury were included in this study. These patients were retrospectively classified into two groups: those who underwent only primary repair (repair group) and those who underwent staged reconstructive surgery (staged group). Follow-up examination included range of motion (ROM), knee joint stability (Lachman test, posterior drawer test, and varus and valgus stress test), Lysholm knee score, Tegner activity scale, and Knee Injury and Osteoarthritis and Outcome Score (KOOS). Results Twelve of the 31 patients did not need or desire further surgery and were included in the repair group. No significant difference was observed in demographic data between the repair and staged groups. Although staged surgery decreased positive posterior drawer test results, no significant difference was observed between the two groups regarding ROM, other knee joint stability tests, Lysholm scores, Tegner scale, or KOOS. Conclusions In this series, all patients returned to their activities of daily living and preinjury occupation levels. Acute primary repair of extraarticular ligaments provides essential knee stability without varus/valgus instability and may reduce the need for subsequent cruciate ligament reconstruction. Level of evidence Level IV, retrospective observational study.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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23
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Abstract
Knee dislocations leading to multiligament knee injuries are associated with a wide variety of bony, ligamentous, soft tissue, and neurovascular injury patterns. Numerous management strategies have been proposed including nonoperative treatment and surgical repair or reconstruction. In recent years, an emphasis has been placed on anatomic repair and reconstruction principles, which have shown superior outcomes compared with older techniques. However, despite these advances, clinical outcomes continue to vary widely, with many patients experiencing chronic pain, stiffness, loss of range of motion, instability, and failure to return to work or sports. The purpose of this chapter is to review clinical outcomes following combined anterior and posterior cruciate ligament, medial collateral ligament, and posterolateral corner injuries sustained during a knee dislocation. Understanding the available treatment options and reported outcomes will allow surgeons to individualize management to address each patient's specific injury pattern and functional goals.
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Mosquera MF, Jaramillo A, Gil R, Gonzalez Y. Controversies in acute multiligamentary knee injuries (MLKI). J Exp Orthop 2020; 7:56. [PMID: 32715370 PMCID: PMC7383048 DOI: 10.1186/s40634-020-00260-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/08/2020] [Indexed: 01/12/2023] Open
Abstract
Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.
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Affiliation(s)
- Manuel F Mosquera
- Clinica Erasmo, Valledupar, Colombia. .,Clinica La Carolina, Carrera 14 # 127-11 Cons 307-308, Bogota, Colombia.
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Single-Stage Arthroscopic Anterior and Posterior Cruciate Ligament Repairs and Open Medial Collateral Ligament Repair for Acute Knee Dislocation. Case Rep Orthop 2020; 2020:7348201. [PMID: 32158579 PMCID: PMC7060436 DOI: 10.1155/2020/7348201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/17/2020] [Indexed: 11/18/2022] Open
Abstract
Till date, there are no clear guidelines regarding the treatment of multiple ligament knee injuries. Ligament repair is advantageous as it preserves proprioception and does not involve grafting. Many studies have reported the use of open repair and reconstruction for multiple ligament knee injuries; however, reports on arthroscopic-combined single-stage anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) repairs are scarce. In this report, we describe a case of type III knee dislocation (ACL, PCL, and medial collateral ligament (MCL) injuries) in a 43-year-old man, caused by contact while playing futsal. On the sixth day after injury, arthroscopic ACL and PCL repairs were performed with open MCL repair. The proximal lesions in the three ligaments that were injured were sutured using no. 2 strong surgical sutures. The ACL was pulled out to the lateral condyle of the femur and fixed using a suspensory fixation device. The PCL was pulled out to the medial condyle of the femur, and the MCL was pulled towards the proximal end of the femur; both were fixed using suture anchors. Early mobilization was performed, and both, clinical and imaging outcomes, were good two years after surgery.
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26
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Abstract
Up to 18% of multiligament knee injuries (MLKI) have an associated vascular injury.All MLKI should be assessed using the ankle brachial pressure index (ABPI) with selective arteriography if ABPI is < 0.9.An ischaemic limb following knee dislocation must be taken to the operating theatre immediately for stabilization and re-vascularization.Partial common peroneal nerve (CPN) injury following MLKI has better recovery than complete palsy.Posterior tibial tendon transfer is offered to patients with complete CPN palsy if there is no recovery at six months.Operative treatment with acute or staged reconstructions provides the best outcome in MLKI.Effective repair can only be performed within three weeks of injury.There is no difference between repair and reconstruction of medial collateral ligament and posteromedial corner.Posterolateral corner reconstruction has a lower failure rate than repair.Early mobilization following MLKI surgery results in fewer range-of-motion deficits. Cite this article: EFORT Open Rev 2020;5:145-155. DOI: 10.1302/2058-5241.5.190012.
