Major concern in the multiligament-injured knee treatment: A systematic review

Multiligament Knee Injuries: Updates of the Debates

Background

Multiligament knee injuries (MLKI) constitute a complex and challenging problem. They can have life-modifying consequences, such as the development of osteoarthritis, and an inability to return to work or sport. At present, there is insufficient high-level evidence or expert consensus to support one management strategy over another.

Purpose

The purpose of this article is to review the updates of the debates about multiligament knee injuries, diagnosis, treatment options, and rehabilitation protocols. This article also aimed to elucidate expert opinions on controversial issues in MLKI from scholars from Egypt and the Arab world.

Study Design

Comprehensive review; Level of evidence, 5.

Methods

Medline, Embase, PubMed, and Physiotherapy Evidence Database (PEDro) databases were searched between inception and February 2024. The terms: 'multi-ligament' OR 'multiligament' OR 'multi ligament' OR multiple ligaments' AND 'knee' were used to extract relevant studies.

Results

Overall, 1009 eligible studies were identified. After applying inclusion and exclusion criteria, there were 251 articles; of which there were 24 systematic reviews and 227 clinical studies.

Conclusion

The relative rarity of MLKI makes it difficult to perform good-powered prospective randomized studies evaluating these injuries. The debates are expected due to the diversity of presentations of MLKI with regard to types of injured ligaments, site of injury within the ligament, time of presentation, and the different management methods. Thorough knowledge and experience are mandatory to tailor a diagnostic workup and management plan for each case.

Outcomes after multiligament knee injury worsen over time: A systematic review and meta-analysis

PURPOSE

Multiligament knee injuries (MLKIs) are devastating injuries that can have life-long consequences. A management plan requires the decision to perform surgery or not, timing of surgery, consideration of repair versus reconstruction, reconstruction technique and reconstruction graft choice. The purpose of this study was to analyze development of clinical outcomes of MLKIs over time at a minimum of 2 years of follow-up.

METHODS

Four databases were queried for surgical outcome-based studies of MLKIs published from 01/2000 through 09/2022 with a minimum 2-year follow-up. Technique articles, nonoperative treatment, arthroplasty, pediatric and review articles were excluded. Study characteristics including design, number of patients, age, follow-up period, anatomical region and posterior-cruciate ligament (PCL)-based injury were collected. Primary outcomes were Lysholm, International Knee Documentation Committee (IKDC) outcome scores and Tegner activity score. Random-effects model analysis was performed.

RESULTS

After the application of inclusion and exclusion criteria, 3571 patients in 79 studies were included in the analysis. The mean age at surgery was 35.6 years. The mean follow-up was 4.06 years (range 2-12.7). The mean Lysholm score at 2-year follow-up was 86.09 [95% confidence interval [CI]: 82.90-89.28], with a yearly decrease of -0.80 [95% CI: -1.47 -0.13], (p = 0.0199). The mean IKDC at 2 years was 81.35 [95% CI: 76.56-86.14], with a yearly decrease of -1.99 [95% CI: -3.14 -0.84] (p < 0.001). Non-PCL-based injuries had a higher IKDC 83.69 [75.55-91.82] vs. 75.00 [70.75-79.26] (p = 0.03) and Lysholm score 90.84 [87.10-94.58] versus 84.35 [82.18-86.52] (p < 0.01) than PCL-based injuries, respectively.

CONCLUSION

According to the present systematic review and meta-analysis of MLKIs with minimum 2-year follow-ups, the patients who suffered an MLKI can expect to retain around 80-85% of knee function at 2 years and can expect a yearly deterioration of knee function, depending on the score used. Inferior outcomes can be expected for PCL-based injuries at 2 years postoperative.

LEVEL OF EVIDENCE

Level IV meta-analysis.

A Systematic Review of all Published Systematic Reviews (SRs) on Multiligament Knee Injuries (MLKIs)

Introduction

Multiligament knee injuries are an uncommon and heterogeneous group of injuries and standardizing reporting on these injuries is a challenge. Given the complexity of multiligament knee injuries (MLKIs) and the ongoing debate regarding optimal management strategies, a comprehensive understanding of the current evidence is essential to guide evidence-based decision-making and improve patient care.

Aim

In this systematic review, we aimed to assess the systematic reviews and meta-analyses on MLKIs and synthesize their findings. This will enable us to identify areas where the current evidence is strong and where further research is needed.

Methods

Adhering to PRISMA guidelines, a comprehensive search in PubMed, Embase, and Cochrane Library identified 36 eligible systematic reviews. AMSTAR 2 criteria were used to assess the methodological quality. For agreement between the raters, the inter-rater reliability Cohen's kappa was used.

Results

Most of the systematic reviews assessed with AMSTAR 2 criteria had a critically low level of evidence (n = 26), with the rest being low (n = 8), moderate (n = 3), and one high, indicating caution in interpreting findings.

Discussion

This study highlights the scarcity of high-quality systematic reviews (SRs) on multiligament knee injuries (MLKIs), largely due to the diversity in injury patterns, management protocols, and reporting standards.

Conclusion

Most research on these injuries are of low quality, and recommendations have been made to improve reporting. Many areas of these injuries require further studies to improve the outcomes.

Patient-Reported Outcomes of Bicruciate Multiligament Versus Single Cruciate Multiligament Knee Injuries

BACKGROUND

Multiligament knee injuries (MLKIs) are heterogeneous, and bicruciate knee ligament injuries are considered a serious form of this injury. The current literature tends not to distinguish between single and bicruciate MLKI when reporting outcomes.

PURPOSE

To investigate patient-reported outcomes after surgical treatment of MLKI comparing single cruciate MLKI with bicruciate MLKI. The secondary aim was to investigate the influence of different factors on patient-reported outcomes after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study was designed as a cross-sectional cohort study. Patients who underwent surgical treatment for MLKI at a single level 1 trauma center between January 2013 and December 2020 were included in this study. Patient-reported outcomes included the Tegner score, Lysholm score, International Knee Documentation Committee (IKDC) subjective knee form, Knee injury and Osteoarthritis Outcome Survey (KOOS), and a visual analog scale for pain.

