Repair and Augmentation with Internal Brace in the Multiligament Injured Knee

Multiligament Knee Reconstruction With Suture Tape Augmentation: Patient-Reported Outcomes at Minimum 2-Year Follow-up

BACKGROUND

Multiligament knee injury (MLKI) is a severe subclass of orthopedic injury and can result in significant functional impairment. Novel MLKI graft constructs such as suture augmentation aim to enhance graft strength and optimize knee stability. The purpose of this study was to present patient-reported outcome measurements of a cohort at a minimum follow-up of 2 years after multiligament knee reconstruction (MLKR) with suture augmentation.

MATERIALS AND METHODS

A retrospective chart review was performed to identify patients who underwent MLKR with suture augmentation. Demographic and injury-specific variables were gathered preoperatively and postoperatively. Patients were contacted at a minimum of 2 years postoperatively to collect Patient-Reported Outcomes Measurement Information System, Multiligament Quality of Life, and Lysholm knee scores.

RESULTS

Twenty-seven patients underwent MLKR with suture augmentation, with 15 being female (55.6%) and 12 being male (44.4%). The mean pain score was 49.93±9.96, the mean physical function score was 49.56±10.94, and the mean mobility score was 47.56±8.58. The mean physical impairment score was 33.96±23.69, the mean emotional impairment score was 36.55±26.60, the mean activity limitation score was 28.00±25.61, and the mean societal involvement score was 30.09±27.45. The mean Lysholm knee score for the cohort was 67.93±22.36.

CONCLUSION

Patients who underwent MLKR with suture augmentation had satisfactory scores across all patient-reported outcome measurements. On the basis of these criteria, the average patient achieved an acceptable clinical outcome, demonstrating that MLKR with suture augmentation is a safe and efficacious surgical technique for the treatment of MLKI. [Orthopedics. 2024;47(4):238-243.].

Patient Reported Clinical Outcomes Following PCL Suture Augmentation in Patients with Multiligamentous Knee Injury: A Retrospective Observational Study

Purpose

To compare the patient-reported outcomes between patients with posterior cruciate ligament (PCL) reconstruction or repair alone versus PCL reconstruction or repair with internal bracing (IB) in the context of multi-ligament knee injuries (MLKI).

Methods

All patients who underwent surgical management of MLKI at two institutions between 2006 and 2020 were retrospectively identified and offered participation in the study. Patient reported outcomes were measured via three instruments: Lysholm Knee score, Multiligament Quality of Life (ML-QOL), and the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT). The postoperative outcomes and reoperation rates were compared between the internal bracing and non-internal bracing groups.

Results

Fifty-two patients were analyzed; 34 were included in the IB group (17.6% female; age 33.1 ±1.60 years), and 18 were included in the non-IB group (11.1% female; age 34.1 ±3.72 years). Mean follow-up time of the entire cohort was 1.44 ± 0.22 years (IB: 1.21 ± 0.18; non-IB: 2.1 ±0.65). There were no significant differences between PROMIS CAT [PROMIS Pain (54.4 ±1.78 vs 51.7 ±1.70, p=0.319), Physical Function (44.3 ±2.27 vs 47.9 ±1.52, p=0.294), Mobility (44.0 ±1.71 vs 46.1 ±2.10, p=0.463)], ML-QOL [ML-QOL Physical Impairment (40.7 ±4.21 vs 41.7±5.10, p=0.884), Emotional Impairment (49.2 ±4.88 vs 44.7±5.87, p=0.579), Activity Limitation (43.5 ±4.56 vs 31.5±3.62, p=0.087), Societal Involvement (44.9 ±4.96 vs 37.5 ±5.30, p=0.345)] and Lysholm knee score (61.8 ±4.55 vs 61.0 ±4.95, p=0.916) postoperatively compared to the non-IB group.

Conclusion

In this group of patients, function and patient-reported outcomes between patients treated with PCL reconstruction and repair without internal brace versus those with additional internal brace augmentation were not significantly different. Further research encompassing a larger patient sample is necessary to investigate the efficacy of the internal brace for PCL injury in the context of MLKI injuries.

