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Blaber OK, DeFoor MT, Aman ZA, McDermott ER, DePhillipo NN, Dickens JF, Dekker TJ. Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis. JBJS Rev 2024; 12:01874474-202406000-00007. [PMID: 38913807 DOI: 10.2106/jbjs.rvw.24.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.
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Affiliation(s)
- Olivia K Blaber
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Zachary A Aman
- Department of Orthopaedics, Duke University, Durham, North Carolina
| | - Emily R McDermott
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | | | | | - Travis J Dekker
- Department of Orthopaedics Surgery, 10th Medical Group, US Air Force Academy, Colorado Springs, Colorado
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Tan D, Ferrante S, DiBartola A, Magnussen R, Welder E, Crouser N, Kaeding C, Flanigan D, Duerr RA. Increased Body Mass Index is Associated with Worse Mid- To Long-Term Patient Outcomes after Surgical Repair of Multiligamentous Knee Injuries. J Knee Surg 2024; 37:498-504. [PMID: 37879357 DOI: 10.1055/a-2198-8068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
We evaluated the relationship between elevated body mass index (BMI) and mid- to long-term outcomes after surgical treatment of multiligamentous knee injury (MLKI). Records identified patients treated surgically for MLKI at a single institution. Inclusion criteria: minimum 2 years since surgery, complete demographics, surgical data, sustained injuries to two or more ligaments in one or both knees, and available for follow-up. Patients were contacted to complete patient-reported outcomes assessments and were classified according to mechanism of injury. Multivariate logistic regression analysis was used to predict the impact of BMI on outcome scores. A total of 77 patients (72.7% male) were included with a mean age at the time of injury of 29.4 ± 11.0 years and a mean BMI of 30.5 ± 9.4 kg/m2. The mean length of follow-up was 7.4 years. For each 10 kg/m2 increase in BMI, there is a 0.9-point decrease in Tegner activity scale (p = 0.001), a 5-point decrease in Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain (p = 0.007), a 5-point decrease in KOOS-ADL (p = 0.003), a 10-point decrease in KOOS-QOL (p = 0.002), and an 11-point decrease in KOOS-Sport (p = 0.002). There were no significant correlations with BMI and Pain Catastrophizing Scale or Patient Health Questionnaire scores. Increasing BMI has a negative linear relationship with mid- to long-term clinical outcomes including pain, ability to perform activities of daily living, quality of life, and ability to perform more demanding physical activity after MLKI. BMI does not appear to have a significant relationship with knee swelling and mechanical symptoms or patients' mental health.
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Affiliation(s)
- Danny Tan
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stephanie Ferrante
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alex DiBartola
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert Magnussen
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric Welder
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nisha Crouser
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christopher Kaeding
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - David Flanigan
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, Jameson Crane Sports Medicine Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Zhong J, Lee NJ, Crutchfield C, Mueller J, Ahmad C, Trofa D, Lynch TS. Perioperative outcomes in isolated versus multiligamentous anterior cruciate ligament reconstruction: a retrospective cohort analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1597-1607. [PMID: 38363347 DOI: 10.1007/s00590-024-03848-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE The outcomes of anterior cruciate ligament reconstruction in the setting of multiligamentous knee injury (M-ACLR) have not been well characterized compared to isolated ACLR (I-ACLR). This study aims to characterize and compare short-term outcomes between I-ACLR and M-ACLR. METHODS This is a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017. Current Procedural Terminology codes were used to identify and compare elective I- and M-ACLR patients, excluding patients undergoing concomitant meniscal or chondral procedures. Patient demographics and outcomes after I- and M-ACLR were compared using bivariate analysis. Multiple logistic regression analyzed if multiligamentous ACLR was an independent risk factor for adverse outcomes. RESULTS There was a total of 13,131 ACLR cases, of which 341 were multiligamentous cases. The modified fragility index-5 was higher in multiligamentous ACLR (p < 0.001). Multiligamentous ACLR had worse perioperative outcomes, with higher rate of all complications (3.8%, p = 0.013), operative time > 1.5 h (p < 0.001), length of stay (LOS) ≥ 1 day (p < 0.001), wound complication (2.1%, p = 0.001), and intra- or post-op transfusions (p < 0.001). In multiple logistic regression, multiligamentous ACLR was an independent risk factor for LOS ≥ 1 (odds ratio [OR] 5.8), and intra-/post-op transfusion (OR 215.1) and wound complications (OR 2.4). M-ACLR was not an independent risk factor for any complication, reoperation at 30 days, readmission, urinary tract infection (UTI), or venous thromboembolism (VTE). CONCLUSION M-ACLR generally had worse outcomes than I-ACLR, including longer LOS, need for perioperative transfusions, and wound complications.
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Affiliation(s)
- Jack Zhong
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA.
- Department of Orthopaedic Surgery, New York University Langone Health, New York, 10010, USA.
| | - Nathan J Lee
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - Connor Crutchfield
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - John Mueller
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - Christopher Ahmad
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - David Trofa
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - T S Lynch
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, 48202, USA
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Li ZI, Green JS, Chalem I, Triana J, Rao N, Hughes AJ, Campbell KA, Jazrawi LM, Medvecky MJ, Alaia MJ. Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up. Knee 2024; 46:89-98. [PMID: 38070381 DOI: 10.1016/j.knee.2023.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old. METHODS This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores. RESULTS Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012). CONCLUSIONS Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports. LEVEL OF EVIDENCE IV, Case series.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States.