RESULTS

Of the 191 patients meeting the inclusion criteria, 124 (65%) agreed to participate and had a complete data set with a follow-up time at a mean 74 ± 27 months. Patients with single cruciate MLKI (type I) had significantly higher scores for IKDC (P = .007), Lysholm (P = .012), KOOS Pain (P = .04), KOOS Activities of Daily Living (P = .01), KOOS Sport and Recreation (P = .005), KOOS Quality of Life (P = .04), KOOS4 (which considers the subscales of Pain, Symptoms, Sport and Recreation, and Quality of Life) (P = .01), Tegner (P = .04), and visual analog scale for pain during activity (P = .004) when compared with patients with bicruciate MLKI (type II-type IV). Furthermore, age was significantly associated with a lower IKDC (P = .001), and an increased severity of injury was significantly associated with IKDC (P = .015), KOOS4 (P = .022), and Lysholm (P = .029) scores.

CONCLUSION

MLKIs involving a single cruciate ligament had significantly higher patient-reported postoperative outcome measures compared with bicruciate MLKIs. Age and type of injury were important predictors for outcomes. Patients presenting with dislocated knees had lower patient-reported outcomes; however, there was no significant difference in outcomes between bicruciate MLKIs and patients presenting with dislocated knees.

Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

Modern multiligament knee injury surgical reconstruction techniques can achieve excellent knee function and patient satisfaction, with low complication rates

PURPOSE

To report on the recovery of strength and functional capacity symmetry following multiligament knee surgical reconstruction (MLKR), as well as the capacity of athletes to return to sport.

METHODS

This prospective cohort study recruited 47 patients undergoing MLKR between February 2018 and July 2021. Forty patients had full outcome assessment postoperatively at 6, 12 and 24 months and were included in the analysis, 75% were knee dislocation one injuries and 60% were injured playing sport. Patient-reported outcome measures (PROMs) assessed included the International Knee Documentation Committee score, the Knee Outcome Survey, the Lysholm Knee Score and the Tegner Activity Scale (TAS). Patient satisfaction was also assessed. Objective assessment included assessment of active knee flexion and extension range of motion (ROM), the single (single horizontal hop for distance [SHD]) and triple (triple horizontal hop for distance [THD]) hop tests for distance and peak isokinetic knee flexor/extensor torque.

RESULTS

All PROMs significantly improved (p < 0.001) from presurgery to 24 months postsurgery. At 24 months, 70% of patients were satisfied with their sports participation. Active knee flexion (p < 0.0001) and extension (p < 0.0001) ROM significantly improved over time, as did the limb symmetry indices (LSIs) for the SHD (p < 0.0001), THD (p < 0.0001), peak knee extensor (p < 0.0001) and flexor (p = 0.012) torque. While LSIs for the SHD, THD and knee flexor strength tended to plateau by 12 months, knee extensor strength continued to improve from 12 to 24 months.

CONCLUSIONS

The majority of patients undergoing modern MLKR surgical techniques and rehabilitation can achieve excellent knee function, with low complication rates.

LEVEL OF EVIDENCE

Level IV.

Surgeon Factors Rather Than Patient Factors Account for Variation in Recommended Treatment Strategy for Patients With Multiligament Knee Injury

OBJECTIVES

To seek the factors associated with timing, staging, and type of surgery in the management of multiligament knee injuries.

METHODS

DESIGN

Cross-sectional scenario-based experiment.

SETTING

Fifteen fictional patient scenarios with randomized elements.

PARTICIPANTS

Fracture surgeons of the Science of Variation Group, an international collaborative of musculoskeletal surgeons who studies variation in care, were invited to participate. Surgeons with limited experience treating multiligament knee injuries were asked to self-exclude.

OUTCOME MEASURES AND COMPARISONS

Surgeon recommendations for operative treatment, timing of surgery, and use of open surgery in addition to arthroscopy were measured. Patient factors (age, time from injury, contralateral fracture, knee dislocation, combinations of ruptured ligaments, and preexisting osteoarthritis) and surgeon factors (gender, practice location, years of experience, and supervision of trainees) associated with surgeon recommendations were assessed.

RESULTS

Eighty-five surgeons participated, of which most were men (89%) and practiced in the United States (44%) or Europe (38%). Operative treatment was less likely among older patients (odds ratio [OR] = 0.051) and preexisting osteoarthritis (OR = 0.32) and more likely in knee dislocation (OR = 1.9) and disruption of anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament with or without medial collateral ligament (MCL; OR = 5.1 and OR = 3.1, respectively). Disruption of anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament was associated with shorter time to surgery (β = -11). Longer time to surgery was associated with contralateral fracture (β = 9.2) and surgeons supervising trainees (β = 23) and practicing in Europe (β = 13). Surgeon factors accounted for more variation in timing than patient and injury factors (5.1% vs. 1.4%, respectively). Open surgery was more likely in patients with lateral collateral ligament injury (OR = 2.9 to 3.3).

CONCLUSIONS

The observation that surgeons were more likely to operate in younger patients with more severe injury has face validity, while the finding that surgeon factors accounted for more variation in timing of surgery than patient or injury factors suggests that treatment variation is based on opinion more so than evidence.

LEVEL OF EVIDENCE

Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

ACL reconstruction demonstrates better stability compared to ACL repair for patients with Schenck III and IV knee dislocations

PURPOSE

This study compared mid-term outcomes of two anterior cruciate ligament (ACL) restoration techniques within an early total surgical care of acute knee dislocation: repair with additional internal bracing (ACLIB) and reconstruction with autograft (ACLR). Initial results at 12 months demonstrated that ACLR offered superior stability compared to ACLIB.

METHODS

Retrospective clinical study of patients with acute type III or IV KD. ACLIB or ACLR procedures were performed accompanied by simultaneous suture and internal bracing of the posterior cruciate ligament (PCL) and repair with lateral augmentation of the medial and lateral complex injuries utilizing Arciero's reconstruction technique. Patient-reported outcome measurements (PROMs), instrumental stability assessment via the Rolimeter-Test, and stress radiographs were analyzed.