Outcomes after Anatomic Double-Bundle Posterior Cruciate Ligament Reconstructions Using Transtibial and Tibial Inlay Techniques

Surgical reconstruction is recommended for symptomatic posterior cruciate ligament (PCL) deficiency. While anatomic double-bundle PCL reconstruction (PCLR) has been reported to be associated with biomechanical and clinical advantages over other methods, there is still debate regarding the optimal technique for tibial positioning and fixation. Based on reported advantages and disadvantages, we employed two tibial fixation techniques, transtibial (TT) and tibial inlay (TI) for anatomic double-bundle PCLR with technique selection based on body mass index, comorbidities, and primary versus revision surgery. This study aimed to compare clinical outcomes following PCLR utilizing either TT or TI techniques to validate relative advantages, disadvantages, and indications for each based on the review of prospectively collected registry data. For 37 patients meeting inclusion criteria, 26 underwent arthroscopic TT PCLR using all-soft- tissue allograft with suspensory fixation in the tibia and 11 patients underwent open TI PCLR using an allograft with calcaneal bone block and screw fixation in the tibia. There were no significant preoperative differences between cohorts. Success rates were 96% for TT and 91% for TI with all successful cases documented to be associated with good-to-excellent posterior stability and range of motion in the knee at the final follow-up. In addition, patient-reported outcome scores were within clinically meaningful ranges for pain, function, and mental health after PCLR in both cohorts, suggesting similarly favorable functional, social, and psychological outcomes. Patient-reported pain scores at 6 months postoperatively were significantly (p = 0.042) lower in the TT cohort, which was the only statistically significant difference in outcomes noted. The results of this study support the use of TT and TI techniques for double-bundle anatomic PCLR in restoring knee stability and patient function when used for the treatment of isolated and multiligamentous PCL injuries. The choice between tibial fixation methods for PCLR can be appropriately based on patient and injury characteristics that optimize respective advantages for each technique.

Outcomes of multiligament knee injury treated with versus without internal brace suture augmentation

PURPOSE

To compare the postoperative outcomes between Internal Brace (IB) and non-IB patients who underwent surgical management of multiple-ligament knee injuries (MLKI).

METHODS

Patients who underwent surgical management of MLKI at two institutions between 2010 and 2020 were identified and offered participation in the study via the collection of postoperative functional outcomes for MLKI; Lysholm Knee score, Multiligament Quality of Life (ML-QOL), Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT), Pain Interference (PI), Physical Function (PF), and Mobility instruments (MI). The postoperative outcomes and reoperation rates were compared between the IB group and non-IB group.

RESULTS

One hundred and twenty-six patients were analyzed; 89 were included in the IB group (31.5% female; age 35.6 ± 1.4 years), and 37 were included in the non-IB group (25.7% female; age 38.8 ± 2.4 years). Mean follow-up time of the entire cohort was 37.9 ± 4.7 months [IB: 21.8 + 1.63; non-IB: 76.4 ± 6.2, p < 0.001). The IB group achieved similar PROMIS CAT [PROMIS Pain (51.8 + 1.1 vs. 52.1 + 1.6, p = 0.8736), Physical Function (46.6 + 1.2 vs. 46.4 + 1.8, p = 0.9168), Mobility (46.0 + 1.0 vs. 43.7 + 1.6, p = 0.2185)], ML-QOL [ML-QOL Physical Impairment (36.6 + 2.5 vs. 43.5 ± 4.2, p = 0.1485), Emotional Impairment (42.5 + 2.9 vs. 48.6 ± 4.6, p = 0.2695), Activity Limitation (34.5 + 2.8 vs. 36.2 ± 4.3, p = 0.7384), Societal Involvement (39.1 + 3.0 vs. 41.7 + 4.2, p = 0.6434)] and Lysholm knee score (64.9 + 2.5 vs. 60.4 + 4.0, p = 0.3397) postoperatively compared the non-IB group, but the differences were not significant.