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Affiliation(s)
- Jimmy Wui Guan Ng
- Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, UK
| | - Yulanda Myint
- Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, UK
| | - Fazal M Ali
- Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield, UK
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27
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National trends, 90-day readmission and subsequent knee surgery following multi-ligament knee reconstruction. J Orthop 2020; 21:49-52. [PMID: 32089609 DOI: 10.1016/j.jor.2020.01.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/24/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction/background Given the uncommon nature of the multi-ligament injured knee, a better understanding of its outcomes may be achieved by contemporary evaluation of a national administrative database. We aim to identify risk factors for 90-day major complications, 90-day readmissions, and subsequent knee surgery after a multi-ligament knee reconstruction. Methods The Humana Claims Database was queried for all patients undergoing a multi-ligament knee reconstruction procedure from 2007 to 2016 using International Classification of Diseases (ICD)-9 procedure codes and Current Procedural Terminology (CPT) codes. Outcomes of interest included Center of Medicaid and Medicare Services (CMS)- reportable 90-day complications, 90-day readmission and subsequent ligament reconstruction or total knee arthroplasty. Predictive factors studied included demographics (ie. age, sex, tobacco use) comorbidity burden and operative factors (ie. surgical setting, diagnosis of knee dislocation, concomitant meniscal repair or meniscectomy). Results 588 multi-ligament knee reconstruction procedures were identified. The 90-day readmission rate 8.3%. The rate of subsequent ligament surgery was 7.1%. On multivariate regression analysis, a diagnosis of knee dislocation was associated with a four times greater likelihood of readmission and a two and a half greater likelihood of subsequent ligament surgery. Concomitant meniscectomy was associated with higher likelihood of subsequent total knee arthroplasty (9.1, 1.4-67.0) and outpatient setting of surgery compared to inpatient hospital setting was associated with reduced likelihood of readmission. Conclusion While uncommon, the patient population undergoing multi-ligament knee surgery is relatively diverse. Understanding common factors predisposing this population to adverse events following surgery may assist in improved outcomes.
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Vermeijden HD, Jonkergouw A, van der List JP, DiFelice GS. The multiple ligament-injured knee: When is primary repair an option? Knee 2020; 27:173-182. [PMID: 31926671 DOI: 10.1016/j.knee.2019.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/23/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of multiple ligament-injured knees (MLIKs) remains complex and most often requires ligament reconstruction surgery. Reconstruction effectively restores knee stability but the procedure is invasive and can be complicated by stiffness or arthrofibrosis. There has been recent resurgence of interest in primary repair of knee ligaments. The goal was therefore to assess incidence of repairable ligaments in MLIKs, and determine patient and injury characteristics associated with potential for primary repair. METHODS A retrospective review of all MLIK patients surgically treated between 2009 and 2018 was conducted. All patients were treated with the same algorithm: primary repair was performed if the ligament was proximally or distally avulsed, and otherwise, reconstruction was performed. Patient characteristics, injury patterns, treatment specifics, and short-term outcomes were compared using independent t-tests and chi-square tests. RESULTS Forty-eight patients were included (mean age 32 years ± 14; 54% were male). Ultimately, 55% of ACL, 73% of PCL, 88% of MCL/PMC, and 87% of LCL/PLC injuries were repaired. Patients above 35 years (OR 6.9, P = 0.010) and higher BMI (OR 3.5, P = 0.046) were more likely to undergo ACL repair. No significant correlation was found in other ligaments. At a minimum of six-month follow-up (range 0.5-7.2 years), ACL repair failed in nine percent, PCL repair in 17%, MCL/PMC repair in 0%, and LCL/PLC repair in 18% of patients. CONCLUSIONS This study noted high incidences of repairable ligaments when MLIKs are treated within six weeks following injury. Although preliminary outcomes following primary repair in MLIK are good, further long-term follow-up studies are needed.