RESULTS

The study involved 20 patients (5 IIIM, 5 IIIL, and 10 IV injuries) with an average follow-up of 35.2 ± 7.4 months. Notable differences in anterior tibial translation on stress radiography favouring ACLR persisted at 24-month follow-up in side-to-side difference (SSD) (ACLIB 2.8 ± 2.5 mm vs. ACLR 0.3 ± 2.6 mm; p = 0.0487), but Rolimeter test variance diminished (SSD ACLIB 2.5 ± 0.9 mm vs. ACLR 1.8 ± 1.7 mm). Both groups showed excellent PROMs (Lysholm Score: ACLIB 84.4 ± 15.8 vs. ACLR 89.9 ± 9.0; IKDC Score: ACLIB 77.1 ± 16.2 vs. ACLR 77.7 ± 8.6).

CONCLUSION

Our results indicate improved anterior stability at 12 months, which persisted at 24 months after ACL reconstruction compared with ACL repair by stress radiography. Both groups showed favourable patient-reported outcomes throughout the follow-up period. Notable rates of postoperative knee stiffness were observed in both groups. These were successfully managed with early, one-time arthroscopic arthrolysis within the first seven months of treatment, resulting in no major range of motion limitations at the 24-month follow-up.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

Effect of Timing of Surgery on the Outcomes and Complications in Multi-ligament Knee Injuries: An Overview of Systematic Reviews and A Meta-analysis

Background and Aims

Multi-ligament knee injuries (MLKI) are serious and challenging to manage. This study aimed to elucidate the impact of surgical timing on both early and long-term outcomes following an MLKI.

Methods

A comprehensive search strategy was employed across PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were identified using a combination of relevant keywords encompassing "multi-ligament knee injury," "knee dislocation," "reconstruction," "repair," "surgery," and "timing," and their synonyms, along with appropriate Boolean operators. Selection of articles (systematic reviews and meta-analyses) adhered to predefined inclusion and exclusion criteria. Furthermore, a meta-analysis was conducted utilizing data extracted from primary studies.

Results

Early surgery for MLKI demonstrated a significant advantage over delayed surgery, reflected by significantly higher Lysholm scores (Mean Difference [MD] 3.51; 95% Confidence Interval [CI] 1.79, 5.22), IKDC objective scores (Mantel-Haenszel Odds Ratio [MH-OR] 2.95; 95% CI 1.30, 6.69), Tegner activity scores (MD 0.38; 95% CI 0.08, 0.69), and Mayer's ratings (MH-OR 5.47; 95% CI 1.27, 23.56). In addition, we found a significantly reduced risk of secondary chondral lesions (MH-OR 0.33; 95% CI 0.23, 0.48), lower instrumented anterior tibial translation in the early surgery group (MD -0.92; 95% CI -1.83, -0.01), but no significant difference was observed in the secondary meniscal tears, between the two groups. However, the early surgery group also exhibited a significantly increased risk of knee stiffness (MH-OR 2.47; 95% CI 1.22, 5.01) and a greater likelihood of requiring manipulation under anaesthesia (MH-OR 3.91; 95% CI 1.10, 13.87).

Conclusion

Early surgery for MLKI improves function, and stability, and reduces further articular cartilage damage, but increases the risk of stiffness.

Level of Evidence

IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01224-1.

An examination from 1990 to 2019: investigating the burden of knee dislocation on a global scale

Background

The literature on the disease burden of knee dislocation is lacking. The aim of the study is to systematically assess the global burden, trends, causes, and influencing factors of knee dislocation.

Methods

The incidence and years lived with disability (YLDs) of knee dislocation were assessed globally, as well as at the regional and national levels from 1990 to 2019. Subsequent analyses focused on the age and gender distribution related to knee dislocation. An investigation into the main causes of knee dislocation followed. Finally, the Pearson correlation between age-standardized rates and social-demographic index (SDI) was calculated.

Results

Although the age-standardized incidence and YLDs rate of knee dislocation decreased over the past 30 years, the incidence and YLDs number increased. The disease burden remained higher in males compared to females. Males and females showed different patterns of incidence rates in each age group, but their YLDs rates were similar. Over the past 30 years, the disease burden of knee dislocation increased in the older population while declining in the younger population. Falls had consistently emerged as the most important cause for both incidence and YLD rates. Additionally, a positive correlation between SDI and the disease burden of knee dislocation was found.

Conclusion

The disease burden of knee dislocation remains heavy. It is essential to recognize the evolving epidemiology of knee dislocation. Utilizing data-driven assessments can assist in formulating public health policies and strategies to improve overall well-being.

A rare concomitant ipsilateral hip and knee dislocations: A case report and review of the literature

Ipsilateral hip and knee dislocation is a rare and complex injury that usually results from high-energy trauma. Only 14 cases were reported in the literature so far. We report the case of a 35-year-old man who presented with an ipsilateral right hip and knee dislocation after being involved in a road traffic accident. A contralateral floating knee was associated. The hip dislocation was associated to a posterior wall fracture of the acetabulum and a femoral head fracture. The knee dislocation was compound and associated with a patella fracture. The hip dislocation was reduced. The posterior wall and the femoral head fractures were treated conservatively. The knee dislocation was reduced and stabilized by external fixator. Early postoperative infection occurred and was treated surgically. At the last follow-up, the knee was ankylosed at 5° of flexion with a bony bridge between the femoral condyle and the tibial plateau. The patient described an occasional hip pain on exertion. He had full range of motion of the right hip. No avascular necrosis of the femoral head was seen. Outcomes of simultaneous hip and knee dislocation are very variable and remain unpredictable. The timing of reducing the hip joint and the knee.

Two-stage ligament reconstruction with remnant preservation as treatment of knee dislocation

OBJECTIVE

The purpose of this study was to evaluate the clinical outcomes of two-stage reconstruction (peripheral reconstruction in phase I and central anterior cruciate ligament (ACL) / posterior cruciate ligament (PCL) reconstruction in phase II) with remnant preservation for patients with knee dislocation.

METHODS

A total of 70 patients (10 IIIM, 17 IIIL, and 43 IV) with knee dislocation were randomly divided into the remnant-preserved group and the simple reconstruction group. Patients underwent two-stage reconstruction, including the reconstruction of collateral ligament in phase I and the reconstruction of ACL/PCL in phase II (12 weeks after phase I). Grafts were harvested from the semitendinosus and gracilis tendons from both lower limbs. After the surgery, the joint flexion and extension, bone tunnel and ligament healing, and joint stability were evaluated.

