1
|
Hoit G, Chahal J, Khan R, Rubacha M, Nauth A, Whelan DB. Early Compared with Delayed Reconstruction in Multiligament Knee Injury: A Retrospective Propensity Analysis. J Bone Joint Surg Am 2024:00004623-990000000-01177. [PMID: 39172809 DOI: 10.2106/jbjs.23.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The purpose of this study was to compare outcomes following early compared with delayed reconstruction in patients with multiligament knee injury (MLKI). METHODS A retrospective cohort analysis of patients with MLKI from 2007 to 2019 was conducted. Patients who underwent a reconstructive surgical procedure with ≥12 months of postoperative follow-up were included. Patients were stratified into early reconstruction (<6 weeks after the injury) and delayed reconstruction (12 weeks to 2 years after the injury). Multivariable regression models with inverse probability of treatment weighting (IPTW) were utilized to compare the timing of the surgical procedure with the primary outcome (the Multiligament Quality of Life questionnaire [MLQOL]) and the secondary outcomes (manipulation under anesthesia [MUA], Kellgren-Lawrence [KL] osteoarthritis grade, knee laxity, and range of motion). RESULTS A total of 131 patients met our inclusion criteria, with 75 patients in the early reconstruction group and 56 patients in the delayed reconstruction group. The mean time to the surgical procedure was 17.6 days in the early reconstruction group compared with 280 days in the delayed reconstruction group. The mean postoperative follow-up was 58 months. The early reconstruction group, compared with the delayed reconstruction group, included more lateral-sided injuries (49 patients [65%] compared with 23 [41%]; standardized mean difference [SMD], 0.44) and nerve injuries (36 patients [48%] compared with 9 patients [16%]; SMD, 0.72), and had a higher mean Schenck class (SMD, 0.57). After propensity adjustment, we found no difference between early and delayed reconstruction across the 4 MLQOL domains (p > 0.05). Patients in the early reconstruction group had higher odds of requiring MUA compared with the delayed reconstruction group (24 [32%] compared with 8 [14%]; IPTW-adjusted odds ratio [OR], 3.85 [95% confidence interval (CI), 2.04 to 7.69]; p < 0.001) and had less knee flexion at the most recent follow-up (β, 6.34° [95% CI, 0.91° to 11.77°]; p = 0.023). Patients undergoing early reconstruction had lower KL osteoarthritis grades compared with patients in the delayed reconstruction group (OR, 0.46 [95% CI, 0.29 to 0.72]; p < 0.001). There were no differences in clinical laxity between groups. CONCLUSIONS Early reconstruction of MLKIs likely increases the likelihood of postoperative arthrofibrosis compared with delayed reconstruction, but it may be protective against the development of osteoarthritis. When considering the timing of MLKI reconstruction, surgeons should consider the benefit that early reconstruction may convey on long-term outcomes but should caution patients regarding the possibility of requiring an MUA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Graeme Hoit
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
| | - Jaskarndip Chahal
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
| | - Ryan Khan
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Matthew Rubacha
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aaron Nauth
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Daniel B Whelan
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada
- Division of Orthopaedic Surgery, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Gupta S, Ashish B, Chavan SK, Gupta P. Reconstruction of Superficial Medial Collateral Ligament: Modified Danish Technique with Dual Adjustable Loop Suspensory Fixation. Arthrosc Tech 2023; 12:e2141-e2151. [PMID: 38196880 PMCID: PMC10772961 DOI: 10.1016/j.eats.2023.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/20/2023] [Indexed: 01/11/2024] Open
Abstract
Injury to the superficial medial collateral ligament (MCL) is treated conservatively for low-grade injury and with surgery for high-grade injury, especially in association with cruciate ligament injury. Acute injuries are treated with MCL repair, and chronic injury requires reconstruction. Anatomic MCL reconstruction can be done using free allograft or autograft and fixed using screws or suspensory fixation. We describe here an anatomic technique that is a modification of a Danish technique in which we reroute the semitendinosus, keeping its tibial attachment intact. The semitendinosus is rerouted anatomically in the tibial tunnel, and a graft is then passed anatomically in the femoral tunnel. The graft is fixed in both tunnels with adjustable loop suspensory fixation, which gives the unique advantage of controlled tensioning of the graft for MCL reconstruction. In this technique further re-tensioning is possible if the knee is unstable in valgus stress, even after final fixation.
Collapse
|
4
|
Kaarre J, Runer A, Benvegnu NA, Dadoo S, Persson F, Nammour M, Musahl V, Samuelsson K. Anatomic Flat Double-Bundle Medial Collateral Ligament Reconstruction. Arthrosc Tech 2023; 12:e1265-e1270. [PMID: 37654890 PMCID: PMC10466096 DOI: 10.1016/j.eats.2023.03.017] [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: 01/17/2023] [Accepted: 03/18/2023] [Indexed: 09/02/2023] Open
Abstract
Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL.
Collapse
Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
- Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Neilen A. Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Fabian Persson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Michael Nammour
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| |
Collapse
|
5
|
Editorial Commentary: The Timing and Treatment of Combined Anterior Cruciate Ligament-Medial Collateral Ligament Injuries: Conservative Management, Early Repair, Augmentation, and Delayed Reconstruction of the Medial Collateral Ligament. Arthroscopy 2023; 39:1108-1110. [PMID: 36872028 DOI: 10.1016/j.arthro.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/23/2022] [Accepted: 09/09/2022] [Indexed: 03/07/2023]
Abstract
Medial collateral ligament (MCL) injuries are commonly encountered in conjunction with anterior cruciate ligament injuries. MCL tears do not universally heal, and residual MCL laxity is not always well tolerated. Although residual MCL laxity results in excess stress on an anterior cruciate ligament reconstruction and may require additional treatment, relatively little interest has been paid to concomitant treatment. Adherence to the dogma of universal conservative treatment of MCL tears in this setting squanders opportunities for preservation of native anatomy and improvements in patient outcomes. Although we currently lack the necessary information to provide evidence-based decision making for combined injuries, the time has come to renew both clinical interest and research interest in pursuing better management of these injuries in high-demand patients.
Collapse
|