Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury

BACKGROUND

This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury.

METHODS

The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed.

RESULTS

On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs.

CONCLUSIONS

After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis

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.

ACL reconstruction provides superior stability than ACL repair in patients with Schenck III and IV knee joint dislocations: first results of a 12 month follow-up study

PURPOSE

Acute knee dislocation is a rare but devastating multi-ligamentous knee injury with only limited evidence-based surgical technique recommendations. The aim of this study was a comparison of two different anterior cruciate ligament (ACL) restoration techniques as part of an early total surgical care concept: (1) repair of ACL with additional internal bracing (ACLIB) compared to; (2) ACL reconstruction with autograft (ACLR).

METHODS

Retrospective, clinical-study of patients with an acute type III or IV knee dislocation (according to Schenck classification), in which the ACL was treated with ACLIB or ACLR within 12 days. The PCL was sutured and internally braced in all cases. Medial and lateral complex injuries were repaired and additionally laterally augmented by an Arciero reconstruction. After a minimum 12 months follow-up different patient-reported outcome measurements (IKDC, Lysholm, VAS, Tegner Score) and instrumental stability assessment by Rolimeter -test and stress radiographs (Telos™) were analyzed. Groups were compared by t test with p < 0.05 considered significant.

RESULTS

In total, 20 patients (5 IIIM, 5 IIIL and 10 IV) were included in this study with an average follow-up of 13.7 ± 2.6 months. There were significant differences in instrumental stability testing (side-to-side difference (SSD) of anterior tibial translation: ACLIB 2.7 ± 1.5 mm vs. ACLR 1.3 ± 1.3; p = 0.0339) and stress radiography (SSD ACL: ACLIB 3.4 ± 2.2 mm vs. ACLR 0.4 ± 2.7; p = 0.0249) between groups. ACLIB group showed greater ROM in terms of flexion (SSD Flexion: ACLIB 7.8 ± 9.9° vs. ACLR 16 ± 7.0°; p = 0.0466; Total Flexion overall 125.5 ± 11.8°). No clinically relevant differences in patient-reported outcome scores (Lysholm Score: ACLIB 82 ± 16.4 vs. ACLR 85 ± 10.4; IKDC subjective score: ACLIB 70.4 ± 17 vs. ACLR 76.6 ± 8.3) were determined.

CONCLUSION

ACLR provides superior translational stability than ACLIB in terms of instrumental testing and stress radiography. Both techniques were equivalent with respect to PROMS and led to good and excellent clinical results.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

The impact of knee arthrodesis on gait kinematics, muscle activity and patient-reported outcome

BACKGROUND

The aim of this retrospective study was to analyze gait kinematicsandoutcome parameters after knee arthrodesis.

METHODS

Fifteenpatients with a mean follow-up of 5.9 (range0.8-36) years after unilateral knee arthrodesis were included. A 3D gait analysis was performed and compared to a healthy control group of14patients. Comparative electromyography was performed bilaterally at the rectus femoris, vastuslateralis/medialisand tibialis anterior muscles. The assessment further included standardized outcome scores- Lower Extremity Functional Scale (LEFS) andShort Form Health Survey (SF-36).

RESULTS

The 3D analysis showed a significantly shortened stance phase (p = 0.000), an extended swing phase (p = 0.000), and an increased time per step (p = 0.009) for the operated side compared with thenonoperatedside. There were statistically significant differences in the extent of movement of the hips, knees and ankles among the operated andnonoperatedsides and the control group. For the mean EMG measurement, no significant difference was found between the healthy control group and the patients with arthrodesis.The average LEFSscorewas 27.5 ± 10.6out of a maximum of 80 points,and the mean physical total scale and mean emotional total scale scores for the SF-36 were 27.9 ± 8.5and 52.9 ± 9.9, respectively.

CONCLUSIONS

Arthrodesis of the knee joint causes significant kinematic changes in gait pattern,and patients achieve poor results in subjective and functional outcomes(SF- 36, LEFS).Arthrodesis ensures that the extremities are preserved and can enable walking, but it must be viewed as a severe handicap for the patient.

Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: a systematic review

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).

One-Stage Arthroscopic Multiple Ligament Reconstruction for Schenck IV Knee Dislocation

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.

Treatment of Knee Dislocation With Primary Repair and Suture Augmentation: A Viable Solution

Background:

Different surgical techniques have been described for the treatment of knee dislocation (KD). Nonoperative approaches are frequently combined with surgical reconstruction using auto- or allograft.

Purpose:

To evaluate the midterm results of primary surgical repair and suture augmentation to treat KD.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 22 patients (5 women, 17 men; mean age, 45 ± 15 years) with KD were evaluated at a mean of 49 ± 16 months after surgical treatment that included primary repair and suture augmentation. Magnetic resonance imaging, stress radiographs, and outcome scores were obtained at the follow-up. Clinical examination including hop tests and force measurements for flexion and extension was performed.

Results:

The mean difference in pre- to postinjury Tegner scores was –2 ± 1. The outcome scores showed mean values of 84 ± 15 (Lysholm), 73 ± 15 (International Knee Documentation Committee) and 65 ± 25 (Anterior Cruciate Ligament–Return to Sport after Injury scale). Compared with the uninjured knee, the range of motion of the injured knee was reduced by 21° ± 12°. Twelve patients felt fit enough to perform hop tests and showed a mean deficit of 7% ± 17%° compared with the uninjured leg. The mean force deficit was 19% ± 18% for extension and 8% ± 16% for flexion. Stress radiographs revealed an 11 ± 7–mm higher anteroposterior translation on the injured side. Four patients had secondary ligament reconstructions due to persistent instability and 7 underwent arthroscopic arthrolysis due to stiffness. A significant increase of osteoarthritis was found for the medial, lateral, and patellofemoral compartments (P = .007, .004, and .006, respectively).

Conclusion:

Primary repair and suture augmentation of KD led to satisfactory clinical midterm results despite persistent radiological instability and a significant increase in osteoarthritis. This technique allows the return to activities of daily living without subjective instability in most nonathletic patients. Secondary ligament reconstructions should be performed if relevant instability persists to decrease the risk of secondary meniscal and cartilage damage.