CONCLUSION

In this cohort of patients with MLKI treated with versus without IB, outcomes and reoperation rates trended toward favoring IB, but the study was not sufficiently powered to reach statistical significance. Internal bracing could be useful in the management of MLKI. In the future, matched patient cohorts with more patients are warranted to further evaluate the clinical impact of the internal brace in MLKI.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

MCL internal brace does not fully recapitulate normal MCL function in valgus stress

PURPOSE

The null hypothesis is that there would be no difference in medial gapping under valgus load between the intact MCL and the ruptured MCL with an internal brace in place.

METHODS

Eight pairs of cadaver knees were used (16 knees). Alternating sides, one knee from each pair was used for one of two "internal brace" constructs. The constructs involved different methods of fixation for securing FiberTape (Arthrex, Naples, FL) to both the femur and tibia in an effort to brace the MCL. The knees were then subjected to valgus stress by applying 10 N m of torque with the knee at 20 degrees of flexion. The amount of medial joint space opening was measured on radiographs. The stress testing was conducted with three MCL states: intact, grade 2 tear, and grade 3 tear.

RESULTS

In the Construct I specimens, gapping increased from 0.7 mm with the MCL intact to 1.1 mm with grade 2 tearing (p < 0.01), and to 1.3 mm with grade 3 tearing (p < 0.01). In the Construct II specimens, gapping increased from 0.7 mm with the MCL intact to 1.0 mm with grade 2 tearing (p < 0.01), and to 1.1 mm with grade 3 tearing (n.s.). Construct I specimens failed primarily at the femoral attachment. All Construct II specimens survived the valgus stress testing.

CONCLUSION

Construct I did not maintain tension. Construct II did maintain tension during application of valgus load, but did not restore valgus opening to the intact state. It is important for clinicians who are considering using this commercially available technique to be aware of how the construct performs under valgus stress testing compared to the intact MCL.

Clinical and radiological outcomes of a modified anatomic posterolateral corner reconstruction technique using a single semitendinosus autograft

PURPOSE

We aimed to assess the clinical and radiological outcomes of a modified anatomical posterolateral corner (PLC) reconstruction technique using a single autograft.

METHODS

This prospective case series included 19 patients with a posterolateral corner injury. The posterolateral corner was reconstructed using a modified anatomical technique that utilized adjustable suspensory fixation on the tibial side. Patients were evaluated subjectively using the international knee documentation form (IKDC), Lysholm, and Tegner activity scales and objectively by measuring the tibial external rotation angle, knee hyperextension, and lateral joint line opening on stress varus radiographs before and after surgery. The patients were followed-up for a minimum of 2 years.

RESULTS

Both IKDC and Lysholm knee scores significantly improved from 49 and 53 preoperatively to 77 and 81 postoperatively, respectively. The tibial external rotation angle and knee hyperextension showed significant reduction to normal values at the final follow-up. However, the lateral joint line opening measured on the varus stress radiograph remained larger than the contralateral normal knee.

CONCLUSION

Posterolateral corner reconstruction with a hamstring autograft using a modified anatomical reconstruction technique significantly improved both the subjective patient scores and objective knee stability. However, the varus stability was not completely restored compared with the uninjured knee.

LEVEL OF EVIDENCE

Prospective case series (Level of evidence IV).

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons

OBJECTIVES

To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR.

METHODS

We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence.

RESULTS

Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p ​= ​0.005).

CONCLUSION

LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population.

LEVEL OF EVIDENCE

Level V.

Ulnar Collateral Ligament Internal Bracing Repair Technique for High-Grade Partial Proximal Tears in the Throwing Athlete

The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.