RESULTS

After the surgery, the lateral stability recovered in all patients, and X-ray revealed a good position of bone tunnel. Follow-up was performed at 12 months postoperatively and ranged from 24 to 91 months. At the final follow-up, knee flexion angle, IKDC, Lysholm, and Tegner scores were all higher in both groups compared to the preoperative period. Notably, the remnant-preserved group showed superior results in these parameters compared to the simple reconstruction group. There was statistical significance between the two groups in terms of the Lachman test.

CONCLUSION

The knee function was well recovered after two-stage ligament reconstruction with remnant preservation.

Outcomes of Operative Management of Multi-Ligament Knee Injuries in an Adolescent Population: A Retrospective Case Series

Background: Multi-ligament knee injuries in adolescent patients are rare. The aim of this study was to describe the presentation, surgical management, and patient outcomes following multi-ligament knee injuries in an adolescent cohort. Methods: A retrospective case series was conducted involving all patients aged ≤18 years who underwent surgery for a multi-ligament knee injury at a single institution between March 2005 and January 2015. Outcome questionnaires were administered, including the pediatric version of the International Knee Documentation Committee (Pedi-IKDC), Lysholm score, Tegner activity scale, and an internal physical activity questionnaire. Results: Twenty-three knees from 23 patients were included with a mean (SD) age of 16.4 (± 2.3) years at time of injury. In this study, multi-ligament knee injuries in adolescents resulted mainly from sports-related accidents. The most commonly injured structures requiring reconstruction or repair were the anterior cruciate ligament (91%), the medial collateral ligament (57%), posterior cruciate ligament (22%), posterolateral corner (22%), and lateral collateral ligament (15%). Meniscal procedures were performed concurrently in 65% of knees. Examination at final follow-up, occurring at a median of 20.1 months, demonstrated 100% knees could achieve full extension, and 87% could achieve full flexion. Subsequent manipulation under anesthesia and arthroscopic lysis of adhesions was performed in four (17%) knees. Prior to the management of arthrofibrosis, the average range of motion was 13 degrees fixed flexion to 95 degrees flexion, which increased postoperatively to 2 degrees fixed flexion to 120 degrees flexion at a median of 20 months. Questionnaires were returned by 12 patients (52%) at a median of 3.7 years postoperatively. The mean Pedi-IKDC, Lysholm, and Tegner scores were 81.0 ± 18.1, 82.5 ± 15.5, and 8.3, respectively. Conclusions: The most commonly injured structure requiring reconstruction or repair was the anterior cruciate ligament after multi-ligament knee injury. Patients with multi-ligament knee injuries should be investigated for concomitant meniscal injuries. Patients were generally able to achieve good functional outcomes at short-term follow-up. Level of Evidence: IV retrospective case series Key Concepts•In this study, multi-ligament knee injuries in children and adolescents resulted mainly from sports-related injuries, and a smaller number were related to traffic accidents.•The most commonly injured structures requiring reconstruction or repair were the anterior cruciate ligament, followed by the medial collateral ligament, posterior cruciate ligament, posterolateral corner, and lateral collateral ligament.•Meniscal injuries should be investigated in this population, as concomitant meniscal procedures were required in 65% of knees.•• Postoperative functional results following operative management of multi-ligament knee injuries were good at shortterm follow-up and return to sport activities was possible.

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.

Bilateral Knee Dislocations in an Active Duty Service Member: A Case Report

This case highlights a staged operative approach for a patient who sustained bilateral knee dislocations and subsequent staged operative treatment and rehabilitation. This patient underwent bilateral multiligamentous knee reconstructions and left-sided peroneal nerve allografting because of complete peroneal nerve palsy. The initial treatment was bilateral medial collateral ligament reconstructions, posterolateral corner reconstructions, and capsular repairs with left leg peroneal nerve allografting and repair of avulsed biceps femoris tendon. The patient underwent physical therapy following the first stage procedure until he regained appropriate motion and soft tissue healing occurred. Subsequently, combined anterior cruciate and posterior cruciate ligament reconstructions were performed in a staged fashion to allow one leg to fully bear weight for rehabilitation purposes. With the help of a multidisciplinary surgical and rehabilitation team, the patient has regained the stability of his knees and achieved acceptable functional outcomes. A staged systematic approach to multiligamentous bilateral knee reconstruction can provide optimal pain management, obtain initial joint stability, minimize complications, and achieve acceptable functional outcomes. Surgical techniques to first restore medial and lateral structures can be utilized to provide initial valgus and varus stability while allowing for knee mobilization and, eventually, in-line ambulation, before staged anterior and posterior cruciate ligament reconstructions. This case demonstrates a multistaged approach to bilateral knee dislocations with favorable outcomes in a 23-year-old active duty patient.

Techniques for Fixing Anterior Cruciate Ligament Tibial Avulsion Fractures in Multiligament Knee Injuries

Background

In patients with multiligament knee injuries, anterior cruciate ligament (ACL) tears are often reconstructed. Recent studies have shown good results when the ACL tibial avulsions are repaired. The advantages of ACL tibial avulsion repair are the preservation of the native anatomy, reduction in donor site morbidity, and lower risk of tunnel convergence.

Indications & Technique Description

We show 2 techniques for repairing ACL tibial avulsion fractures. The first case describes the use of hybrid fixation (screw and suture), with staged repair and reconstruction in a patient with high-energy knee fracture-dislocation. The second case describes the use of suture ACL repair via tunnels in a patient with a low-energy knee dislocation and an ACL tibial avulsion fracture. When repairing ACL tibial avulsion fractures, screw fixation is recommended for larger tibial fragments. In smaller comminuted fragments, tying sutures passed through the ACL via tibial tunnels may be more appropriate.

Results

Several studies have demonstrated good postoperative results in patients following the fixation of ACL tibial avulsion fractures. Both screw and suture fixation are effective methods of repairing ACL tibial avulsion fractures and have similar postoperative outcomes. It has been found that screw fixation is associated with a higher risk of subsequent surgery and implant removal than suture fixation.