| | - Joshua S Green
- Frank H. Netter School of Medicine at Quinnipiac University, North Haven, CT, United States
| | - Isabel Chalem
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Jairo Triana
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Naina Rao
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Andrew J Hughes
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
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Schemitsch GW, Hauer TM, Hoit G, Al Hulaibi FH, Hu SY, Etemad-Rezaie A, Pinsker EB, Khan RM, Coulter O, Whelan DB. Comparing the Interobserver Reliability of 4 Methods Used to Measure Knee Laxity on Coronal Plane Stress Radiograph. Orthop J Sports Med 2024; 12:23259671231215740. [PMID: 38188619 PMCID: PMC10768591 DOI: 10.1177/23259671231215740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 01/09/2024] Open
Abstract
Background Varus and valgus knee stress radiographs provide valuable information in the pre- and postoperative evaluation of joint laxity in patients with multiligament knee injuries (MLKIs). Purpose To review the literature for described techniques of quantifying laxity on coronal stress radiographs of the knee and identify the most reliable method. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods A thorough literature search using the MEDLINE and Embase databases identified 4 studies with distinct methods for objectively measuring laxity on varus and valgus stress radiographs: Heesterbeek et al (2008), Jacobsen (1976), LaPrade et al (2004), and Sawant et al (2004). To compare these methods, 200 coronal plane stress radiographs from 50 patients with MLKIs were retrospectively reviewed from an MLKI database at a single institution. The amount of varus and valgus laxity on each radiograph was measured independently by 4 reviewers using each method. Intraclass correlation coefficients (ICCs) with 95% CIs were calculated to assess the interobserver reliability of each method overall and the varus and valgus measurements individually. Results For all 4 methods, the overall interobserver reliability was considered at least moderate. The method by Heesterbeek et al proved to have the highest interrater reliability in all domains-overall (ICC, 0.87 [95% CI, 0.85-0.90]), valgus (ICC, 0.83 [95% CI, 0.78-0.88]), and varus (ICC, 0.87 [95% CI, 0.83-0.90])-demonstrating good to excellent reliability both overall and in varus measurements and showing good reliability in valgus measurements. The method by Sawant et al demonstrated good reliability in valgus measurements. All other measures demonstrated moderate reliability. Conclusion Available methods for measuring knee joint laxity on varus and valgus knee stress radiographs in patients with MLKIs demonstrated moderate to good interobserver reliability. The method described by Heesterbeek et al proved to have the highest reliability overall as well as in measurements on varus and valgus views individually.
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Affiliation(s)
| | - Tyler M. Hauer
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Graeme Hoit
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Shu Yang Hu
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ali Etemad-Rezaie
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ellie B. Pinsker
- St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ryan M. Khan
- St. Michael’s Hospital, Division of Orthopaedic Surgery, Toronto, Ontario, Canada
| | - Owen Coulter
- Kinesiology, Dalhousie University, Nova Scotia, Canada
| | - Daniel B. Whelan
- St. Michael’s Hospital, Division of Orthopaedic Surgery, Toronto, Ontario, Canada
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Boos AM, Wang AS, Hevesi M, Krych AJ, Stuart MJ, Levy BA. Long-term Outcomes After Surgical Reconstruction of Multiligamentous Knee Injuries: Results at Minimum 10-Year Follow-up. Orthop J Sports Med 2024; 12:23259671231223188. [PMID: 38222026 PMCID: PMC10787528 DOI: 10.1177/23259671231223188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/31/2023] [Indexed: 01/16/2024] Open
Abstract
Background Multiligamentous knee injuries (MLKIs) are devastating injuries with concomitant injuries that complicate treatment and recovery. Short-term studies have shown satisfactory patient outcomes after surgical treatment; however, evaluations of long-term outcomes remain scarce. Purpose To evaluate long-term outcomes after surgically reconstructed MLKIs and further investigate the relationship between patient age on clinical outcomes. Study Design Case series; Level of evidence, 4. Methods A total of 55 knees (age, 36 ± 11 years; 24% female subjects) who underwent surgical reconstruction for MLKI between 1992 and 2013 met the study inclusion criteria and were evaluated with postoperative patient-reported outcomes (PROs) including International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) for pain, Forgotten Joint Score, subjective improvement ratings and surgery satisfaction, and Tegner activity scores. PRO scores, revision, and conversion to arthroplasty were analyzed using descriptive statistics, linear regression, Wilcoxon rank-sum, and Fisher exact tests. Results At final follow-up (mean, 15 ± 5 years; range, 10-31 years), 67% of the cohort reported subjective improvement in their knee, and 82% reported satisfaction with their surgery. Compared with preoperative scores, there were significant improvements in postoperative VAS pain at rest in the full cohort, age ≤30-year cohort, and age >30-year cohort (4 ± 1 vs 2 ± 2; 4 ± 1 vs 2 ± 3; 4 ± 1 vs 1 ± 2, respectively; P≤ .029 for all) but significant reductions in Tegner scores (6 ± 3 vs 4 ± 2; 7 ± 2 vs 5 ± 2; 5 ± 2 vs 3 ± 1; P≤ .003 for all). Younger patients had higher postoperative Tegner scores than older patients (5 ± 2 vs 3 ± 1, respectively; P = .003), but no other differences in PROs were observed based on age. At a mean 15-year follow-up, 3.6% of the cohort underwent revision ligament surgery and 10.9% required arthroplasty. Conclusion The majority of the cohort reported modest subjective improvement and were satisfied with their surgery. Gradual but expected age-related decreases in Tegner scores were observed, and some patients demonstrated continued symptomatic and functional limitations, but mean PRO scores remained satisfactory. Revision surgery and conversion to arthroplasty were not commonly required.
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Affiliation(s)
- Alexander M. Boos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen S. Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Özbek EA, Dadoo S, Grandberg C, Runer A, Cong T, Hughes JD, Irrgang JJ, Musahl V. Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:4448-4457. [PMID: 37486368 DOI: 10.1007/s00167-023-07514-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness. METHODS This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries. RESULTS Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.). CONCLUSION Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Emre Anil Özbek
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
- Department of Orthopedics and Traumatology, Ibni Sina Hospital, Ankara University, Ankara, Turkey.