Rehabilitation and functional outcomes in internally braced and standard ACL reconstructions

Purpose

The purpose of this study was to compare surgical outcomes in patients who underwent ACL reconstruction, with and without internal bracing, at 1-3, 4-7, and 8-12 months of postoperative physical therapy. Previous studies show that ACL reconstruction with internal bracing allows earlier and more aggressive rehabilitation. Therefore, it was hypothesized that patients with internal bracing would display superior surgical recovery compared to ACL reconstruction alone after adjusting for length of physical therapy.1, 2, 3.

Methods

Patients who underwent ACL reconstruction and had a minimum two-year follow-up were included. Demographics including age, gender, use of internal bracing, and pre-operative level of activity were collected. Patient-reported outcomes were assessed using KOOS scores.

Results

46 patients underwent ACL reconstruction between January 2013 and December 2015. The mean age was 31.53 ± 8.37 years. Patients who received ACL reconstruction with internal bracing reported similar improvement in KOOS scores (mean = 42.82 ± 15.44; median = 46.39 [34.52-51.80]) compared to ACL reconstruction alone (mean = 38.18 ± 19.91; median = 40.17 [29.49-53.90]) (p = 0.475). Patients who received ACL reconstruction with internal bracing reported comparable improvement to ACL reconstruction alone at 0-3 months (Internal bracing: mean = 35.39 ± 15.26, median = 40.45 [26.49-47.73]; No internal bracing: mean = 42.51 ± 12.33, median = 39.32 [35.69-52.94], p = 0.4113), 4-7 months (Internal bracing: 41.96 ± 14.49, 45.55 [33.94-52.68]; No internal bracing: 30.64 ± 32.29, 41.65 [26.17-46.12], p = 0.7491) and 8+ months groups (Internal bracing: 63.36 ± 13.06, 63.36 [58.74-67.98]; No internal bracing: 47.05 ± 10.14, 47.05 [43.46-50.63]) (p = 0.6985).

Conclusion

This study demonstrates no statistical difference in functional outcome scores when comparing patients with internally braced ACL reconstruction compared to standard reconstruction. Therefore, the increased structural support provided by use of internal bracing in ACL reconstruction does not afford to quicker improvement in patient-reported recovery.

Suture tape reinforcement of hamstring tendon graft reduces postoperative knee laxity after primary ACL reconstruction

Purpose

To evaluate and compare subjective and objective knee outcomes following hamstring tendon (HT) and quadriceps tendon (QT) anterior cruciate ligament reconstruction (ACLR) with or without suture tape (ST) reinforcement. It was hypothesized that the addition of an intra-articular synthetic augmentation with a ST would reduce postoperative knee laxity and graft ruptures after ACLR.

Methods

A 1:1 matched-cohort comparison of patients who underwent HT and QT autograft ACLR with or without ST reinforcement was performed. Patients with ST reinforcement were consecutively assigned to the study groups until a number of 20 in each group was achieved. Medical records were reviewed for demographic characteristics and additional injuries. Laxity measurements with KT-1000, strength measurements and physical examination findings were collected both preoperatively and at 6 months and patient reported outcome (PRO) scores were collected both preoperatively and at 12 months, and comparison was made HT vs HT + ST and QT vs QT + ST. Reoperations and re-ruptures were recorded during the 24-month follow-up period.

Results

Overall, 80 patients who underwent ACLR were included. Patients with HT + ST had significant less laxity postoperatively compared to HT at 6 months, 1.9 vs 0.8 mm, p < 0.05. No differences were found between the QT and QT + ST group. At 6 weeks patients treated with ST, both QT and HT, had a significant deficit in flexion compared to those without ST. However, this resolved at 6 months. There were no significant differences between HT + ST vs HT, or QT + ST vs QT, regarding postoperative PROs or strength measurements. Furthermore, the incidence of subsequent surgery and graft rupture was not significantly different between the groups.

Conclusion

ACLR with HT + ST reduces laxity at 6 months compared to ACLR without ST, a difference not seen when ACLR was performed using QT with or without ST. No other differences were seen between the two techniques comparing subjective and objective findings.

Level of evidence

Level III.

