Clinical outcome of primary medial collateral ligament-posteromedial corner repair with or without staged anterior cruciate ligament reconstruction

Do Age and Timing Influence the Outcomes of Single-stage Reconstruction of Multiple Ligament Knee Injuries? 5-10 Years Follow Up

OBJECTIVES

Multiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single-stage reconstruction of MLKIs.

METHODS

The patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF-36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann-Whitney U test or χ2 test.

RESULTS

A total of 102 MLKI patients managed by single-stage multi-ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2-10.7 years). At the last follow-up, no significant difference was found in knee ROM, functional scores, and patient-reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%-80.4% of patients, and grade B in 11.8%-23.5% patients.

CONCLUSION

The single-stage reconstruction of MLKIs can obtain comparative long-term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries-Which Is Best? A Systematic Review and Meta-analysis

BACKGROUND

Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries.

PURPOSE

To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach.

RESULTS

In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength.

CONCLUSION

Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

Acute Percutaneous Repair of Medial Collateral Ligament With Suture Augmentation in the Multiligamentous Injured Knee Results in Good Stability and Low Rates of Postoperative Stiffness

Purpose

To assess the clinical and patient-reported outcome measures (PROMs) of acute superficial medial collateral ligament (sMCL) repair with suture augmentation (SA) in the setting of a multiligamentous injured knees (MLIKs) at 2-year follow-up.

Methods

A retrospective analysis of consecutive patients with MLIK with grade III sMCL injuries who underwent acute (<6 weeks) sMCL repair with SA was conducted. Clinical follow-up was performed at minimum 1-year postoperatively, and PROMs were collected at the latest follow-up (minimum 2 years' postoperatively). Continuous variables were reported in median with interquartile range (IQR).

Results

A total of 20 patients (41.4 [28.5-47.9] years of age) with grade III sMCL injury and additional injury to 1 cruciate ligament (KDI-M; n = 13) or bicruciate (KDIII-M; n = 7) were enrolled with a median follow-up of 4.3 (3.6-5.2) years. In total, 90% (n = 18) of patients with MLIK treated with acute sMCL repair and early range of motion rehabilitation protocol demonstrated negative valgus laxity stress testing in 0 and 30° flexion and low reoperation rates (n = 1, 5%) due to stiffness. In addition, good-to-excellent subjective outcomes were reported at final follow-up: median International Knee Documentation Committee 82.2 (78.7-90.8), Lysholm 95.0 (90.0-100.0), modified Cincinnati Score 89.0 (83.3-96.0), Single Assessment Numeric Evaluation 90.0 (83.8-95.0), Forgotten Joint Score 79.2 (62.5-91.7), Tegner 5.0 (IQR 4.0-6.0), and ACL-Return to Sport after Injury Scale 78.3 (IQR 66.7-90.0).

Conclusions

In this study, 20 heterogenous patients with MLIKs treated with acute percutaneous sMCL repair with SA had excellent stability, low rates of postoperative stiffness, and good-to-excellent PROMs at short-term follow-up.

Level of Evidence

Level IV, therapeutic case series.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review

PURPOSE

To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up.

METHODS

A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria.

RESULTS

A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively.

CONCLUSIONS

MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures

PURPOSE

To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports.

METHODS

Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities.

RESULTS

A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF.

CONCLUSION

Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II-IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort.

LEVEL OF EVIDENCE

Level IV.

The management of combined ACL and MCL injuries: A systematic review

Background

The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies.

Methods

A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score.

Results

52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury.

Conclusions

Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.

Current concepts on management of medial and posteromedial knee injuries

Traditionally, while managing ligament injuries around the knee, medial side injuries are frequently overlooked or considered 'benign' with very little influence on overall knee stability outcomes. However, much has changed in the recent past, and like the lateral side of the knee, it is gaining considerable attention. It is now well known that the Medial collateral ligament and Posteromedial corner are fundamentally two distinct structures that differ in anatomy and biomechanics. When it comes to decision making between conservative versus operative approach for medial side injuries, treating orthopaedic surgeons are subjected to walking on a thin line trying to balance between potential residual laxity and joint stiffness. This review will delve into some of the recent works focusing on the medial side injuries and discuss the evolving concepts.

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.