| | - Sahil Dadoo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Armin Runer
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department for Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ting Cong
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Medvecky MJ, Kahan JB, Richter DL, McLaughlin WM, Moran J, Islam W, Miller MD, Wascher DC, Treme GP, Campos TVO, Held M, Schenck RC. Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method. J Bone Joint Surg Am 2023; 105:1182-1192. [PMID: 37352339 DOI: 10.2106/jbjs.23.00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2023]
Abstract
BACKGROUND Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Dustin L Richter
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - William M McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Wasif Islam
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel C Wascher
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Gehron P Treme
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Túlio V O Campos
- Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Michael Held
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
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9
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Poploski KM, Lynch AD, Burns TC, Harner CD, Levy BA, Owens BD, Richter DL, Schenck RC, Musahl V, Irrgang JJ. Presentation and Surgical Management of Multiple Ligament Knee Injuries: A Multicenter Study from the Surgical Timing and Rehabilitation (STaR) Trial for MLKIs Network. J Bone Joint Surg Am 2023; 105:607-613. [PMID: 36827383 DOI: 10.2106/jbjs.20.02051] [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: 02/26/2023]
Abstract
BACKGROUND Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system. METHODS This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively. RESULTS A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range [IQR], 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication. CONCLUSIONS A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kathleen M Poploski
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew D Lynch
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Rehabilitation and Movement Science, Rutgers University, New Brunswick, New Jersey
| | | | | | | | | | - Dustin L Richter
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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10
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Vascular Injury After Knee Dislocation: A Meta-Analysis Update. J Am Acad Orthop Surg 2023; 31:e198-e206. [PMID: 36730697 DOI: 10.5435/jaaos-d-22-00339] [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] [Received: 04/05/2022] [Accepted: 08/30/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Multisystem injuries affecting vasculature and nerves can be detrimental sequelae of knee dislocations (KDs). The purpose of this study was to provide an update of the current literature since the conducted search used in the publication of Medina et al on May 3, 2013, to evaluate (1) the frequency of vascular and neurologic injury after KD, (2) the frequency with which surgical intervention was conducted for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury. METHODS A two-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the MEDLINE database. Frequency of vascular injury, surgical intervention, and amputation after KD were analyzed. Diagnostic modalities used in the acute-care setting were also evaluated. RESULTS Nineteen articles were analyzed for a total of 37,087 KDs. Of these, 10.7% sustained vascular injuries and 19.6% sustained nerve injuries. Overall, 62.2% of patients with vascular injury underwent surgical repair and 2.2% limbs resulted in amputation. Angiography was the most frequently used diagnostic modality (91.7%). DISCUSSION This review updates our understanding on the clinical implications of KDs including frequency of vascular injury (10.7%), amputation (2.2%), and nerve injuries (19.6%). Compared with prior literature, there was an increased prevalence of KD1 (32.4%) and lateral KDs (80.4%). Most vascular injuries after KD undergo surgical repair (62.2%).
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11
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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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12
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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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13
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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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14
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Bi AS, Mojica ES, Markus DH, Blaeser AM, Kahan J, Moran J, Jazrawi LM, Medvecky MJ, Alaia MJ. Risk of Postoperative Stiffness Following Multiligamentous Knee Injury Surgery Is Not Affected by Obesity: A Multicenter Study. Arthroscopy 2022; 38:3175-3181. [PMID: 35777677 DOI: 10.1016/j.arthro.2022.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to examine the relationship between obesity and postoperative stiffness following surgical management of multiligamentous knee injuries (MLKIs) using a large two-center cohort, by both 1) using binary cutoffs at various body mass indexes (BMIs) and 2) a linear regression model. METHODS 190 consecutive patients who underwent surgical management of MLKIs between January 2001 and March 2020 were reviewed at two level 1 academic trauma centers. Patient demographics, surgical characteristics, and manipulation under anesthesia (MUA)/lysis of adhesions (LOA) were reviewed. Patients were stratified by obesity grades: grade 1 (BMI 30 to <35) grade 2 (BMI 35 to <40); grade 3 (BMI >40), and compared with a nonobese comparison group with BMI <30. Multivariate logistic regressions were performed, including the covariates of age, gender, BMI, acute versus chronic injury, external fixator, vascular injury, knee dislocation, and Schenck Classification. Fisher's exact test was used to compare rate of MUA between grades of obesity. Analyses were performed with R. Statistical significance was set at P < .05. RESULTS The mean BMI of the cohort was 29.2 kg/m2. The mean overall follow-up was 27.2 ± 7.2 months (range: 14-142 months). There were 55 (29.1%) MUA procedures observed at a mean 3.77 ± 2.18 months (range: 1.8-9.7 months) after final MLKI surgery. No significant difference was found in BMI of patients who underwent a MUA compared to patients who did not (30.2 vs 28.8; P = .67). There was no significant difference in rate or time to MUA following MLKI surgery between groups, with logistic regression demonstrating no significance (P = .144). Use of external fixation at the index surgery (OR = 3.3 [95% CI: 2.2, 4.7; P < .0001]) and vascular injury (OR = 6.2 [95% CI: 1.8, 24.5; P = .005]) were found to be independent predictors for need for MUA. CONCLUSION No difference in risk for postoperative stiffness requiring MUA following surgery for MLKI was found based on BMI. At all BMI levels, there were no significant increase in need for postoperative MUA, suggesting at minimum a neutralizing effect of obesity on postoperative stiffness. In addition, patients with external fixator use and vascular injury at index surgery were found to be at significantly higher risk for postoperative stiffness requiring MUA following surgery for MLKI. Surgeons should be aware of the risk factors for arthrofibrosis when proceeding with surgical repair or reconstruction of two or more ligaments of the knee. LEVEL OF EVIDENCE III, multicenter retrospective cohort study.
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Affiliation(s)
- Andrew S Bi
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A..
| | - Edward S Mojica
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A
| | - Danielle H Markus
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A
| | - Anna M Blaeser
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A
| | - Joseph Kahan
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - Jay Moran
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - Laith M Jazrawi
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A
| | - Michael J Medvecky
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, U.S.A
| | - Michael J Alaia
- New York University Langone Health, Orthopedic Surgery, Division of Sports Medicine, New York, New York, U.S.A
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15
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Held M, Scheepers W, von Bormann R, Wascher DC, Richter DL, Schenck RC, Harner CD. Inclusion of open injuries in an updated Schenck classification of knee dislocations based on a global Delphi consensus study. J ISAKOS 2022; 7:95-99. [PMID: 35604318 DOI: 10.1016/j.jisako.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/05/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. METHODS A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. RESULTS Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). CONCLUSION Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.
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Affiliation(s)
- Michael Held
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town, Western Cape, South Africa.
| | - Waldo Scheepers
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town, Western Cape, South Africa.
| | - Richard von Bormann
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town Sports & Orthopaedics Clinic, Cape Town, Western Cape, South Africa.
| | - Daniel C Wascher
- University of New Mexico School of Medicine, Department of Orthopaedics, Albuquerque, New Mexico, USA.
| | - Dustin L Richter
- University of New Mexico Health Sciences Center, Department of Orthopaedics & Rehabilitation, Albuquerque, New Mexico, USA.
| | - Robert C Schenck
- University of New Mexico School of Medicine, Department of Orthopaedics, Albuquerque, New Mexico, USA.
| | - Christopher D Harner
- University of Texas Health Sciences Center Houston, Department of Orthopaedics, Houston, Texas, USA.
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16
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Lau BC, Varsheya K, Morriss N, Wickman J, Kirkendall D, Abrams G. Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment. Arthrosc Sports Med Rehabil 2022; 4:e1659-e1666. [PMID: 36312718 PMCID: PMC9596897 DOI: 10.1016/j.asmr.2022.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries. Methods The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ2 tests, and Fisher exact tests were used with an α level of .05 set as significant. Results We identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group. Conclusions Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured. Level of Evidence Level III, retrospective cohort study.