Biologically Augmented Suture for Ligament Bracing Procedures Positively Affects Human Ligamentocytes and Osteoblasts In Vitro

PURPOSE

The purpose was to evaluate the response of human ligamentocytes and osteoblasts after biological augmentation with thrombin, concentrated bone marrow aspirate (cBMA), or platelet-rich plasma (PRP) on two different types of nonresorbable flat braided suture used for ligament bracing.

METHODS

Uncoated (U) and collagen-coated (C) flat braided suture material was augmented with either thrombin (T), cBMA (B), PRP (P), or a combination of these three (A), while platelet-poor plasma was used as a source for fibrin (F) in each assay. Previously cultured ligamentocytes and osteoblasts were added with a defined density and assayed after the required time period for adhesion, proliferation, and alkaline phosphatase activity.

RESULTS

Biological augmentation of uncoated [(UFT, UFBT, UFA; P < .001), (UFPT; P = .017)] and collagen-coated suture (CFT, CFPT, CFBT, CFA; P < .001) led to a significantly higher ligamentocyte adhesion. Significantly higher adhesion was also observed for osteoblasts (UFT, UFPT, UFBT, UFA; P < .001; CFT, CFPT, CFBT, CFA; P < .001). Similarly, ligamentocyte proliferation was significantly higher [(UFT, UFPT, UFA; P = .009), (UFBT; P = .001), (CFT; P = .009), (CFBT; P = .001), and (CFA; P = .01)]. Osteoblasts showed significantly higher proliferation as well [(UFT, UFPT, UFA; P = .002), (UFBT; P = .001); (CFT: P = .003), and (CFPT, CFBT, CFA; P = .001)]. Augmentation with thrombin, PRP, and BMA for uncoated (UFT; P = .006, UFPT; P = .035, UFBT; P = .001) and BMA for coated suture (CFBT; P = .027) led to significantly higher alkaline phosphatase activity.

CONCLUSION

Biological enhancement of suture used for ligament bracing significantly increased ligamentocyte and osteoblast adhesion and proliferation, as well as alkaline phosphatase activity of osteoblasts in an in vitro model. After biological augmentation, cellular adhesion, proliferation, and alkaline phosphatase activity changed up to 1,077%, 190%, and 78%, respectively. Furthermore, no overall superiority between uncoated or collagen-coated suture material was observed for cellular adhesion, proliferation, or alkaline phosphatase activity.

CLINICAL RELEVANCE

This study provides in vitro data on a new treatment concept of biologic augmentation for acute ligamentous lesions treated with ligament bracing that has not been widely described. This concept may improve the healing of injured ligaments, in addition to providing immediate biomechanical stabilization.

[Short-term effectiveness of one-stage anterior and posterior cruciate ligaments and posterolateral complex reconstruction combined with medial collateral ligament repair for KD- knee dislocation]

OBJECTIVE

To investigate the short-term effectiveness of one-stage anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posterolateral complex (PLC) reconstruction combined with medial collateral ligament repair for KD-Ⅳ knee dislocation.

METHODS

Between January 2018 and June 2020, 9 patients with KD-Ⅳ knee dislocation were treated. Of 9 cases, 7 were male and 2 were female with an average age of 32.3 years (range, 23-43 years). The knee dislocation was caused by falling from height in 6 cases and traffic accident in 3 cases. The injury located at left knee in 2 cases and right knee in 7 cases. The time from injury to operation was 14-24 days, with an average of 19 days. The preoperative International Knee Joint Documentation Committee (IKDC) score was 45.6±4.2, Lysholm score was 42.4±7.0, and the knee joint active flexion range of motion was (75.2±12.3)°. The posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test were all positive. Under arthroscopy, PCL was reconstructed with the autologous tendons, ACL with allogeneic Achilles tendon, PLC with the allogeneic anterior tibial tendon by Larson enhanced reconstruction method, and MCL was repaired with anchor or simple suture.