Conclusion

The repair of ACL tibial avulsion fractures in multiligament knee injuries is an alternative to ACL reconstruction that demonstrates excellent postoperative patient outcomes, good patient satisfaction, and good return to sports.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review

OBJECTIVE

To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs).

DESIGN

Scoping review.

DATA SOURCES

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary.

RESULTS

Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups.

CONCLUSIONS

There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.

Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries

PURPOSE

Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions.

METHODS

Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations.

RESULTS

The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels.

CONCLUSION

The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.

Incidence and type of meniscal tears in multilligament injured knees

PURPOSE

Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery.

METHODS

Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury.

RESULTS

A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries p = 0.025; lateral-sided injuries p = 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (p < 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (p < 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (p < 0.001).

CONCLUSIONS

Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.

Hemp Seed Oil in Association with β-Caryophyllene, Myrcene and Ginger Extract as a Nutraceutical Integration in Knee Osteoarthritis: A Double-Blind Prospective Case-Control Study

Background and Objectives: Nutraceuticals are gaining more and more importance as a knee osteoarthritis (KOA) complementary treatment. Among nutraceuticals, hemp seed oil and terpenes are proving to be very useful as therapeutic support for many chronic diseases, but there are still few studies regarding their effectiveness for treating KOA, both in combination and separately. The aim of this study is thus to compare the effect of two dietary supplements, both containing hemp seed oil, but of which only one also contains terpenes, in relieving pain and improving joint function in patients suffering from KOA. Materials and Methods: Thirty-eight patients were recruited and divided into two groups. The control group underwent a 45 day treatment with a hemp seed oil-based dietary supplement, while the treatment group assumed a hemp seed oil and terpenes dietary supplement for the same period. Patients were evaluated at the enrollment (T0) and at the end of treatment (T1). Outcome measures were: Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Short-Form-12 (SF-12), Knee Injury Osteoarthritis Outcome Score (KOOS), and Oxford Knee Score (OKS). Results: All outcome measures improved at T1 in both groups, but NRS, KOOS and OKS had a greater significant improvement in the treatment group only. Conclusions: Hemp seed oil and terpenes resulted a more effective integrative treatment option in KOA, improving joint pain and function and representing a good complementary option for patients suffering from osteoarthritis.

Mid-Term Results following Traumatic Knee Joint Dislocation

PURPOSE

Although treatment strategies of knee joint dislocations have evolved, there is still no consensus on the best method and timing. New therapeutic concepts suggest that early one-stage treatment, including suturing and bracing of the cruciate ligaments in acute knee joint dislocation, are leading to improved functional results. This study aimed to evaluate the midterm functional outcome following traumatic knee joint dislocation and to determine whether the outcome is influenced by the surgical management, patient habitus or concomitant injuries.

METHODS

In this retrospective single center study, 38 patients with acute Schenck type II to IV knee dislocations were treated over an eight-year period in a level I trauma center. At follow-up, various clinical scores, such as the International Knee Documentation Committee (IKDC) Score, Lysholm Score, and Tegner Activity Scale (TAS), and individual questions about rehabilitation and activity levels of 38 patients were evaluated.

RESULTS

Mean follow-up was 5.5 ± 2.7 years. The mean IKDC Score was 65.6 ± 15.7 points, the average Lysholm Score was 70.5 ± 16.4 points and the median TAS was 4 (0-7), resulting in a loss of activity of 2 (range 0-6) points. There was no significant difference between a one-stage treatment compared to a two-stage approach. Ligament reconstruction of the ACL in a two-stage approach was required in only 33.3%. Further operations (early and late) were performed in 37% of cases. Being overweight was associated with more complications and worse outcomes, and external fixation with arthrofibrosis.

CONCLUSIONS

Knee dislocation is a severe trauma that often leads to a prolonged loss of function and increased knee pain over years, affecting the patient's activity. Clinical outcome is influenced significantly by concomitant injuries. Severe cases with initial external fixation are associated with a higher risk of knee stiffness and should be considered during rehabilitation. Obese patients present a challenge due to higher complication rates and lower postoperative knee function.

LEVEL OF EVIDENCE

Retrospective single center study, level III.

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).

No Difference in Knee Kinematics Between Anterior Cruciate Ligament-First and Posterior Cruciate Ligament-First Fixation During Single-Stage Multiligament Knee Reconstruction: A Biomechanical Study

Background:

For combined reconstruction of both the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), there is no consensus regarding which graft should be tensioned and fixed first.

Purpose:

The purpose of this study was to determine which sequence of graft tensioning and fixation better restores normal knee kinematics. The hypothesis was that ACL-first fixation would more closely restore normal knee kinematics, graft force, and the tibiofemoral orientation in the neutral (resting) position compared with PCL-first fixation.

Study Design:

Controlled laboratory study.

Methods:

A total of 15 unpaired human cadaveric knees were examined using a robotic testing system under the following 4 conditions: (1) 89.0-N anterior tibial load at different knee angles; (2) 89.0-N posterior tibial load at different knee angles; (3) combined rotational 7.0-N·m valgus and 5.0-N·m internal rotation load (simulated pivot shift) at 0°, 15°, and 30° of flexion; and (4) 5.0-N·m external rotation load at 0°, 15°, and 30° of flexion. The 4 evaluated knee states were (1) intact ACL and PCL (intact), (2) ACL and PCL deficient (deficient), (3) combined anatomic ACL-PCL reconstruction fixing the ACL first (ACL-first), and (4) combined anatomic ACL-PCL reconstruction fixing the PCL first (PCL-first). A 9.0 mm–diameter quadriceps tendon autograft was used for the ACL graft, tensioned with 40.0 N at 30° of flexion. A 9.5 mm–diameter hamstring tendon autograft (gracilis and semitendinosus, quadrupled loop, and augmented with an additional allograft strand if needed), tensioned with 40.0 N at 90° of flexion, was used for the PCL graft.