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Affiliation(s)
- Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States.
| | - Anne Jonkergouw
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States
| | - Jelle P van der List
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States; Amsterdam UMC, University of Amsterdam Department of Orthopaedic Surgery, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Gregory S DiFelice
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, 535 E. 70th Street, New York, NY 10021, United States.
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Hantes M, Fyllos A, Papageorgiou F, Alexiou K, Antoniou I. Long-term clinical and radiological outcomes after multiligament knee injury using a delayed ligament reconstruction approach: A single-center experience. Knee 2019; 26:1271-1277. [PMID: 31575512 DOI: 10.1016/j.knee.2019.08.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/29/2019] [Accepted: 08/20/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To present long-term clinical and radiological results of patients treated with delayed reconstruction of multiligament knee injuries. METHODS Clinical data from 26 patients (21 men, five women, mean age 27.44 years) were retrospectively reviewed. Patients were evaluated at final follow-up with the use of: The International Knee Documentation Committee score (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity level, Lysholm Knee Scoring Scale, EuroQol subjective knee evaluation form, and KT-2000 arthrometer. Mean follow-up time was 105.38 months. Both knees were radiographically evaluated for osteoarthritis according to the Kellgren-Lawrence classification. RESULTS No patient required mobilization under anesthesia for adhesion lysis at the immediate or later postoperative duration. There was no statistically significant difference in range of motion between the healthy and operated sides (P = 0.713). Mean time to final range of motion regain was 2.1 ± 0.4 months. Average KT-2000 side-to-side (operated vs. normal) difference was 2.03 ± 1.1 mm, and the difference was statistically significant (P = 0.007). The mean IKDC, KOOS, Lysholm, Tegner, and Euroqol-5D postoperative scores were 82.13 ± 17.5, 84.59 ± 16.8, 90.6 ± 6.4, 4.3 ± 1.3, and 80 ± 11.74, respectively. Multiple regression analysis showed that age and follow-up time had significant effects on each clinical score, except for the Lysholm and Tegner scores. Progression of osteoarthritic changes of the reconstructed knee and its contralateral side was significantly different (P = 0.003). CONCLUSION Excellent clinical results were reported from this center's long-term experience with delayed ligament reconstruction, and osteoarthritic changes of reconstructed knees were recorded.
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Affiliation(s)
- Michael Hantes
- Department of Orthopedics, University Hospital of Larissa, Larissa, Greece.
| | - Apostolos Fyllos
- Department of Orthopedics, University Hospital of Larissa, Larissa, Greece
| | | | | | - Ioannis Antoniou
- Department of Orthopedics, University Hospital of Larissa, Larissa, Greece
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Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2710-2718. [PMID: 30631909 DOI: 10.1007/s00167-018-5317-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 12/04/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. METHODS In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. RESULTS Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0-3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. CONCLUSION In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. LEVEL OF EVIDENCE Prospective multicentre study, II.
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31
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Richards JT, Dickens JF. Multiligamentous Knee Injuries in the Military Tactical Athlete. Sports Med Arthrosc Rev 2019; 27:92-98. [PMID: 31361717 DOI: 10.1097/jsa.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multiligament knee injuries pose a significant challenge to military service members looking to return to active duty service. They represent a diverse injury pattern and recovery is often complicated by other ipsilateral extremity trauma and systemic injuries. There is a paucity of high-quality evidence guiding the treatment of these injuries. Despite this, orthopedic surgeons are tasked with a young, active, high demand population looking to maximize their recovery after these complex injuries. We present a synthesis of the available civilian and military literature and provide an evidence-based review with considerations specific to a military population.