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17
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Wascher DC, Schenck RC, Treme GP, Richter DL. The Knee Dislocation Classification System Is Simple, Reproducible, and Allows Communication among Surgeons. J Knee Surg 2022; 35:1044-1045. [PMID: 33184799 DOI: 10.1055/s-0040-1721036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Daniel C Wascher
- Department of Orthopaedic Surgery, The University of New Mexico, Albuquerque, New Mexico
| | - Robert C Schenck
- Department of Orthopaedic Surgery, The University of New Mexico, Albuquerque, New Mexico
| | - Gehron P Treme
- Department of Orthopaedic Surgery, The University of New Mexico, Albuquerque, New Mexico
| | - Dustin L Richter
- Department of Orthopaedic Surgery, The University of New Mexico, Albuquerque, New Mexico
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18
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The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury. Skeletal Radiol 2022; 51:981-990. [PMID: 34557951 DOI: 10.1007/s00256-021-03907-4] [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: 06/17/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.
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Shamrock AG, Hall JR, Hajewski CJ, An Q, Duchman KR. Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction. J Knee Surg 2022; 35:560-565. [PMID: 32898906 DOI: 10.1055/s-0040-1716378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p < 0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p < 0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.
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Affiliation(s)
- Alan G Shamrock
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - James R Hall
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Christina J Hajewski
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Qiang An
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Kyle R Duchman
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Bozkurt I, Ozdemir G, Bingol O, Kilic E, Korucu A, Ocguder DA. Demographic analysis of knee dislocation: A rare mechanism of injury. J Orthop Surg (Hong Kong) 2022; 29:23094990211061253. [PMID: 34872397 DOI: 10.1177/23094990211061253] [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] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The aim of this study was to present to the literature a rare injury mechanism that causes knee dislocation (KD) and describe its characteristics. METHODS A retrospective review of patients with KD who were treated between January 2014 and December 2019 at our hospital was performed. Patients with KD due to rotavator machine injury were included in Group 1 and all patients with KD due to other etiological reasons were included in Group 2. Patients' age, gender, side, injury mechanism, time to surgery, length of stay (LOS), operation time, follow-up time, neurological injury status, vascular injury status, open injury status, and surgical interventions were evaluated. RESULTS A total of 34 patients were evaluated in the study. There was no statistically significant difference between the groups in terms of age, gender, side, or follow-up time (p = .915, p = 1.000, p = .682, p = .374, respectively). However, LOS and time to surgery were statistically significantly longer in Group 1 (p = .037, p = .010, respectively). Moreover, neurovascular damage was statistically significantly more common in Group 1. CONCLUSION As a rare injury mechanism for KD, rotavator machine injuries cause more neurovascular injuries in patients compared to other injury mechanisms and increase the time to surgery and LOS due to preoperative soft tissue damage.
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Affiliation(s)
- Ibrahim Bozkurt
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Guzelali Ozdemir
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Olgun Bingol
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Enver Kilic
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Alperen Korucu
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Durmus Ali Ocguder
- Medical Faculty, Orthopedics and Traumatology Department, 442146Yildirim Beyazit University, Cankaya, Ankara, Turkey
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Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution. Arthroscopy 2022; 38:427-438. [PMID: 34052381 DOI: 10.1016/j.arthro.2021.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 05/05/2021] [Accepted: 05/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We sought to determine the rate of intraoperative and early postoperative (90-day) complications of multiligamentous knee reconstruction surgeries, both medical and surgical, and associated variables from the 15-year experience of a single academic institution. METHODS Patients treated at a single academic institution between 2005 and 2019 who underwent multiligament knee surgery were identified. Inclusion criteria included intervention with 2+ ligament reconstructions performed concurrently, and more than 90 days postoperative follow-up. Exclusion criteria included revision ligamentous knee surgery. Patient demographics, mechanism of injury, and associated injuries of patients with intraoperative and postoperative complications, time from injury to multiligamentous knee reconstruction, and surgical data, including tourniquet time, procedure time, and type of procedures performed were retrospectively recorded. RESULTS 301 knees in 296 patients met the eligibility criteria. There were 11 intraoperative complications in 9 knees (rate of 3%) and 136 postoperative complications in 90 knees (rate of 30%). Shorter time from injury to date of surgery was associated with arthrofibrosis (P = .001) and superficial wound infections (P = .015). Concurrent head injuries were associated with less complications (P = .029). Procedural time >300 minutes was associated with intraoperative blood transfusions (P > .05), deep infections (P = .003) and arthrofibrosis (P = .012). Inside-out meniscal repair was associated with superficial and deep infections (P = .006 and .0004). Tibial-based posterolateral corner (PLC) reconstruction was associated with symptomatic hardware (P = .037) and arthrofibrosis (P = .019) in comparison with fibular-based PLC reconstruction. Posterior cruciate ligament (PCL) reconstruction was associated with deep infections (P = .015), arthrofibrosis (P = .003), and postoperative blood transfusions (P = .018). CONCLUSION Our 15-year data reveal there is a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery. Surgeons should be wary of the increased intraoperative and postoperative complications associated with longer procedure times, inside-out meniscal repair, tibia-based PLC reconstruction, PCL reconstruction, and shorter time to surgery. LEVEL OF EVIDENCE Case series: IV.
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22
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Paterson-Byrne PA, Wilson WT, Hopper GP, MacKay GM. Primary repair of multiligament knee injury with InternalBrace ligament augmentation. BMJ Case Rep 2022; 15:e247173. [PMID: 34983813 PMCID: PMC8728444 DOI: 10.1136/bcr-2021-247173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/04/2022] Open
Abstract
Multiligament injury of the knee usually occurs as a result of high-energy trauma causing tibiofemoral dislocation. These are rare but potentially limb-threatening injuries, frequently involving nerve or arterial damage and often leading to severe complex instability. Management generally favours surgical reconstruction of the affected ligaments, with controversy regarding optimal treatment. We present a severe multiligament knee injury (Schenk classification KD-IV involving both cruciate and both collateral ligaments) in a competitive showjumper. A combined arthroscopic/open technique of single-stage surgical repair and suture augmentation was used, repairing all affected ligaments. The patient made an excellent recovery, returning to work after 12 weeks and riding after 22 weeks. After 5-year follow-up, she has regained her previous level of competition without subsequent injury. Multiligament repair with suture augmentation is a viable approach to the management of knee dislocation injuries. We propose that this could provide superior outcomes to traditional reconstruction techniques using autograft or synthetic reconstruction.