Results:

There were no statistically significant differences between ACL-first and PCL-first fixation regarding knee kinematics. ACL-first fixation restored anterior tibial translation to the intact state at all tested knee angles, while PCL-first fixation showed higher anterior tibial translation than the intact state at 90° of flexion (9.05 ± 3.05 and 5.87 ± 2.40 mm, respectively; P = .018). Neither sequence restored posterior tibial translation to the intact state at 30°, 60°, and 90° of flexion. At 15° of flexion, PCL-first fixation restored posterior tibial translation to the intact state, whereas ACL-first fixation did not.

Conclusion:

There were no differences in knee laxity between ACL-first and PCL-first fixation with the ACL graft fixed at 30° and the PCL graft fixed at 90°.

Clinical Relevance:

This study showed that there was no evidence to support the use of one tensioning sequence over the other in single-stage multiligament knee reconstruction.

Clinical, functional, and patient-reported outcome of traumatic knee dislocations: a retrospective cohort study of 75 patients with 6.5-year follow-up

INTRODUCTION

At present, limited knowledge regarding clinical, functional, and patient-reported outcomes at mid- and long-terms after surgical treatment of traumatic knee dislocations is available. This study aimed to investigate the mid-term recovery regarding clinical, functional, and patient-reported outcomes in patients following knee dislocation with associated multi-ligament injuries.

MATERIALS AND METHODS

The study design was a cross-sectional cohort study. Data were collected by retrospective chart review, clinical examination, and interview of patients. All patients treated surgically following a knee dislocation between January 2000 and December 2011 were included. The surgical technique was up to the decision of the individual surgeon. The main outcome was the Lysholm knee score. Secondary outcomes consist of clinical knee examination, functional performance test, pain, and patient-reported outcome across several domains in function, sport, pain, and quality of life.

RESULTS

Seventy-five patients (66.3%) accepted the invitation to participate. The mean age at the time of knee dislocation was 33.5 years, with a range of 16-65 years of age. The mean follow-up time was 78 months (R: 17-147). 75% of patient a Schenck's type 1 lesion and 23% a type 3. The median Lysholm knee score was 83 (R: 18-100). The mean KOOS for the five subscales were pain 84.5 (95% CI 80.5-88.5), symptoms 75.1 (95% CI 70.7-79.4), ADL 87.0 (95% CI 83.1-90.9), sport 59.9 (95% CI 53.3-66.4), and QOL 71.3 (95% CI 67.0-75.6). The mean Tegner activity level was 5.1 (95% CI 4.5-5.7). The median single assessment numeric evaluation (SANE) was 93 (R: 0-100). The pain intensity score for pain (VAS) during activity was reported with a mean of 2.7 (95% CI 2.1-3.3). The objective IKDC examination showed 76% of patients grouped by Grade A (normal knee function) or Grade B (nearly normal).

CONCLUSION

With a mean follow-up of 6.5 years, combined repair and reconstruction surgery following a knee dislocation shows good to excellent patient-reported outcome and more than 75% of patients experiencing normal knee functioned evaluated by the IKDC score.

The Functional Outcomes of Delayed Surgical Reconstruction in Nonsport-Induced Multiligament Knee Injuries: A Retrospective Cohort Study

Multiligament knee injuries (MLKIs) are among the most detrimental injuries, which can cause significant compromise of joint stability and function. Our aim was to investigate the functional outcomes of nonsport-induced MLKIs who presented late after injury and underwent delayed arthroscopic reconstruction. In a retrospective cohort of 18 MLKI patients (19 knees, January 2012-2018) who had undergone arthroscopic reconstruction, we assessed the knee range of motion, return to work/sport, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner scores. The preoperative scores were retrieved from the patients' registry database. We reviewed their surgical notes and extracted the operation data, including the damaged ligaments, stages of the surgery, and associated meniscal injury. There were 14 males and 4 females with a mean age of 30.57 ± 10.31 years. The mean time from injury to surgery was 17.31 ± 11.98 months. The most common injury was anterior cruciate ligament/posterior cruciate ligament (31.6%). The mechanisms of injury were motor vehicle accidents (72.2%), falls (22.2%), and sports (5.6%). The reconstruction was either single (61.2%) or multiple stage (38.8%). The pre- and postoperative scores were 45.31 ± 7.30 versus 79.16 ± 11.86 IKDC, 3.84 ± 1.26 versus 8.37 ± 1.16 Tegner, and 60.42 ± 7.68 versus 89.42 ± 8.81 Lysholm, respectively. All the scores showed significant improvement at mean follow-up of 24.05 ± 9.55 months (p < 0.001). In conclusion, delayed arthroscopic reconstruction of MLKIs significantly improved the functional outcomes and return to work in patients presenting late to the orthopaedic clinic. There was no relationship between the demographic variables, mechanism of injury, number of injured ligaments, and the stages of surgery and the functional outcomes in this group of patients.

An Evidence-Based Approach to Multi-Ligamentous Knee Injuries

Multi ligament knee injuries (MLKIs) are highly complex injuries with associated complications and often present with difficult management strategies. MLKIs may affect the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (or posteromedial corner (PMC)), and lateral collateral ligament (or posterolateral corner (PLC)) in addition to other structures including the menisci, common peroneal nerve, and popliteal artery. MLKIs are highly associated with the male sex and are commonly seen in high-velocity motor vehicle accidents and low-velocity sports injuries. Given the multiple planes of movement in the knee and various primary and secondary stabilizers throughout those planes, there is great heterogeneity in an injury pattern and most involve the ACL and PCL. Initial evaluation of this injury includes assessment of lower extremity sensation, distal pulses, and ankle-brachial index (ABI). If vascular compromise is suspected, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are indicated to evaluate the vasculature. As opposed to CTA, MRA offers visualization of the soft-tissue structures that are commonly damaged in MLKIs. Initial management typically includes closed reduction of the knee with subsequent external fixation. Classification systems guide initial assessments; however, further management is unclear and leads the surgical team to decide the best, individualized management option for each patient. As a result, optimal surgical and postoperative treatment options remain complicated, and clinical outcomes remain difficult to predict. The purpose of this review is to consolidate the most up-to-date practices of the diagnostic workup, management, and treatment of MLKIs.

Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction

The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p < 0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p < 0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.

