Complex knee injuries treated in acute phase: Long-term results using Ligament Augmentation and Reconstruction System artificial ligament

Functional and MRI results after a 7.5 year follow-up of 35 single-stage ACL and PCL reconstructions using gracilis and semitendinosus tendon grafts and LARS artificial ligaments

PURPOSE

The aim of this study was to evaluate the long-term functional and MRI results of 35 patients who underwent bicruciate ligament reconstruction combining an ACL autograft using the gracilis and semitendinosus tendons and double-bundle PCL reconstruction using the LARS artificial ligament.

METHODS

The outcomes were measured using the Lysholm score, the Tegner activity level scale and the International Knee Documentation Committee form (IKDC 2000). KT-1000 was used to assess the clinical anterior knee laxity. Radiographs and Magnetic Resonance Imaging (MRI) was used to evaluate osteoarthritis, the continuity and integrity of ACL autograft and LARS.

RESULTS

This retrospective study examined 35 patients who underwent single-stage bicruciate ligament reconstruction between May 2005 and January 2017 with a follow-up period ranging from 3 to 15 years (a mean of 7.5 years). The mean Lysholm score was 74, mean IKDC 2000 was 71. There was a statistically significant difference with a higher Lysholm score (78.9) in early versus delayed surgical intervention (p = 0.023). Using the Kellgren Lawrence osteoarthritis classification system, radiographic findings showed stage II or III in 83% of the sample population. The MRI results revealed a rupture rate of 22% of the anterior autografted ligament and 28% of the posterior LARS artificial ligament. However, there were no long-term artificial ligament-induced complications. There was no correlation between artificial ligament rupture and poor functional results (Lysholm < 65).

CONCLUSION

The results of this study with a mean follow-up of 7.5 years show satisfactory functional scores considering the initial trauma. It seems reasonable to propose early surgical treatment with double reconstruction of the cruciate ligaments within the first 21 days of the trauma. Post-traumatic osteoarthritis is inevitable in multi-ligament knee injuries despite anatomical reconstruction. The use of a LARS artificial ligament appears to be a valid alternative for PCL reconstruction in the context of multi-ligament injury and in the absence of sufficient autologous transplants.

Pedicled Rectus Femoris Flap for Restoration of Suprapatellar Quadriceps Tendon and Defect Coverage after Multiple Reconstruction Attempts-A Case Report and Literature Review

There is no unified approach for restoring the suprapatellar quadriceps tendon and covering tissue defects simultaneously. In this case report, we present the pedicled myocutaneous rectus femoris flap as one effective approach in two cases with extensive loss or impairment of the suprapatellar muscle-tendon structures after trauma-related suprapatellar quadriceps tendon rupture and multiple reconstruction attempts. Additionally, we provide a literature review of the reconstructive use of the functional pedicled myocutaneous rectus femoris flap.

METHODS

Two male patients, 48 and 74 years old, with extensive loss or impairment of the suprapatellar muscle-tendon structures due to multiple reconstruction attempts, underwent restoration of the knee extension with a pedicled myocutaneous rectus femoris flap.

RESULTS

Three months after reconstruction, both patients were able to walk freely, unaided. After a six-month follow-up, the free passive mobility of the knee joint was restored, and the active extension of the knee joint was possible in both patients.

CONCLUSION

The authors conclude that the pedicled rectus femoris flap is a reliable method for the restoration of knee extension, with excellent functional results in cases of suprapatellar tendon lesions. Further to the functional restoration, this technique has the additional advantage of simultaneously achieving coverage of soft-tissue defects, while a direct closure of the donor site is possible. Elderly patients and patients with relevant comorbidities or multiple revisions may especially benefit from this technique.

Arthroscopic Reconstruction of the Posterior Cruciate Ligament with a Ligament-advanced Reinforcement System and Hamstring Tendon Autograft: A Retrospective Study

OBJECTIVE

Both ligament-advanced reinforcement system (LARS) and hamstring tendon autograft can serve as grafts for posterior cruciate ligament (PCL) reconstruction. However, few studies have compared the effectiveness of these two approaches. This study therefore aimed to compare the clinical efficacy of arthroscopic reconstruction of the PCL using either the LARS or hamstring tendon autograft.