Comparison between single- and double-bundle anterior cruciate ligament reconstructions for knee with grade 2 medial collateral ligament injury

This research discussed clinical outcomes of anterior cruciate ligament reconstruction accompanied by conservative treatment for grade 2 medial collateral ligament injury, and comparison was performed between double-bundle and single-bundle anterior cruciate ligament reconstruction.Clinical information was retrospectively collected for 41 cases suffering anterior cruciate ligament injuries accompanied by grade 2 medial collateral ligament injuries. Within 14 days after their injuries 22 cases received single-bundle anterior cruciate ligament reconstruction (SB group), while 19 were treated with double-bundle medial collateral ligament reconstruction (DB group). Physical statuses were estimated based on International Knee Documentation Committee (IKDC) and Lysholm scores, Lachman, pivot shift and manual valgus test, and range of motion (ROM), while side-to-side difference was estimated through KT 2000 arthometer.Anterior cruciate ligament reconstruction accompanied by conservative treatment showed significantly improved anteroposterior, rotational and valgus stability, and IKDC and Lysholm scores (in comparison to pre-operative status, P < .05). Incidence of pivot shift was dramatically lower in DB group (2/19) than in SB group (7/22 and 2/22; P = .028). No substantial dissimilarity existed between DB and SB groups either in Lachman and valgus tests, KT 2000, ROM, IKDC, or Lysholm scores.Anterior cruciate ligament reconstruction accompanied by conservative treatment could achieve outstanding stability and functional manifestations for cases facing anterior cruciate ligament injury accompanied by grade 2 medial collateral ligament injury. Moreover, double-bundle anterior cruciate ligament reconstruction is superior to single-bundle operation in treating rotational instability of the knee.Level of evidence: Retrospective comparative study, Level III.

Influence of posteromedial corner injuries on clinical outcome and second-look arthroscopic findings after allograft transtibial anterior cruciate ligament reconstruction

BACKGROUND

The purpose of this study was to evaluate the influence of posterior medial corner (PMC) injuries on clinical outcome and second-look arthroscopic findings after anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventy-eight consecutive patients underwent a second-look arthroscopic surgery after ACL reconstruction and magnetic resonance imaging (MRI) examination of the PMC. The patients were divided into a PMC intact group (n = 42) and a PMC injured group (n = 36). The stability and clinical outcomes were evaluated using the Lachman test, pivot-shift test, a KT-2000 arthrometer, and the Lysholm knee scoring scale. Graft tension and synovial coverage were evaluated in second-look arthroscopy.

RESULTS

The clinical function showed no significant differences regarding PMC injury. Although the graft tendon tension revealed no significant differences (p = 0.141), the second-look arthroscopic findings indicated that the PMC intact group showed better synovial coverage compared to the PMC injured group (p = 0.012).

CONCLUSION

Patients who injured the PMC had poor synovial coverage as assessed by second-look arthroscopic findings after transtibial ACL reconstruction, even though clinical outcomes and stability showed no significant differences.

The multiple ligament-injured knee: When is primary repair an option?

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.

Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction

PURPOSE

The purpose of this study was to carefully analyse the reasons for revision ACLR failure to optimize the surgical revision technique and minimize the risk of recurrent re-rupture. Large studies with a minimum of 2 years of follow-up that clinically examine patients with revision ACLR are rare.

METHODS

Between 2013 and 2016, 111 patients who underwent revision ACLR were included in the retrospective study. All patients were examined for a minimum of 2 years after revision surgery (35 ± 3.4 months, mean ± STD) and identified as "failed revision ACLR" (side-to-side difference ≥ 5 mm and pivot-shift grade 2/3) or "stable revision ACLR".

RESULTS

Failure after revision ACLR occurred in 14.5% (n = 16) of the cases. Preoperative medial knee instability (n = 36) was associated with failure; thus, patients had a 17 times greater risk of failure when medial knee instability was diagnosed (p = 0.015). The risk of failure was reduced when patients had medial stabilization (n = 24, p = 0.034) and extra-articular lateral tenodesis during revision surgery (n = 51, p = 0.028). Increased posterior tibial slope (n = 11 ≥ 12°, p = 0.046) and high-grade anterior knee laxity (side-to-side difference > 6 mm and pivot-shift grade 3, n = 41, p = 0.034) were associated with increased failure of revision ACLR. Obese patients had a 9 times greater risk of failure (p = 0.008, n = 30).

CONCLUSION

This study demonstrates the largest revision ACLR patient group with pre- and postoperative clinical examination data and a follow-up of 2 years published to date. Preoperative medial knee instability is an underestimated risk factor for revision ACLR failure. Additionally, high-grade anterior knee laxity, increased PTS and high BMI are risk factors for failure of revision ACLR, while additional medial stabilization and lateral extra-articular tenodesis reduce the risk of failure.

LEVEL OF EVIDENCE

III.