Primary repair of multiligament knee injury with InternalBrace ligament augmentation

Multiligament injury of the knee usually occurs as a result of high-energy trauma causing tibiofemoral dislocation. These are rare but potentially limb-threatening injuries, frequently involving nerve or arterial damage and often leading to severe complex instability. Management generally favours surgical reconstruction of the affected ligaments, with controversy regarding optimal treatment. We present a severe multiligament knee injury (Schenk classification KD-IV involving both cruciate and both collateral ligaments) in a competitive showjumper. A combined arthroscopic/open technique of single-stage surgical repair and suture augmentation was used, repairing all affected ligaments. The patient made an excellent recovery, returning to work after 12 weeks and riding after 22 weeks. After 5-year follow-up, she has regained her previous level of competition without subsequent injury. Multiligament repair with suture augmentation is a viable approach to the management of knee dislocation injuries. We propose that this could provide superior outcomes to traditional reconstruction techniques using autograft or synthetic reconstruction.

External fixation increases complications following surgical treatment of multiple ligament knee injuries

PURPOSE

The purpose of this study was to review post-operative complications after surgical intervention of MLKIs within the first 6 months to be better able to counsel patients before surgical intervention.

METHODS

All patients who underwent surgical reconstruction for a MLKI at one institution from 2009 to 2018 were included in this study. A retrospective review was performed of all patients and post-operative complications were recorded, including motion loss (which included > 10 degree flexion loss or > 3 degree extension loss), hematoma formation, infection, iatrogenic vascular or nerve injury, deep vein thrombosis (DVT), pulmonary embolism (PE), skin lesions, symptomatic hardware, recurrent ligamentous laxity, and need for additional surgery. Knee ligament injuries were classified based on the Schenck Knee Dislocation (KD) Classification.

RESULTS

A total of 136 patients were included in this study, 83 with KD I injuries, 40 with KD III injuries, 9 with KD IV injuries, and 4 with KD V injuries. Of these total patients, 48 (35.5%) sustained a post-operative complication: 11 out of 133 (8.3%) from 0 to 1 week, 46 out of 132 (34.8%) from 1 week to 1 month, 28 out of 124 (22.6%) from 1 to 3 months, and 26 out of 121 (21.5%) from 3 to 6 months. Out of the total complications, 99 (78.5%) occurred at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common complication was motion loss in 39 (28.6%) patients. There was a significant difference in mean number of complications between the KD I and KD III groups, as well as the KD III and KD IV-V groups. There was no significant difference in the overall prevalence of post-operative complications or occurrence of motion loss with KD grade.

CONCLUSION

The main finding of this study was 48 (35.5%) patients sustained a complication after surgical treatment of MLKIs, with 99 (78.5% of all complications) complications occurring at 1 week-3 months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common post-operative complication was motion loss in 39 (28.6%) patients. The KD grade was not associated with post-operative development of motion loss, but KD III had a significantly greater mean number of complications than KD I or KD IV-V grades.

LEVEL OF EVIDENCE

IV.

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.

Low rate of return to pre-injury level of sports after multi-ligament knee injury - Functional outcomes after MLKI

BACKGROUND

Multi-ligament knee injury (MLKI) is a rare but severe injury with potential devastating complications. The primary goal of this study was to investigate return to sports and work after MLKI. Secondary outcomes were patient reported outcome measures (PROMs), treatment, time between trauma, diagnosis and treatment, and neurovascular damage.

METHOD

A database search was performed to identify all patients with MLKI in our hospital (2010-2017). Pre-defined variables were collected from patient files and questionnaires. Multiple regression analysis was used to study the relationship between different variables and PROMs.

RESULTS

31 patients were included. The overall return to sports rate after a MLKI was 88.5%, but only 23.1% returned to their pre-injury level. 83.3% of the patients were able to return to work. Multiple regression analyses led to a significant prediction model for pain during rest (F(7,16) = 2.808, p = 0.041, R² = 0.355). Within this model, a higher age was a significant predictor for higher pain scores (p = 0.002). Age was also a significant (negative) predictor within the non-significant models for IKDC (p = 0.004) and Lysholm (p = 0.024). A delay between trauma and diagnosis of more than three months was seen in 32.3% of the patients.

CONCLUSIONS

This study showed a relatively high overall return to sports and work after MLKI, but less than a quarter returned to their pre-injury level of sports. An important finding was the substantial number of patients with a delay between trauma and diagnosis. This study contributes to more awareness and knowledge about MLKI among physicians, which is essential to reduce these delays.

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

Posterolateral Complex Reconstruction With Distal Femoral Varus Opening-Wedge Osteotomy for Unstable Neglected Multiligamentous Knee Injury With Valgus Malalignment

We presented a case of a 25-year-old woman with early posttraumatic degenerative change to the articular cartilage accompanied with valgus malalignment despite receiving anterior cruciate ligament reconstruction after a multiligamentous injury sustained 2 years earlier. Rapid deteriorating valgus malalignment may result from chronic instability and intra-articular bone loss. Simultaneous distal femoral varus osteotomy and posterolateral complex reconstruction were performed during a single surgery. Six months after the surgery, the patient could walk briskly and climb stairs without any discomfort. Salvage procedures and biological reconstruction could be the primary choice for young patients to recover their knee function while avoiding joint replacement.

[Combined PCL ligament bracing and ACL reconstruction in acute knee dislocation (Schenck IV) - The Hamburg Approach : Video article]

OBJECTIVE

Stepwise reconstruction of knee stability and physiological kinematics in acute knee dislocation.

INDICATIONS

The operative technique is demonstrated in a case of multiligamentous injury of the knee with involvement of both cruciate ligaments and additional medial and lateral peripheral injuries (type IV according to Schenck classification).

CONTRAINDICATIONS

Critical soft tissue conditions, infections, old age, obesity, lack of compliance.

SURGICAL TECHNIQUE

Time-limited arthroscopy in order to primarily identify and treat posterior horn/root injuries of the meniscus and concomitant intra-articular injuries. Anatomical placement of anterior cruciate ligament (ACL) drill wires for later ACL tunnel drilling is arthroscopically guided. Subsequent conversion to an anteromedial arthrotomy and ligament bracing of the posterior cruciate ligament. The ACL is reconstructed using the ipsilateral semitendinosus tendon. Medial and lateral peripheral injures are anatomically reconstructed followed by a posterolateral augmentation in a technique described by Arciero.