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Affiliation(s)
- John T Richards
- USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
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32
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Vicenti G, Solarino G, Carrozzo M, De Giorgi S, Moretti L, De Crescenzo A, Moretti B. Major concern in the multiligament-injured knee treatment: A systematic review. Injury 2019; 50 Suppl 2:S89-S94. [PMID: 30797544 DOI: 10.1016/j.injury.2019.01.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review was to address the treatment of multiligament knee injuries in three major aspects, specifically (1) surgical versus nonoperative treatment, (2) repair versus reconstruction of injured ligamentous structures, and (3) early versus late surgery of damaged ligaments. METHODS Two independent reviewers performed a search on PubMed from 1966 to March 2016 using Levy's review as a starting-point, and the same terms "knee dislocation," "multiple ligament-injured knee," and "multiligament knee reconstruction." Study inclusion criteria were (1) levels I to IV evidence, (2) "multiligament" defined as disruption of at least 2 of the 4 major knee ligaments, (3) measures of functional and clinical outcomes, and (4) minimum of 12 months' follow-up, with a mean of at least 24 months. RESULTS Two high-level studies compared surgical treatment with nonoperative treatment. There was a higher Lyshom scores (85 v 67) in surgically treated patients, as well as higher excellent/good IKDC scores (69% v 64%) and return to sport (41% v 18%). There were four studies comparing repair with reconstruction of damaged structures, with similar mean Lysholm scores (84 v 84) and excellent/good IKDC scores (63% v 63%). Nevertheless, repair of the posterolateral corner had a higher failure rate (39% v 8%) and a lower return to sport activities (25% v 51%). Similarly, repair of the cruciates achieved decreased stability and range of motion. There were six studies comparing early surgery (within 3 weeks) with delayed surgery. Early treatment resulted in higher mean Lysholm scores (89 v 82) and a higher percentage of excellent/good IKDC scores (57% v 41%), as well as higher mean ROM (129° v 124°). CONCLUSIONS Our review suggests that the best treatment does not exist, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. Surgery must be performed within the first three weeks. Delayed ACL reconstruction allows to reduce arthrofibrosis rate.
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Affiliation(s)
- Giovanni Vicenti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
| | - Giuseppe Solarino
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
| | - Massimiliano Carrozzo
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy.
| | - Silvana De Giorgi
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
| | - Lorenzo Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
| | - Angelo De Crescenzo
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Italy
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Freychet B, Desai VS, Sanders TL, Kennedy NI, Krych AJ, Stuart MJ, Levy BA. All-inside Posterior Cruciate Ligament Reconstruction. Clin Sports Med 2019; 38:285-295. [DOI: 10.1016/j.csm.2018.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns. Knee Surg Sports Traumatol Arthrosc 2018; 26:3731-3737. [PMID: 29872868 DOI: 10.1007/s00167-018-5009-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection. METHODS Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31 years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging. RESULTS 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05). CONCLUSIONS Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury. LEVEL OF EVIDENCE IV.
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Ranger P, Senay A, Gratton GR, Lacelle M, Delisle J. LARS synthetic ligaments for the acute management of 111 acute knee dislocations: effective surgical treatment for most ligaments. Knee Surg Sports Traumatol Arthrosc 2018; 26:3673-3681. [PMID: 29691616 DOI: 10.1007/s00167-018-4940-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/04/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to describe the longitudinal outcomes of acute repair and augmentation for the reconstruction of dislocated knees, using LARS synthetic ligaments. METHODS Patients with a knee dislocation surgically treated using LARS synthetic ligament augmentation, with a minimum follow-up of 24 months, were enrolled between 1996 and 2014. Range of motion, Lachman, pivot shift, posterior drawer, step off sign, valgus, varus, KT-1000 arthrometer, Telos technique, IKDC, Lysholm, Tegner, and Meyers scores were obtained every 2 years up to 10 years. RESULTS Median age was 32.1 years (IQR 23.2-43.3) at time of surgery. Median time from trauma to surgery was 9 days and mean follow-up time was 6.6 years. Median questionnaire scores were: Lysholm 79.5 (IQR 65.0-89.0), Tegner 4.0 (IQR 3.7-6.0), Meyers 3.0 (IQR 3.0-4.0), and mean IKDC was 63.8 (SD 18.9). Median flexion and extension of the injured knee was 124° (IQR 115-129.5) and 0° (IQR - 5 to 0), respectively. Median KT-1000 differential was 0.7 mm (IQR 0.1-3.1) for ACL and 0.9 mm (IQR 0.2-1.4) for PCL. Mean differential for Telos was 2.5 mm (SD 5.8) for ACL, 4 mm (IQR 2-6.3) for PCL 30°, and 8.2 mm (SD 4.4) for PCL 90° (consistent with PCL laxity). More than 90% of patients had good anterior articular stability and > 60% of patients had good posterior articular stability. CONCLUSIONS Acute repair and augmentation of knee dislocations with LARS synthetic ligaments resulted in satisfactory outcomes for the ACL and collateral structures. Telos stress radiography showed PCL laxity in more than half of cases despite low laxity results with KT-1000. The perception of patients about knee function was sustained in time. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Pierre Ranger
- Orthopaedic Research Center, Hôpital du Sacré-Coeur de Montréal, 5400, boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, H2E 1S6, Canada
- Université de Montréal, 2900 bl. Edouard-Montpetit, Montreal, H3T 1J4, Canada
| | - Andréa Senay
- Orthopaedic Research Center, Hôpital du Sacré-Coeur de Montréal, 5400, boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Université de Montréal, 2900 bl. Edouard-Montpetit, Montreal, H3T 1J4, Canada
| | | | - Marc Lacelle
- Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, H2E 1S6, Canada
| | - Josée Delisle
- Orthopaedic Research Center, Hôpital du Sacré-Coeur de Montréal, 5400, boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada.
- Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, H2E 1S6, Canada.
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Sheth U, Sniderman J, Whelan DB. Early surgery of multiligament knee injuries may yield better results than delayed surgery: a systematic review. J ISAKOS 2018. [DOI: 10.1136/jisakos-2015-000021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ImportanceMultiligament knee injuries are rare, but can lead to significant functional limitations. Surgery has been shown to improve outcomes, however, there remains considerable debate regarding the optimal timing of surgery.ObjectiveWe aimed to determine whether early surgery in the setting of a multiligamentous knee injury was associated with superior functional outcomes when compared with surgery on a delayed basis.Evidence reviewA comprehensive literature search of the MEDLINE, EMBASE and PubMed databases was conducted up to March 2018. We identified studies with a sample size greater than 10 that included subjects with an injury to at least two of the four major knee ligaments and compared outcomes between early and delayed surgery. We assessed the methodological quality of each included study using the Newstead-Ottawa Scale.FindingsWe identified 11 eligible studies, including a total of 320 patients (195 early and 125 delayed). The mean time to surgery among patients treated early was 11.2 days in comparison to 294.8 days for the delayed group. Early surgery was found to have a statistically significantly higher Lysholm score (p<0.0001) and Meyers rating (p=0.02) when compared with delayed surgery. No statistically significant differences in International Knee Documentation Committee, Tegner Activity Scale, total arc of motion, loss of extension or loss of flexion were demonstrated between early and delayed surgery. Early surgery was noted to have a statistically significantly higher odds of requiring a manipulation under anaesthesia or arthrolysis (p=0.04), however, subsequent subgroup analysis showed no difference between early and delayed surgery when only studies employing an early range of motion protocol were pooled.Conclusions and relevanceBased on the current body of literature, which primarily consists of level IV evidence, early surgery in the setting of multiligament knee injury may provide better functional outcomes without compromising range of motion when using early postoperative mobilisation protocols. Further studies of higher quality are required to corroborate these findings.Level of evidenceLevel IV, systematic review.
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Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique. Knee Surg Sports Traumatol Arthrosc 2018; 26:1258-1265. [PMID: 28685303 DOI: 10.1007/s00167-017-4631-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Increasing importance has been placed on the posterolateral corner (PLC) in maintaining varus and rotational stability of the knee. The goal of this study was to evaluate knee function and clinical stability following a single-graft PLC reconstruction technique and identify factors associated with poor knee function. METHODS This study identified patients with a multi-ligament knee injury between 2006 and 2013. Patients who received a single-graft fibular collateral ligament and PLC reconstruction with a single-stage surgery during the study period and had a minimum follow-up of 2 years after surgery were included. Functional outcomes were assessed using Lysholm and IKDC scores. Varus and rotational knee laxity and range of motion were assessed using physical examination. RESULTS The final study cohort included 61 patients who underwent PLC reconstruction using a single-graft technique. The mean IKDC score was 74.1 (± 22.3) and the mean Lysholm score was 80.3 (± 21.8) at mean follow-up of 3.8 years (range 2-9 years). Mean range of motion at final follow-up measured from 0° to 126° [range flexion: 95-145, range extension: 0-5]. Fifty-eight patients (95%) had grade 0 varus laxity in full knee extension, and 54 patients (88.5%) had grade 0 varus laxity at 30° of knee flexion. Female gender was associated with a lower postoperative IKDC score (p = 0.04). CONCLUSION Surgical treatment of the PLC using a single-graft technique can result in satisfactory knee function and stable physical examination findings at minimum 2 years after surgery. Female gender was predictive of poor knee function after PLC reconstruction. Surgical treatment of PLC injuries should be individualized based on the timing of surgery, specific injured knee structures, and physical examination findings. This study helps validate the use of a single-graft technique for PLC reconstruction and can be used to help counsel patients about expected knee function after surgical treatment of PLC injuries. Level of evidence IV.