METHODS

A total of 36 patients who underwent PCL reconstruction were retrospectively analyzed. Within this cohort, 15 patients received a reconstruction using the LARS (LARS group) and 21 using the hamstring tendon autograft (HT group).

RESULTS

The pre- and post-operative subjective scores and knee stability were evaluated and the patients were followed up for a period of 2 to 10.5 years (4.11±2.0 years on average). The last follow-up showed that functional scores and knee stability were significantly improved in both groups (P<0.05). Six months after operation, Lysholm scores and IKDC subjective scores were higher in the LARS group than in the HT group (P<0.05). Nonetheless, the last follow-up showed no significant differences in the functional scores or the posterior drawer test between the two groups (P>0.05). In the LARS and HT groups, 12 and 9 patients, respectively exhibited KT1000 values <3 mm, with the difference being statistically significant (P<0.05). In the HT group, the diameter of the four-strand hamstring tendon was positively correlated with height (P<0.05), which was 7.37±0.52 mm in males and 6.50±0.77 mm in females (P<0.05).

CONCLUSION

Both LARS and hamstring tendon approaches achieved good efficacy for PCL reconstruction, but patients in the LARS group exhibited faster functional recovery and better knee stability in the long term. LARS is especially suitable for those who hope to resume activities as early as possible.

The use of the ligament augmentation and reconstruction system for posterior cruciate ligament reconstruction in isolated and multiligament knee injuries: A systematic review

PURPOSE

To evaluate the efficacy and safety of the Ligament Augmentation and Reconstruction System (LARS) in posterior cruciate ligament (PCL) reconstruction in isolated PCL injuries and multiligament knee injuries, analysing clinical, radiographic, and patient reported outcome measures (PROMs).

METHODS

A systematic review according to PRISMA guidelines was performed through Embase via Ovid, PubMed, and the Cochrane Library to identify studies reviewing LARS use for PCL reconstruction. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

From 225 results screened, 13 studies were included published between 2004 and 2020, analysing LARS use for PCL reconstruction. Mean follow-up was 21 months to 11.9 years, however only four studies had follow-up of over five years. Results in isolated PCL reconstruction utilising LARS demonstrated scores that were consistent with good function and minimal limitation in daily or sporting activities, in addition to a significant improvement in knee laxity and low complication rates. Symptomatic rupture and synovitis rates were both 1.7% in this group. LARS use in complex multiligament injuries demonstrated satisfactory PROMs, although there was concern regarding residual laxity on stress radiography.

CONCLUSIONS

LARS demonstrates good outcomes in PCL injury reconstruction in the short to mid-term, particularly in isolated PCL injuries, achieving equivocal or improved results compared to autograft reconstruction using hamstring tendon in the three comparative studies included. LARS has a quicker recovery time and no donor-site morbidity, however long-term data is lacking. Utilising LARS for reconstruction of the PCL in multiligament injuries revealed more variable results.

Injury to the Medial Superior Genicular Artery After Isolated Posterior Cruciate Ligament Reconstruction: A Case Report

CASE

A 19-year-old male patient with isolated posterior cruciate ligament (PCL) rupture underwent arthroscopic reconstruction using reinforced synthetic ligament (LARS system). Three weeks postoperatively, he presented with active bleeding from the medial side of his knee, near the proximal interference screw. An angiogram revealed extravasation from the medial superior genicular artery which was successfully embolized. One week later, he returned with active bleeding from the same area, located just under the initial coiling; a second embolization during superselective angiography was successful.

CONCLUSION

Although rare, minor vascular injuries are a risk inherent to PCL surgery.

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.

