Acute primary repair of extraarticular ligaments and staged surgery in multiple ligament knee injuries

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.

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.

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).

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

Background:

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

Purpose:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

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.

Factors Influencing the Progression of Patellofemoral Articular Cartilage Damage After Anterior Cruciate Ligament Reconstruction

Background:

Although anterior cruciate ligament reconstruction (ACLR) can restore the stability and function of the knee joint, patellofemoral joint cartilage damage still progresses. Currently, the clinically important factors that lead to the progression of patellofemoral articular cartilage damage are not fully understood.

Purpose:

To investigate the factors that affect the progression of patellofemoral articular cartilage damage after ACLR.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Among 160 patients who underwent ACLR between January 2015 and December 2019, the authors evaluated 129 patients for at least 1 year after surgery. Within 1 week before ACLR and at the last follow-up, patients underwent subjective functional assessment and magnetic resonance imaging evaluations of articular cartilage damage (modified Outerbridge assessment). At the last follow-up, the side-to-side difference on KT-2000 arthrometer and bilateral quadriceps muscle strength were measured. Univariate and multivariate logistic regression analyses were performed.

Results:

The mean follow-up was 24.69 ± 10.74 months. Progression of patellar cartilage damage from preoperatively to final follow-up was seen in 45 patients (P < .001). Logistic regression analysis revealed that the follow-up period (P = .047; odds radio (OR) = 0.953) (improvement of patellar cartilage damage with longer follow-up), partial lateral meniscal resection (P = .004; OR = 6.929), partial medial meniscal resection (P = .004; OR = 6.032), and quadriceps muscle strength <80% of the contralateral side (P = .001; OR = 4.745) were risk factors for the progression of patellar cartilage damage.

Conclusion:

Cartilage damage at the patellofemoral joint, especially the patellar cartilage, still progresses after ACLR. At a mean follow-up of 24.69 months after ACLR, partial meniscal resection and quadriceps femoris muscle strength were found to be the main risk factors for the progression of patellofemoral articular cartilage damage after ACLR.

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.

Single-stage versus two-stage reconstruction in chronic multi ligament knee injury

BACKGROUND

Multi ligament knee injury (MLKI) refers to the disruption of at least 2 of the 4 major knee ligaments. These injuries are managed in single and two-stage surgeries however, treatment guidelines for best practice are unsettled. There is no study in the literature that compares single and two-stage surgery for the management of chronic multiligament knee injury. Therefore, the aim of this study was to compare the functional outcome between single-stage and two-stage surgical fixation in chronic multi-ligament knee injury.

METHODS

Twenty seven patients with chronic MLKI with at least 2 years of follow up were included. Fourteen patients underwent reconstruction of torn ligaments in a single-stage operation (Group I) and 13 patients underwent reconstruction of torn ligaments in two stages (Group II). Assessment of clinical outcome was done with IKDC knee score, TEGNER LYSHOLM knee score, range of movement and laxity tests (Anterior drawer test, Lachman, Posterior drawer test, pivot shift test, dial test, varus and valgus stress test).

RESULTS

At final follow up, there was no significant difference in post-operative IKDC knee scores in group I and group II (84.7±7.1 and 81.4±8.4 respectively, p=0.3) and Lysholm scores (85.8±8.3 and 80.9±8.3 respectively, p=0.1), range of movement (133.2±5.7 and 131.5±6.6 respectively, p=0.5) and all the patients regained full extension. At the final follow up 12/14 patients (85.7%) in group I and 11/13 patients (84.6%) in group II had a negative/grade 1 anterior drawer test (p=0.6), 14/14 (100%) in group I and 13/13 (100%) patients had negative/grade 1 lachman test (p=0.6), 13/14 patients (92.8%) in group I and 13/13 patients (100%) patients in group II had negative/grade 1 pivot shift test (p=0.4), 9/10 patients (90%) in group I and 12/13 patients (92.3%) in group II had negative/grade 1 posterior drawer (p=0.6), 6/6 patients (100%) in group I and 6/7 patients (85.7%) in group II had negative/grade 1 dial test (p=0.3), 5/6 patients (83.3%) in group I and 5/7 patients (71.4%) in group II had negative/grade 1 varus stress test (p=0.4), 6/7 patients (85.7%) in group I and 7/7 patients (100%) in group II had negative/grade 1 valgus stress test (p=0.1).

CONCLUSION

Chronic MLKI managed by single stage and two stage reconstruction provides similar functional outcomes.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

A Meta-Analysis of Systemic Evaluation of Knee Ligament Injury or Intervention of Knee Proprioceptive Function Recovery

OBJECTIVE

The knee ligaments, as a passive knee joint stability device, provide protection for the knee joint and ensure its functional integrity. This role has long been known and recognized by people. The original purpose of knee ligament reconstruction after knee ligament injury is to restore its anatomical structure and mechanical stability mechanism.

METHODS

Taking athletes as the research object, randomized controlled trials (RCTs) on improving ankle joint function of athletes related to proprioception training at home and abroad were included. The search time was from the establishment of the database to December 31, 2019, and the references of related documents were traced. Two researchers independently screened the literature, extracted data, and evaluated the quality of the literature. RevMan 5.3 software was used for data analysis.

RESULTS

The extensor strength, flexor strength, and flexor strength/extensor strength of the affected limb were higher than before the operation one year after surgery (P < 0.01). The Lysholm score, Lysholm instability score, and one-foot jump distance were all higher than those before surgery (P < 0.05); the difference of KT-2000 for both knees was smaller than that before surgery (P < 0.05).

CONCLUSION

In maintaining the anterior stability of the knee joint, the knee ligament provides 85% static resistance to prevent the tibia from moving forward, so knee ligament injury will cause knee instability. The proprioceptive feedback mechanism plays an important role in maintaining the functional stability of joints.

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.

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