RESULTS

The operation time was 2-3 hours (mean, 2.5 hours). All incisions healed by first intention after operation. All patients were followed up12-25 months (mean, 16.1 months). After operation, 2 cases developed knee flexion disorder and pain, and 1 case had knee joint stiffness. At last follow-up, the IKDC score was 76.9±7.4, the Lysholm score was 81.6±6.4, and the knee active flexion range of motion was (122.9±7.2)°, all of which significantly improved when compared with preoperative ones ( P<0.05). During follow-up, there was no failure of the grafts. At last follow-up, there were significant differences in the posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test between pre- and post-operation ( P<0.05). The imaging review showed that the positions of the bone tunnels were satisfactory, the reconstructed ACL, PCL, and PLC structures were continuous, and MCL insertions were restored.

CONCLUSION

One-stage ACL, PCL, and PLC reconstruction combined with MCL repair to treat KD-Ⅳ knee dislocation can effectively restore knee joint stability, improve joint laxity, and improve joint movement.

Current concepts in the assessment and management of multiligament injuries of the knee

Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

All-Inside Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: Button Tie-Over Technique (BTOT)

The anterior cruciate ligament (ACL) is the most common ligamentous knee injury in pivoting sports. There are multiple techniques described for ACL reconstruction; however, still there is an ongoing debate regarding the optimal technique with minimal residual laxity and least risk of rerupture. All-inside ACL reconstruction with suture tape augmentation (InternalBrace) is a newly developed method of ACL reconstruction to help address these issues. Suture tape protects the graft during ligamentization process. The aim of this article is to describe a modified all-inside ACL reconstruction technique with suture tape augmentation in which the internal brace is tied distally over the distal TightRope button without an extra method of fixation.

Results of multiple ligament reconstruction after knee dislocation--A prospective study with 95 patients and minimum 2-year follow up

Background

There is still a lack of clinical data in arthroscopic treatment for treating multiple ligament injuries. This study aims to evaluate the clinical outcomes of patients with multiple ligament injuries undergoing treatment based on the classification stage and type of injury.

Methods

A prospective, clinical trial on multiple ligament injuries was planned, which included 95 patients (58 men and 37 women; age: 42.8 ± 11.9 [range, 18–63] years) from October 2017 to June 2018. Injuries were classified into three stages (emergency stage < 24 h; acute stage: 24 h to 3 weeks, and chronic stage: > 3 weeks) and six types (KD I–VI) based on injuries time and structures, which indicated appropriate treatments. The clinical outcomes were evaluated at 2, 4, 6, 8, and 12 weeks and at 6, 9, 12 months and 24 months after surgery. The final choices in efficacy index included International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) score, and range of motion.

Results

During the follow-up, all patients exhibited statistically significant functional improvement in the injured limb compared with their preoperative situation. The mean postoperative scores of acute stage patients at 2-year follow-up were IKDC subjective score, 77.54 ± 11.53; Lysholm score, 85.96 ± 9.39; Tegner score, 4.13 ± 1.08; and VAS score, 1.21 ± 0.76. The mean postoperative scores of chronic stage patents at 2-year follow-up were IKDC subjective score, 74.61 ± 12.38; Lysholm score, 81.71 ± 10.80; Tegner score, 3.96 ± 1.14; and VAS score, 1.71 ± 0.60. The IKDC subjective score, Lysholm score, and Tegner score were significantly improved (P < 0.01) and the VAS score was significantly decreased (P < 0.01) at 2-year follow-up. Regarding the multiple ligament injuries classification, patients with more structural damage in stages V and VI showed less progress in functional recovery than those in stages I–IV.

Conclusions

This new classification with three stages and six types helps to identify the severity of injury and plan the management effectively. The outcomes were encouraging and the subjective functional results showed significant improvement at 2-year follow-up.

Study design

Prospective clinical trial.

Level of evidence

II

Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee

PURPOSE

Medial collateral ligament (MCL) injury is very common and surgical repair is sometimes necessary. Especially in the setting of simultaneous anterior cruciate ligament reconstruction (ACLR) as the ACL is the secondary restraint against valgus stress. The goal of this study was to evaluate knee biomechanics after suture repair of the MCL augmented with suture tape, as compared to MCL repair alone, in the setting of concomitant ACL reconstruction (ACLR).