FOLLOW-UP

Limited weight bearing for 6 weeks and stepwise increase of flexion using a standard knee brace and close clinical monitoring.

EVIDENCE

Ligament bracing of both cruciate ligaments is an established treatment technique in acute knee dislocations and has been proven to achieve good to excellent clinical results. In an ongoing clinical study primary ACL reconstruction as a modified treatment approach indicated superior stability in a 12-month follow-up in patients with acute knee dislocations.

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

PURPOSE

The purpose of this study was to compare clinical outcomes and incidence of concomitant injuries in patients undergoing early vs delayed surgical treatment of single anterior cruciate ligament (ACL) injury and multiligament knee injury (MLKI).

METHODS

A literature search using PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, and Scopus from their inception to April 30, 2020 was conducted. Studies with levels I to IV evidence reporting the incidence of meniscus or cartilage injury according to early vs delayed surgery in single ACL injuries and MLKIs were included. In the meta-analysis, data based on the number of meniscus and cartilage injuries were extracted and pooled. Lysholm and Tegner scores were analyzed using two-sample Z-tests to calculate the non-weighted mean difference (NMD). A meta-regression analysis was also performed to determine the effect of single ACL injury and MLKI/study design.

RESULTS

Sixteen studies on single ACL injury and 14 studies on MLKI were included in this analysis. In the analysis, there were significant decreases in Lysholm score (NMD - 5.3 [95% confidence interval (CI) - 7.37 to - 3.23]) and Tegner score (NMD - 0.25 [95% CI - 0.45 to - 0.05]) and increases in risk of meniscus tear (odds ratio [OR] 1.73 [95% CI 1.1-2.73], p = 0.01) and cartilage injury (OR 2.48 [95% CI 1.46-4.2], p = 0.0007) in the delayed surgery group regardless of single ACL injury or MLKI. The result of the meta-regression analysis indicated that single ACL injury and MLKI/study design were not significant moderators of overall heterogeneity (p > 0.05).

CONCLUSIONS

Our study suggests that delayed ACL surgery significantly resulted in a higher risk of meniscus tear and cartilage injury and decreased Lysholm and Tegner scores compared to early ACL surgery. The Lysholm scores in the delayed MLKI surgery group were significantly decreased, but the risks of meniscus tear and cartilage injury in the delayed MLKI surgery group remained unclear.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Mechanical Properties and Characteristics of the Anterolateral and Collateral Ligaments of the Knee

Biomechanical studies assessing the major knee ligaments, such as the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament (MCL), and lateral collateral ligament (LCL), have been conducted using various methodologies. However, despite the anterolateral ligament (ALL) being regarded as the important ligament for the stability of the knee, a lack of biomechanical research focusing on the ALL exists to date. Moreover, studies assessing the relative mechanical properties of each ligament of the knee are insufficient. Therefore, this study examined the mechanical properties of the ALL, MCL, and LCL and considered the relative differences between these ligaments. Twenty-one fresh cadaver knees were chosen to investigate the mechanical properties. The width, thickness, and length were measured. The stiffness, ultimate load, and elastic modulus were also tested. The MCL showed the greatest ultimate load (498.5 N) and the highest stiffness (71.97 N/mm), and the ALL presented the smallest ultimate load (146.64 N) and lowest stiffness (42.62 N/mm). Meanwhile, the LCL was second concerning the ultimate load (263.22 N) and stiffness (69.70 N/mm). The elastic modulus of the LCL (493.86 MPa) was greater than those of both the MCL and ALL (326.75 MPa and 345.27 MPa, respectively). There was no difference between the sides according to the different properties of all the ligaments. A sex difference was apparent only concerning the ultimate load for all the ligaments. Each ligament showed similar stiffness irrespective of its size; for this reason, stiffness should be considered initially and while conducting biomechanical simulations of these ligaments.

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.

The outcomes of one-stage treatment for multiple knee ligament injuries combined with extensor apparatus rupture

Background

Multiple knee ligament injuries combined with extensor apparatus rupture are serious and complex knee injuries that are rare in clinical practice. The management is extremely challenging and controversial.

The aim of this study is to describe a patient collective with multiple knee ligament injuries combined with extensor apparatus injuries in detail and to report the mid-term outcomes of a one-stage surgical treatment regarding subjective outcome scores, complications, knee instability, and ROM.

Methods

Eleven of 425 patients with multiple knee ligament injuries combined with extensor apparatus injuries admitted to our hospital were reviewed from July 2008 to May 2017. All patients underwent one-stage repair and reconstruction of multiple knee ligaments and extensor apparatus. The Lysholm knee score and the International Knee Documentation Committee (IKDC) score were adopted to evaluate the surgical effect preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at the final follow-up.

Results

Ten patients were followed up with a mean time of 40 (range, 24–60) months. At the last follow-up, 8 patients had joint flexion range of motion greater than or equal to120 degrees, 2 patients had joint flexion range of motion of 100–120 degrees, and 1 patient had active knee extension limitation of 5 degrees. Stress radiographs showed that the mean differences in posterior displacement were reduced from 10.8 ± 3.0 mm preoperatively to 2.0 ± 2.5 mm at the last follow-up. There were significant improvements in stress radiographs from pre- to postoperative states for all patients with multiple knee ligament injuries. The Lysholm score ranged from 85 to 96, with a mean of 92.1 (compared with 33 before surgery, P < 0.05). The final IKDC scores were A in 2 patients (20%), B in 7 (70%), and C in 1 (10%). Nine of the 10 patients (90%) returned to their former activity level.

Conclusion

Multiple knee ligament injuries combined with extensor apparatus rupture are rare. Single-stage management of the repair and reconstruction of multiple knee ligaments and extensor apparatus with proper rehabilitation is an effective and reliable procedure to restore knee stability and function.

Level of evidence

Level IV, therapeutic case series.

Evaluation and Management of Knee Dislocation in the Emergency Department

BACKGROUND

Knee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them.

OBJECTIVE

This article provides a review of the diagnosis and management of knee dislocation for the emergency provider.

DISCUSSION

Knee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission.

CONCLUSION

Knee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.