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Recurrent posterior knee laxity: diagnosis, technical aspects and treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2017; 25:3046-3052. [PMID: 27026027 DOI: 10.1007/s00167-016-4085-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Aim of this study was to determine the characteristics, clinical and radiological diagnostic methods of PCL isolated and combined knee injuries. METHODS One hundred and twelve patients with a recurrent posterior knee laxity were surgically treated. Clinical examination, MRI, Telos™ stress dynamic X-rays, KT-1000 measurements and the IKDC questionnaire were used to diagnose and evaluate these injuries. RESULTS Median follow-up was 4.5 years (2-11 years). Thirty-two patients (28.6 %) had an isolated posterior laxity, 53 (47.3 %) a posterior posterolateral laxity, 21 (18.7 %) a posterior posteromedial laxity and six (5.4 %) patients had a complex posterior and mediolateral laxity. Road traffic accidents and sports injuries were the main causes of trauma. The mean preoperative value of posterior tibial translation was 13.5 mm (SD 1.4) and the mean postoperative value was 4.4 mm (SD 1.7) as measured with the Telos device. In the cases with a concomitant ACL rupture, the mean preoperative value of anterior tibial translation was 6.5 mm (SD 1.3) and the mean postoperative value was 1.7 mm (SD 0.8). The mean pre- and postoperative IKDC scores were 74.5 (SD 4.2) and 87.9 (SD 3.1), respectively. Meniscal and/or cartilage injuries were found in 80 patients (71.4 %). CONCLUSIONS Recurrent posterior knee laxity can be restored with the one-stage PCL reconstruction using a quadriceps graft and reconstruction of the posteromedial-posterolateral lesions using the LaPrade techniques. The benefits of this study include enabling surgeons to accurately manage these injuries from a clinical perspective, and treating them with a specific surgical algorithm. LEVEL OF EVIDENCE III.
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Sanders TL, Johnson NR, Levy NM, Cole PA, Krych AJ, Stuart M, Levy BA. Effect of Vascular Injury on Functional Outcome in Knees with Multi-Ligament Injury: A Matched-Cohort Analysis. J Bone Joint Surg Am 2017; 99:1565-1571. [PMID: 28926386 DOI: 10.2106/jbjs.16.01540] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Multi-ligament knee injury (MLKI) associated with knee dislocation can result in vascular injury. The purpose of this study was to compare knee function after MLKI between patients with a vascular injury requiring popliteal artery bypass grafting and patients without vascular involvement. Additionally, factors associated with poor knee function in patients who had MLKI with vascular injury were evaluated. METHODS This retrospective study identified patients with an MLKI between 1992 and 2014. Each patient who had a concomitant vascular injury requiring bypass grafting (vascular cohort, n = 16; mean age, 30.3 years) was matched to 2 patients without a vascular injury (control cohort, n = 32; mean age, 31.4 years) on the basis of age, knee dislocation (KD) grade, and peroneal nerve status. Fifteen patients in the vascular cohort and 26 patients in the control cohort had an isolated knee injury. Functional outcomes were assessed with physical examination of range of motion and ligamentous stability as well as patient-reported outcome scores. RESULTS The vascular cohort had a mean Lysholm score of 62.5 points (range, 16 to 100 points) and a mean International Knee Documentation Committee (IKDC) score of 59.7 points (range, 14.9 to 100 points) at a mean (and standard deviation) of 8.3 ± 5.0 years after surgery. The control cohort had a mean Lysholm score of 86.4 points (range, 51.0 to 100.0 points) and a mean IKDC score of 83.8 points (range, 35.6 to 100.0 points) at a mean of 6.0 ± 4.0 years. The vascular cohort had significantly lower Lysholm (p = 0.001) and IKDC (p = 0.002) scores than the control cohort. A body mass index (BMI) of >30 kg/m was predictive of lower IKDC (p = 0.0009) and Lysholm (p = 0.0008) scores. CONCLUSIONS Patients who sustain an MLKI with an associated popliteal artery injury requiring bypass grafting have significantly lower knee function scores than patients without vascular involvement. This information can be used to help counsel patients with combined multiple ligament and popliteal artery injuries. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Thomas L Sanders
- 1Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota
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Lynch AD, Chmielewski T, Bailey L, Stuart M, Cooper J, Coady C, Sgroi T, Owens J, Schenck R, Whelan D, Musahl V, Irrgang J. Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury. Curr Rev Musculoskelet Med 2017; 10:328-345. [PMID: 28779476 DOI: 10.1007/s12178-017-9425-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation. RECENT FINDINGS MLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested. Consideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.