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23
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External fixation increases complications following surgical treatment of multiple ligament knee injuries. Knee Surg Sports Traumatol Arthrosc 2022; 30:161-166. [PMID: 33638684 DOI: 10.1007/s00167-021-06508-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of this study was to review post-operative complications after surgical intervention of MLKIs within the first 6 months to be better able to counsel patients before surgical intervention. METHODS All patients who underwent surgical reconstruction for a MLKI at one institution from 2009 to 2018 were included in this study. A retrospective review was performed of all patients and post-operative complications were recorded, including motion loss (which included > 10 degree flexion loss or > 3 degree extension loss), hematoma formation, infection, iatrogenic vascular or nerve injury, deep vein thrombosis (DVT), pulmonary embolism (PE), skin lesions, symptomatic hardware, recurrent ligamentous laxity, and need for additional surgery. Knee ligament injuries were classified based on the Schenck Knee Dislocation (KD) Classification. RESULTS A total of 136 patients were included in this study, 83 with KD I injuries, 40 with KD III injuries, 9 with KD IV injuries, and 4 with KD V injuries. Of these total patients, 48 (35.5%) sustained a post-operative complication: 11 out of 133 (8.3%) from 0 to 1 week, 46 out of 132 (34.8%) from 1 week to 1 month, 28 out of 124 (22.6%) from 1 to 3 months, and 26 out of 121 (21.5%) from 3 to 6 months. Out of the total complications, 99 (78.5%) occurred at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common complication was motion loss in 39 (28.6%) patients. There was a significant difference in mean number of complications between the KD I and KD III groups, as well as the KD III and KD IV-V groups. There was no significant difference in the overall prevalence of post-operative complications or occurrence of motion loss with KD grade. CONCLUSION The main finding of this study was 48 (35.5%) patients sustained a complication after surgical treatment of MLKIs, with 99 (78.5% of all complications) complications occurring at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common post-operative complication was motion loss in 39 (28.6%) patients. The KD grade was not associated with post-operative development of motion loss, but KD III had a significantly greater mean number of complications than KD I or KD IV-V grades. LEVEL OF EVIDENCE IV.
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Patel NK, Hadley CJ, Leite S, Brahmabhatt S, Mazur D, Parvizi J, Ciccotti MG. Knee Arthroplasty with Prior Ligamentous Knee Surgery: A Matched Case-Control Study. J Knee Surg 2021; 34:1539-1544. [PMID: 32434235 DOI: 10.1055/s-0040-1710375] [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
We aimed to evaluate the timing, operative details, and outcomes of total knee arthroplasty (TKA) in patients with prior ligamentous knee surgery (LKS). All consecutive patients undergoing TKA with prior LKS at a single institution were identified from a large prospectively collected database. Patients were matched on a 2:1 basis according to age, sex, and body mass index to a group of patients without previous LKS undergoing primary TKA. A total of 39 patients with prior LKS and a mean age of 55.6 years (range: 42.8-76.4) were identified and matched with 78 patients without LKS with a mean age of 57.6 years (range: 44.0-79.4) undergoing primary TKA (p = 0.24). Significantly more posterior stabilized implants were used in patients with LKS compared with control patients (29 [74.3%] vs. 27 [34.6%], p < 0.001). In the LKS group, 15 patients (38.4%) required hardware removal. Postoperative complications and rate of further surgery were greater in the LCS group, but the difference was not significant (10.6 vs. 6.4%, p = 0.25). Mean difference in pre- to postoperative knee flexion and clinical outcome scores (12-item Short Form Survey, International Knee Documentation Committee, and Oxford Knee Score) were similar between the two groups, with no cases of loosening or osteolysis. TKA with prior LKS often warranted hardware removal and generally more constrained implants. Those patients with prior LKS undergoing subsequent TKA have higher complication rates and an increased rate of subsequent surgery related to post-TKA stiffness.
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Affiliation(s)
- Nirav K Patel
- Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia
| | - Christopher J Hadley
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samantha Leite
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Shyam Brahmabhatt
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Donald Mazur
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael G Ciccotti
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Maheshwer B, Drager J, John NS, Williams BT, LaPrade RF, Chahla J. Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature. Am J Sports Med 2021; 49:3443-3452. [PMID: 33502894 DOI: 10.1177/0363546520981697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. PURPOSE To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. RESULTS After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). CONCLUSION Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.
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Affiliation(s)
| | - Justin Drager
- Tufts University Medical Center, Boston, Massachusetts, USA
| | - Nalin S John
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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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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Fakhre E, Connors KM, Curley AJ, Argintar EH. Outcomes of Prophylactic Negative Pressure Wound Therapy in Multiligament Knee Reconstruction. Orthopedics 2021; 44:187-191. [PMID: 34039213 DOI: 10.3928/01477447-20210415-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Negative pressure wound therapy (NPWT) has shown promise in reducing postoperative complications in several applications in orthopedic surgery, including trauma and arthroplasty. To the authors' knowledge, no study has evaluated its use in multiligament knee reconstruction. Multiligament knee reconstruction is often fraught with arthrofibrosis and wound-healing complications. This retrospective study assessed complications requiring reoperation in patients who underwent multiligament knee reconstruction and received either NPWT (n=14) or a dry sterile dressing (DSD) (n=44). There were significantly more reoperations in the cohort of patients who received a DSD (P=.011). Arthrofibrosis in particular showed a significantly lower rate of occurrence in the NPWT cohort compared with the DSD cohort (P=.025). There was a trend toward a lower infection rate in the NPWT cohort (P=.322). This study provides evidence that NPWT may be effective in reducing reoperation after multiligament knee reconstruction. Further investigations with prospective studies are needed to draw stronger conclusions about the benefits of NPWT. [Orthopedics. 2021;44(3):187-191.].