METHODS

Fifteen fresh-frozen human cadaveric knees were tested using a six-degrees-of-freedom robotic system under four loadings: (a) an 89.0 N anterior tibial load, (b) a 5.0 Nm internal and external rotation torque, (c) a 10.0 Nm valgus load, (d) a 7.0 Nm valgus load combined with 5.0 Nm internal rotation torque as a static simulated pivot-shift. The tested conditions were ACLR with the following states: (1) MCL intact, (2) MCL deficient, (3) MCL Repair, and (4) MCL repair augmented with suture tape (MCL Repair + ST). Under the different knee loadings, the tibial displacement, and the force in either the intact MCL, suture repaired MCL or repaired MCL-suture tape complex was measured.

RESULTS

While neither the MCL Repair nor the MCL Repair + ST restored valgus rotation to the MCL intact state, displacement was significantly smaller after MCL Repair + ST (p < 0.05). The knee rotation under external rotation torque in MCL Repair + ST did not differ MCL intact (n.s.), while with MCL Repair the rotation was significantly greater (p < 0.05). MCL Repair + ST did not cause an over-constraint of the knee in any of the tested loading conditions.

CONCLUSION

In a combined ACL-reconstruction-MCL-repair model, MCL Repair augmented with suture tape improved valgus and external rotation laxity when compared to MCL suture repair alone. Suture tape augmentation may provide this additional means of stabilization and can be added at the time of surgical repair of the MCL. Clinically this may result in lower failure rates and less residual laxity after MCL repair, as well as shorter immobilization times and faster return to play.

Posterolateral Corner Repair With Internal Bracing and Peroneal Nerve Neurolysis

Posterolateral corner (PLC) reconstruction has been shown to be an effective treatment for PLC injuries. Acute anatomical repair of the PLC has the same potential to stabilize the knee; however, outcomes are less defined. Surgical repair minimizes graft harvest morbidity and allows for the maintenance of native tissue proprioception. Furthermore, augmentation with a flat-braided suture (SutureTape; Arthrex) portends additional repair strength and protection. The purpose of this Technical Note and video is to provide our preferred method of PLC repair in a patient with an acute knee dislocation and injury to the biceps femoris, lateral collateral ligament, iliotibial band, popliteofibular ligament, and the meniscocapsular attachment of the lateral meniscus.

Comparison of the outcomes of isolated anterior cruciate ligament reconstruction and combined anterolateral ligament suture tape augmentation and anterior cruciate ligament reconstruction

OBJECTIVES

This study aims to compare the outcomes of isolated anterior cruciate ligament (ACL) reconstruction and combined anterolateral ligament (ALL) suture tape augmentation (STA) and ACL reconstruction after a minimum follow-up of two years.

PATIENTS AND METHODS

This retrospective study included 63 patients (36 males, 27 females; mean age 27.8±4.0; range, 19 to 35 years) who had unilateral ACL injury and participated in pivoting sports and were randomly assigned to undergo either isolated ACL reconstruction (Group 1, n=33) or combined ACL reconstruction and ALL STA (Group 2, n=30) between January 2015 and February 2018. The presence of an associated meniscal injury, chondral pathology, contralateral ACL rupture, and residual pivot shift; subjective and objective International Knee Documentation Committee scores; Cincinnati and Lysholm functional scores; KT-1000 measurements; and graft rupture rate were evaluated.

RESULTS

Patients were followed for a minimum of two years. The groups did not differ with respect to age, sex, side, time from injury to surgery, postoperative follow-up time, ACL graft size, contralateral ACL rupture, graft size, partial meniscectomy, chondral pathology or preoperative physical examination results. A total of 9.1% of the patients in Group 1 and 0% of those in Group 2 presented postoperative positive pivot shift (p=0.357). The graft failure rate was 6.06% (n=2) in Group 1 and 0% in Group 2 (p=0.270). In the final evaluation, compared with Group 1, Group 2 showed better anteroposterior clinical stability, as evaluated by KT-1000 arthrometry (p=0.006). Although better results were observed in Group 2, the clinical evaluation results for postoperative function did not differ significantly between groups.