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Affiliation(s)
- Andrew D Lynch
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA.
| | | | - Lane Bailey
- University of Texas at Houston, Houston, TX, USA
| | | | | | - Cathy Coady
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Johnny Owens
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | | | - Volker Musahl
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
| | - James Irrgang
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
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Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc 2017; 25:524-531. [PMID: 27000392 DOI: 10.1007/s00167-016-4067-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 02/23/2016] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of this study was to analyse the clinical outcomes of multiligament injured knees with respect to the medial collateral ligament and posteromedial corner (PMC) repair or reconstruction versus the posterolateral corner (PLC) reconstruction in patients operated according to a codified surgical protocol. METHODS Patients were divided into two groups depending on whether PMC or PLC was injured. Cruciate ligaments as well as PMC or PLC were reconstructed/repaired in a one-stage procedure. At minimum of 1-year follow-up, objective and subjective International Knee Documentation Committee (IKDC) forms, Lysholm score and sports activity level were recorded. RESULTS Thirty-nine patients with a median follow-up time of 57 months (range 12-129) were reviewed. No significant difference was found for functional scores between acute PMC and PLC subgroups. In Group PLC, subjective outcomes tend to be better in the acute than in chronic reconstruction subgroup. CONCLUSIONS A one-stage protocol with early surgery rather than delayed reconstruction produced better clinical outcomes whatever the injured collateral ligament, medial or lateral. In the future, early and chronic reconstructions as well as each injury pattern should be considered as separate entities in studies on multiple ligament injured knees to reach a better level of evidence. LEVEL OF EVIDENCE IV.
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Abstract
BACKGROUND Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts. MATERIALS AND METHODS Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury. RESULTS Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries. CONCLUSION Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.
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Affiliation(s)
- Ankit Goyal
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India,Address for correspondence: Dr. Ankit Goyal, Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi - 110 029, India. E-mail:
| | - Milind Tanwar
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
| | - Deepak Joshi
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
| | - Deepak Chaudhary
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
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Abstract
Knee dislocations are devastating when they occur on the athletic field or secondary to motor sports. The complexity of presentation and spectrum of treatment options makes these injuries unique and extremely challenging to even the most experienced knee surgeons. An astute appreciation of the treatment algorithm is essential to plan individualized management since no two complex knee dislocations are ever the same. Moreover, attention to detail and finesse of surgical technique are required to obtain a good functional result and ensure return to play. Over the past 10 years, our service has treated 43 competitive sportsmen with knee dislocations, and this experience forms the basis for this narrative review.
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Affiliation(s)
- Dinshaw N Pardiwala
- Centre for Sports Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India,Address for correspondence: Dr. Dinshaw N Pardiwala, Kokilaben Dhirubhai Ambani Hospital, Four Bungalows, Andheri (W), Mumbai - 400 053, Maharashtra, India. E-mail:
| | - Nandan N Rao
- Centre for Sports Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
| | - Karthik Anand
- Centre for Sports Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
| | - Alhad Raut
- Centre for Sports Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
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Zhang C, Li J. Comments on: Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator by Angelini FJ, Helito CP, Bonadio MB, da Mota E Albuquerque RF, Pecora JR, Camanho GL published in Orthop Traumatol Surg Res 2015 Feb;101(1):77-81. Orthop Traumatol Surg Res 2016; 102:139. [PMID: 26774905 DOI: 10.1016/j.otsr.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/01/2015] [Indexed: 02/05/2023]
Affiliation(s)
- C Zhang
- Sichuan University, West China Hospital, Sichuan, China
| | - J Li
- Guo Xue Xiang, Chengdu No.37, 610041 Sichuan, China.
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