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Multi-ligament reconstructions as a risk factor for adverse outcomes in arthroscopic surgery. Knee Surg Sports Traumatol Arthrosc 2021; 29:1913-1919. [PMID: 32902685 DOI: 10.1007/s00167-020-06252-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Multi-ligament knee injuries are a serious consequence of knee dislocation with a poorly evaluated post-operative complication profile due to low incidence. The aim of this study is to assess the risk of adverse post-operative events associated with operative management of multi-ligament knee injuries. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing surgical procedures for multi-ligament knee injuries from 2006 to 2016 using Current Procedural Terminology codes. We evaluated data on patient demographics and used a propensity score algorithm to adjust for baseline differences in these patients and developed univariate and multivariate logistic regression models to assess effects on minor and severe 30-day post-operative complications. RESULTS We identified 444 patients in this database who underwent multi-ligament knee reconstructions between 2006 and 2016. After propensity matching, minor and major adverse post-operative events were more frequent in patients with multi-ligament knee injuries (1.4% vs 0.2%, p < 0.001 and 2.7% vs 1.1%, p = 0.002, respectively). Patients with multi-ligament knee injuries experienced a 55-fold increase risk of need for transfusion (p < 0.001) and a fivefold increased risk of pulmonary embolism (p = 0.025), with most occurring in bicruciate reconstructions (Schenck Classification KD-III and KD-IV injuries). CONCLUSION The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse event over arthroscopic ACL reconstruction. These patients are most at risk for post-operative blood transfusion requirement, and pulmonary embolism, with patient's undergoing surgery for bicruciate ligament injuries at particularly high risk of complication. LEVEL OF EVIDENCE IV.
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29
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Kahan JB, Schneble CA, Li D, Petit L, Huang P, Bullock J, Porrino J, Richter DL, Schenck RC, Medvecky MJ. Increased Neurovascular Morbidity Is Seen in Documented Knee Dislocation Versus Multiligamentous Knee Injury. J Bone Joint Surg Am 2021; 103:921-930. [PMID: 33587513 DOI: 10.2106/jbjs.20.01151] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This article was updated on May 19, 2021 because of previous errors, which were discovered after the preliminary version of the article was posted online. In the legend for Figure 3-A, the phrase that had read "T1-weighted coronal MRI showing a right knee" now reads "T1-weighted coronal MRI showing a left knee." On page 924, in the section entitled "Materials and Methods," the sentence that had read "If there was no radiographic evidence or if there was a clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." now reads "If there was no radiographic evidence or if there was no clinical note that documented visible deformity around the knee with no reduction maneuver being performed, then the patient was classified into the non-dislocated MLKI group." On page 925, in the section entitled "Analysis," the sentence that had read "Our study included 78 dislocated MLKIs and non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." now reads "Our study included 45 dislocated MLKIs and 78 non-dislocated MLKIs, so both cohorts were adequately powered for the overall analysis." Finally, on page 927, in the section entitled "Discussion," the sentence that had read "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (23%) compared with those without (3%)." now reads "Interestingly, we found that MLKIs with a documented knee dislocation had a substantially higher rate of vascular injury (18%) compared with those without (4%)."
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Affiliation(s)
- Joseph B Kahan
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Christopher A Schneble
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Don Li
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Logan Petit
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Patrick Huang
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - James Bullock
- Orthopaedic Center of South Florida, Plantation, Florida
| | - Jack Porrino
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
| | - Dustin L Richter
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Robert C Schenck
- Department of Orthopaedics & Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Michael J Medvecky
- Departments of Orthopaedics and Rehabilitation (J.B.K., C.A.S., L.P., and M.J.M.) and Radiology and Biomedical Imaging (J.P.), Yale School of Medicine (D.L. and P.H.), New Haven, Connecticut
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Drogset JO, Størset KH, Nitteberg TM, Gifstad T. Clinical outcome after knee ligament reconstruction with tendon allografts. J Exp Orthop 2021; 8:11. [PMID: 33554303 PMCID: PMC7868311 DOI: 10.1186/s40634-021-00331-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/27/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this study is to investigate the clinical outcome for patients after knee ligament reconstructions with allografts at a university hospital. METHODS A total of 33 patients received allografts for reconstructive knee surgery between 2007 and 2017. The follow up evaluation consisted of a clinical knee examination including evaluation of range of motion (ROM), lateral and medial laxity, the Lachman test, the Pivot shift test, the sag test, the posterior drawer test and checking for patellofemoral pain. The following patient-reported outcome measures (PROMs) were used; the Lysholm Function Score, the Tegner activity score, and the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS Twenty-one (64%) patients were available for the follow-up evaluation and the mean follow-up time was 4.8 years. A total of 16 out of 21 patients had multiligament injuries of which the ACL was the ligament most frequently ruptured. At the time of follow-up, 14 out of 16 patients (87%) with ACL injury had Lachman test grade 0 or grade 1 + , and 12 out of 13 (92%) had a pivot shift grade 0 or 1 + . The mean Lysholm Score was 74. All mean KOOS subscale values were ≥ 59 at the follow-up. The preoperative Tegner activity score was 3 (range, 1-6) and 4 (range, 2-6) at follow up. There were no deep postoperative infections. A total of 19 out of 21 patients (90%) reported that they would have undergone surgery again had they known the clinical outcome in advance. CONCLUSIONS The patients improved from the preoperative score to the follow-up score in the knee-related Quality of Life (QoL) KOOS subscale. None of the patients were diagnosed with deep postoperative infections.
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Affiliation(s)
- Jon Olav Drogset
- Norwegian University of Science and Technology, Trondheim University Hospital, Trondheim, Norway.
| | - Kristina Hovde Størset
- Norwegian University of Science and Technology, Trondheim University Hospital, Trondheim, Norway
| | - Thea Marie Nitteberg
- Norwegian University of Science and Technology, Trondheim University Hospital, Trondheim, Norway
| | - Tone Gifstad
- Norwegian University of Science and Technology, Trondheim University Hospital, Trondheim, Norway
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Maxwell GT, Warth RJ, Amin A, Darlow MA, Bailey L, Lowe WR, Harner CD. Multiple Ligament Knee Injuries: Does the Knee Dislocation Classification Predict the Type of Surgical Management? J Knee Surg 2021; 34:273-279. [PMID: 32185787 DOI: 10.1055/s-0039-1695739] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study aims to evaluate relationships among multiple ligament knee injury (MLKI) patterns as classified according to the knee dislocation (KD) classification and the types of surgical management pursued. We hypothesized that the KD classification would not be predictive of the types of surgical management, and that categorizing injuries according to additional injury features such as structure, chronicity, grade, and topographic location would be predictive of the types of surgical management. This is a Retrospective cohort study. This study was conducted at a level I trauma center with a 150-mile coverage radius. Query of our billing database was performed using combinations of 43 billing codes (International Classification of Diseases [ICD] 9, ICD-10, and Current Procedural Terminology) to identify patients from 2011 to 2015 who underwent operative management for MLKIs. There were operative or nonoperative treatment for individual ligamentous injuries, repair, or reconstruction of individual ligamentous injuries, and staging or nonstaging or nonstaging of each surgical procedure. The main outcome was the nature and timing of clinical management for specific ligamentous injury patterns. In total, 287 patients were included in this study; there were 199 males (69.3%), the mean age was 30.2 years (SD: 14.0), and the mean BMI was 28.8 kg/m2 (SD: 7.4). There were 212 injuries (73.9%) categorized as either KD-I or KD-V. The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament (p > 0.05). Recategorization of injury patterns according to structure, chronicity, grade, and location revealed the following: partial non-ACL injuries were more frequently repaired primarily (p < 0.001), distal medial-sided injuries were more frequently treated operatively than proximal medial-sided injuries (odds ratio [OR] = 24.7; p <0.0001), and staging was more frequent for combined PCL-lateral injuries (OR = 1.3; p = 0.003) and nonavulsive fractures (OR = 1.2; p = 0.0009). The KD classification in isolation was not predictive of any surgical management strategy. Surgical management was predictable when specifying the grade and topographic location of each ligamentous injury. This is a Level IV, retrospective cohort study.