Artificial ligament made from silk protein/Laponite hybrid fibers

With developments in tissue engineering, artificial ligaments are expected to be future materials for anterior cruciate ligament (ACL) reconstruction. However, poor healing of the intraosseous part after ACL reconstruction significantly hinders their applications in this field. In this study, a bioactive clay Laponite (LAP) was introduced into the regenerated silk fibroin (RSF) spinning dope to produce functional RSF/LAP hybrid fibers by wet-spinning. These RSF/LAP hybrid fibers were then woven into artificial ligament for ACL reconstruction. The structure and mechanical properties of RSF/LAP hybrid fibers were extensively studied by different means. Results confirmed the presence of LAP in RSF fibers and revealed that the addition of LAP slightly deteriorated the comprehensive mechanical properties of RSF fibers. However, they were still much tougher (with higher breaking energy) than those of degummed natural silkworm silk that was earlier used for making artificial ligament. The artificial ligament woven from RSF/LAP hybrid fibers showed better cytocompatibility and osteogenic differentiation with mouse pre-osteoblasts in vitro than those made from degummed natural silkworm silks and pure RSF fibers. Furthermore, in vivo study in a rat ACL reconstruction model demonstrated that the presence of LAP in the artificial ligament could significantly enhance the graft osseointegration process and also improve the corresponding biomechanical properties of the artificial ligament. Based upon these results, the RSF/LAP hybrid fibers, which can be mass produced by wet-spinning process, are believed to have a great potential for use as artificial ligament materials for ACL reconstruction. STATEMENT OF SIGNIFICANCE: In this study, we successfully introduced Laponite (LAP), a kind of clay that has the function of osteogenic induction, into regenerated silk fibroin (RSF) fibers, which was prepared by a mature wet-spinning method developed in our lab. We believe that through artificial spinning, additional functional components can be added into RSF fibers, which one can hardly achieve with natural silks. We showed that the artificial ligament woven from RSF/LAP hybrid fibers had better cytocompatibility and osteogenic differentiation for mouse pre-osteoblasts in vitro, and significantly enhanced the graft osseointegration process and improved the corresponding biomechanical properties in a rat ACL reconstruction model in vivo, compared to those artificial ligaments made from degummed natural silkworm silks and pure RSF fibers.

LARS synthetic ligaments for the acute management of 111 acute knee dislocations: effective surgical treatment for most ligaments

PURPOSE

The purpose of this study was to describe the longitudinal outcomes of acute repair and augmentation for the reconstruction of dislocated knees, using LARS synthetic ligaments.

METHODS

Patients with a knee dislocation surgically treated using LARS synthetic ligament augmentation, with a minimum follow-up of 24 months, were enrolled between 1996 and 2014. Range of motion, Lachman, pivot shift, posterior drawer, step off sign, valgus, varus, KT-1000 arthrometer, Telos technique, IKDC, Lysholm, Tegner, and Meyers scores were obtained every 2 years up to 10 years.

RESULTS

Median age was 32.1 years (IQR 23.2-43.3) at time of surgery. Median time from trauma to surgery was 9 days and mean follow-up time was 6.6 years. Median questionnaire scores were: Lysholm 79.5 (IQR 65.0-89.0), Tegner 4.0 (IQR 3.7-6.0), Meyers 3.0 (IQR 3.0-4.0), and mean IKDC was 63.8 (SD 18.9). Median flexion and extension of the injured knee was 124° (IQR 115-129.5) and 0° (IQR - 5 to 0), respectively. Median KT-1000 differential was 0.7 mm (IQR 0.1-3.1) for ACL and 0.9 mm (IQR 0.2-1.4) for PCL. Mean differential for Telos was 2.5 mm (SD 5.8) for ACL, 4 mm (IQR 2-6.3) for PCL 30°, and 8.2 mm (SD 4.4) for PCL 90° (consistent with PCL laxity). More than 90% of patients had good anterior articular stability and > 60% of patients had good posterior articular stability.

CONCLUSIONS

Acute repair and augmentation of knee dislocations with LARS synthetic ligaments resulted in satisfactory outcomes for the ACL and collateral structures. Telos stress radiography showed PCL laxity in more than half of cases despite low laxity results with KT-1000. The perception of patients about knee function was sustained in time.

LEVEL OF EVIDENCE

IV.