CONCLUSION

Combined ALL STA and ACL reconstruction was found to be effective in improving subjective and objective outcomes. Nevertheless, these findings were not significantly superior to those of isolated ACL reconstruction with hamstring grafts, except for the side-to-side differential anterior laxity testing results.

Controversies in acute multiligamentary knee injuries (MLKI)

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.

Normal Kinematics of the Syndesmosis and Ankle Mortise During Dynamic Movements

Background:

Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space.

Methods:

Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition.

Results:

Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space (P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space (P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively.

Conclusion:

These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics.

Clinical Relevance:

Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.

Biomechanical assessment of lateral ulnar collateral ligament repair and reconstruction with or without internal brace augmentation

Background

Surgical treatment of posterolateral rotatory instability (PLRI) using primary repair or reconstruction of the lateral collateral ligament complex have proven inconsistent. This study aimed to test the hypothesis that augmentation of LUCL repair or palmaris longus tendon reconstruction using a suture tape augmentation would be associated with less rotational displacement and greater torque load to failure (LTF) compared with nonaugmented constructs.

Methods

Cadaveric elbows (n = 12 matched pairs) were used. Baseline stiffness and displacement values were obtained. The LUCL was transected followed by repair alone, repair with augmentation, reconstruction with palmaris longus graft, or reconstruction with augmentation. Specimens were retested including torque LTF. Paired t tests were performed to assess the biomechanical effects of augmentation.

Results

Augmentation was associated with higher LTF than repair and reconstruction alone (P = .008 and .047, respectively). Displacement was less with augmentation in reconstruction groups (P = .048) but not in repair groups. Suture tape augmentation maintained rotational stiffness better than repair alone (P = .01). Although reconstruction with augmentation maintained rotational stiffness better than nonaugmented reconstruction, the differences were not statistically significant (P = .057). Mode of failure for repair alone was predominantly suture pulling through repaired ligament. Augmented repairs primarily failed at the anchor-bone interface. Modes of failure for both reconstruction groups were similar, including graft tearing and/or slipping at the anchor.

Conclusion

When positioned in neutral forearm rotation and 90^o of flexion to simulate postoperative conditions, augmentation of LUCL repair or tendon reconstruction using suture tape is associated with better resistance to rotational loads compared with nonaugmented repair or reconstruction, while maintaining near-native rotational stiffness.

Outcomes Following ACL Reconstruction Based on Graft Type: Are all Grafts Equivalent?

PURPOSE OF REVIEW

Anterior cruciate ligament reconstruction is one of the most common orthopedic procedures performed, accounting for over 200,000 cases annually. Despite the high prevalence, there is still much debate as to the optimal graft choice. The purpose of this review is to evaluate the current literature and discuss the reported outcomes for the most common graft choices.

RECENT FINDINGS

The most common autografts being used include bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and quadriceps tendon (QT). Hamstring tendon might have a slightly higher re-tear rate when compared with BPTB (2.84 versus 2.80). However, BPTB has a higher rate of anterior knee and kneeling pain in the short- and mid-term follow-up. This has not been shown to be the case in long-term follow-up. Allograft is a viable option for revisions and primaries in patients greater than 35 years old; however, re-tear rate increases significantly in younger patients. ACL reconstruction graft choice is a highly studied and yet still exceedingly debated topic. Most large studies report either no significant difference or a small difference in failure rate and outcome scores between the different autograft choices. Allografts have been demonstrated to have an increased risk of failure in younger athletes and should be reserved for revision cases and those aged 35 years and older. Graft choice should ultimately be decided upon based on surgeon comfort and experience and individual patient characteristics.