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Affiliation(s)
- Garrett T Maxwell
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Ryan J Warth
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Adeet Amin
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Matthew A Darlow
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Lane Bailey
- Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
| | - Walter R Lowe
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.,Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
| | - Christopher D Harner
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.,Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
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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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Goyal T, Paul S, Banerjee S, Das L. Outcomes of one-stage reconstruction for chronic multiligament injuries of knee. Knee Surg Relat Res 2021; 33:3. [PMID: 33413666 PMCID: PMC7792069 DOI: 10.1186/s43019-020-00083-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/24/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE This article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts. METHODS All patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years' follow-up. RESULTS A total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years' follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years' follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty. CONCLUSION Single-stage surgical reconstruction for chronic MKI has favourable functional outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab 151001 India
| | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Sushovan Banerjee
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Lakshmana Das
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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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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Richter DL, Held M, Campos T, Wascher DC, Schenck RC. The Management of Knee Dislocations in the Limited-Resource Setting. J Bone Joint Surg Am 2020; 102:e136. [PMID: 33060423 DOI: 10.2106/jbjs.20.00743] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Michael Held
- University of Cape Town, Cape Town, South Africa
| | - Túlio Campos
- Federal University of Minas Gerais, Belo Horizonte, Brazil
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Billières J, Labruyère C, Steltzlen C, Gonzalez A, Boisrenoult P, Beaufils P, Pujol N. Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes. Orthop Traumatol Surg Res 2020; 106:937-944. [PMID: 31494067 DOI: 10.1016/j.otsr.2019.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 06/28/2019] [Accepted: 08/24/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts. HYPOTHESIS MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes. METHODS Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters. RESULTS Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis. CONCLUSIONS Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Julien Billières
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France; Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Charlotte Labruyère
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France
| | - Camille Steltzlen
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France
| | - Amanda Gonzalez
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Philippe Boisrenoult
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France
| | - Philippe Beaufils
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France
| | - Nicolas Pujol
- Orthopedic Department, centre hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France.
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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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Bisping L, Lenz R, Lutter C, Schenck RC, Tischer T. Hyperflexion Knee Injury with Anterior Cruciate Ligament Rupture and Avulsion Fractures of Both Posterior Meniscal Attachments: A Case Report. JBJS Case Connect 2020; 10:e1900541. [PMID: 32910586 DOI: 10.2106/jbjs.cc.19.00541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 54-year-old patient presented with low-velocity hyperflexion knee trauma while falling at a ski lift with anterior cruciate ligament (ACL) rupture and avulsion fractures of both posterior meniscal attachments. Meniscal avulsions were treated arthroscopically using transtibial sutures; a partial medial collateral ligament tear was treated conservatively. Six weeks later, reconstruction of the ACL was performed, and both meniscal attachments were stable. CONCLUSION Hyperflexion of the knee puts direct shear and compressive force on the posterior tibia. This can result in ligament injuries combined with avulsion fractures of both posterior meniscal attachments. Arthroscopic treatment is a practicable technique for this type of injury.
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Affiliation(s)
- Lucas Bisping
- 1Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany 2Department of Orthopaedic Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
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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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Chowdhry M, Burchette D, Whelan D, Nathens A, Marks P, Wasserstein D. Knee dislocation and associated injuries: an analysis of the American College of Surgeons National Trauma Data Bank. Knee Surg Sports Traumatol Arthrosc 2020; 28:568-575. [PMID: 31559462 DOI: 10.1007/s00167-019-05712-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/11/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Knee dislocations (KDs) are potentially devastating injuries, leading to loss of function or limb in often young patients. This retrospective database review aims to determine the relative incidence and risk factors for KDs presenting to North American Level I and II trauma centers. METHODS The National Trauma Data Bank (NTDB) was retrospectively interrogated using ICD-9-CM codes to identify KDs between 2010 and 2014 to derive KD incidence. KDs were stratified by age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), drug and alcohol use, injury mechanism, open vs. closed KD, vascular injury and fracture. Each co-variate was tested against different mechanisms of injury, using Chi-squared tests and risk adjusted analyses to derive risk factors for KD. The same calculations were done for secondary outcomes (vascular and neurological injuries, compartment syndrome, amputation, and mortality). RESULTS A total of 6454 KDs met the inclusion criteria (18/10,000 admissions). KDs occurred most commonly amongst men, aged 20-39, with an ISS score 1-14 and following motor vehicle collision (MVC). A vascular investigation was performed in 29%, with injury documented in 15% of KDs and 10.8% receiving a vascular procedure. Associated fractures were observed in 41.4% of KDs. Open injuries in 13.6%. Neurological injury documented in 6.2%, compartment syndrome in 2.7%, amputation in 3.8% (> 50% had vascular injury) and 2.8% died. MVC was the most common mechanism of injury (p < 0.001), significantly more common in young, male patients, associated with higher ISS and lower GCS, especially when drugs or alcohol were involved (p < 0.0001). Being male, having a vascular injury or open KD were all risk factors for compartment syndrome, amputation and neurological injuries. CONCLUSIONS KDs are rare injuries, but their relative incidence may be increasing. Young, male patients involved in MVCs are risk factors for KDs and their associated injuries, such as neurological injuries, amputations and compartment syndrome. Vascular injury occurs at a frequency of around 15%. The findings of the current study may guide future research and help to inform clinicians on the expected rates of associated injuries in patients identified to have KD in a trauma center population. It informs regarding risk factors for KD, which may improve diagnosis rates of spontaneously reduced knee dislocations by increasing index of suspicion in high-risk patients and identifies specific links with impaired driving. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Majid Chowdhry
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex, UK.
| | - Daniel Burchette
- Department of Trauma and Orthopaedics, Brighton and Sussex University Hospitals, Brighton, East Sussex, UK
| | - Danny Whelan
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Orthopaedic Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Avery Nathens
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul Marks
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - David Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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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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Demographics, risk factors, and complication or readmission rates after multiligament knee reconstruction: A retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Ravikanth R, Abraham MJ, Pilar A, Alapati A. MRI diagnosis in multiligamentous injuries of knee with associated dislocations and neurovasacular sequelae: a retrospective analysis of injury patterns. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_22_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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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Westermann RW, Marx RG, Spindler KP, Huston LJ, Amendola A, Andrish JT, Brophy RH, Dunn WR, Flanigan DC, Jones MH, Kaeding CC, Matava MJ, McCarty EC, Parker RD, Reinke EK, Vidal AF, Wolcott ML, Wolf BR. No Difference Between Posterolateral Corner Repair and Reconstruction With Concurrent ACL Surgery: Results From a Prospective Multicenter Cohort. Orthop J Sports Med 2019; 7:2325967119861062. [PMID: 31431898 PMCID: PMC6685111 DOI: 10.1177/2325967119861062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Injuries to the posterolateral corner (PLC) may occur concurrently with anterior cruciate ligament (ACL) injury. Purpose/Hypothesis: This study evaluated the outcomes of patients who underwent operative management of PLC injuries concurrently with ACL reconstruction in a prospective multicenter cohort. We hypothesized that there would be no differences in outcomes between patients who were treated with PLC repair and PLC reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing ACL reconstruction were enrolled into a prospective longitudinal multicenter cohort between 2002 and 2008. Those with complete 6-year follow-up data (patient-reported outcomes and subsequent surgery information) were identified. Excluded from the study were patients with posterior cruciate ligament injuries. Patients who underwent PLC repair were compared with those who underwent PLC reconstruction with regard to interval from injury to surgery, need for revision surgery, and long-term outcomes at 6 years. Results: During the identified time frame, 3026 identified patients underwent primary ACL reconstruction; 34 (1.1%) also underwent concurrent PLC surgery (15 repairs, 19 reconstructions [18 allografts, 1 autograft]). With the numbers available, we did not detect significant differences between groups regarding the rate of meniscal or chondral injuries. Median time to PLC reconstruction was 121 days as compared with 19 days for concurrent ACL reconstruction and PLC repair (P = .01). There were no between-group differences in Marx activity scores prior to surgery (P = .4). At 6-year follow-up, there were no between-group differences in Knee injury and Osteoarthritis Outcome Score (P = .36-.83) or International Knee Documentation Committee score (P = .84); however, patients treated with PLC reconstructions had lower Marx activity scores (4.1 vs 9.4; P = .02). There was 1 ACL revision in the PLC reconstruction group, and 1 of the PLC repairs was revised to a reconstruction during the follow-up period. Conclusion: Good outcomes were achieved at 6-year follow-up with both repair and reconstruction of PLC injuries treated concurrently with ACL reconstruction. The PLC reconstruction group had lower activity levels 6 years after surgery. The present data suggest that, for appropriately selected patients undergoing acute surgical treatment of combined ACL and PLC injuries, PCL repair can achieve good long-term outcomes.
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Affiliation(s)
- Robert W Westermann
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Robert G Marx
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Kurt P Spindler
- Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
| | - Laura J Huston
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Annunziato Amendola
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Jack T Andrish
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Robert H Brophy
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Warren R Dunn
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - David C Flanigan
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Morgan H Jones
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Christopher C Kaeding
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Matthew J Matava
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Eric C McCarty
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Richard D Parker
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Emily K Reinke
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Armando F Vidal
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Michelle L Wolcott
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Brian R Wolf
- Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA.,Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA, and University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
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Richter DL, Bankhead CP, Wascher DC, Treme GP, Veitch A, Schenck RC. Knee Dislocation (KD) IV Injuries of the Knee. Clin Sports Med 2019; 38:247-260. [DOI: 10.1016/j.csm.2018.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Factors predictive of poorer outcomes in the surgical repair of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc 2019; 27:445-459. [PMID: 30083969 DOI: 10.1007/s00167-018-5053-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 07/06/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the influence of injury and treatment factors on clinical/functional outcomes in multiligament knee injuries (MLKI). METHODS Thirty-nine consecutive patients with confirmed and surgically treated MLKI who met inclusion criteria were scheduled for a follow-up visit to obtain: SF-12 and subjective feeling of normalcy between the operated and healthy knee, and IKDC, active range of motion (ROM), and stability exam (Lachman test, posterior drawer, and dial test at 30°). A chart review was used to obtain data on injury and treatment factors. RESULTS The postoperative mean (SD) outcomes were: IKDC score 62.7 (25.9), flexion-extension ROM 125° (29°), and percentage of normalcy 74% (20%). The postoperative normal/nearly normal stability exam was: Lachman test 36 (95%) patients, posterior drawer at 90° 38 (97%) patients, and dial test of 39 (100%) patients. There were 24 (61.5%) and 23 (59%) patients with complications and reoperations, respectively. The presence of bicruciate injuries was associated with worse Lachman (p = 0.03) and posterior drawer tests (p = 0.03). Presence of injury to meniscal structures was associated with worse Lachman test (p = 0.03), lower percentage of normalcy (p = 0.02) and extension lag (p = 0.04). Injury to cartilage structures was associated with worse IKDC scores (p = 0.04). IKDC was lower in cases of posterolateral corner reconstruction (p = 0.03) and use of allograft tendons for reconstruction (p = 0.02); ROM was lower in allograft reconstruction (p = 0.02) and need for meniscal repair (p = 0.01). Bicruciate reconstruction led to worst posterior drawer test (p = 0.006). CONCLUSIONS The outcomes of MLKI might be negatively influenced by bicruciate ligament, meniscal, and cartilage injuries; with regards to treatment characteristics, need for posterolateral corner or bicruciate ligament reconstruction, use of allografts, or need for meniscal repair may similarly diminish outcomes. While surgical treatment provides good overall function, ROM and stability, it rarely results in a "normal" knee and the chances of complications and reoperations are high. LEVEL OF EVIDENCE Cross-sectional comparative study, Level III.
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