Controversies in the treatment of knee dislocations and multiligament reconstruction

Surgical Management and Rehabilitation of Ultra-Low Velocity Bilateral Multi-Ligament Knee Injury: A Case Report

Bilateral low-velocity multi-ligament knee Injury (MLKI) is a rare injury increasing in prevalence along with obesity. Early surgical intervention is indicated to improve long-term outcomes. We describe the surgical and postoperative management of a bilateral MLKI. The patient underwent staged multi-ligament knee reconstruction 17 and 35 days after injury. Return to light-duty was achieved 4 weeks following each procedure and progression to exercise at 6 months. The patient is 2 year postoperative and returned to all activity without complaint. We describe successful surgical and rehabilitation management, which encourages early surgery and rehabilitation strategies to improve long-term outcomes.

Vascular Injuries in Multiligament Knee Injuries (MLKIs)

Purpose

Vascular injuries are rarely associated with severe knee injuries; nonetheless, it is imperative to efficiently detect this condition and plan for either immediate or definitive treatment at later stages. The diagnosis and management of multiligament knee injuries still present unresolved issues, particularly in the early detection of vascular issues and the sequential stabilisation of ligaments. High-energy trauma is a frequently encountered cause, however, even low-energy trauma in those who are morbidly obese might pose a significant risk. Advancements in detection and management methods have greatly decreased the occurrence of vascular complications and amputation rates over time. MLKIs after transient knee dislocations are frequently misdiagnosed for vascular injuries, underscoring the necessity for improved diagnostic techniques to avoid avoidable amputations.

Methods

This article is a new conceptual review of vascular injuries associated with MLKIs. It provides a full overview of these conditions and includes a review of the most recent literature. We have included pertinent citations from the literature, together with suggestions derived from the latest studies. This review article had additional evaluation by proficient specialists with commendable outcomes and more than a decade of expertise in surgical techniques.

Results

This article offers a detailed overview of orthopaedic management, including new definitions and summaries of the causes, evaluation of patients, clinical assessment, identification of vascular injuries, and initial management in patients with vascular impairment following major limb and joint injuries (MLKIs).

Conclusion

MLKIs (patients with lower limb ischaemia) who have vascular damage necessitate meticulous physical assessment and sophisticated treatments in order to decrease amputation rates. Prompt identification and timely treatment of vascular lesions, namely in the popliteal artery, can substantially reduce the occurrence of amputations. Emerging research suggests that there is a heightened risk in low-energy situations, particularly amongst individuals who are extremely obese. Progress in vascular intervention has led to a reduction in amputation rates, whilst the implementation of new guidelines has enhanced identification. Thorough patient assessment is essential, utilising physical examinations and imaging techniques such as Computed tomography angiography, magnetic resonance angiography (CTA or MRA) to guide treatment decisions. MRA, in particular, is capable of identifying both vascular and knee structural damage.

Level of Evidence

Level IV, Literature reviews.

Early Compared with Delayed Reconstruction in Multiligament Knee Injury: A Retrospective Propensity Analysis

BACKGROUND

The purpose of this study was to compare outcomes following early compared with delayed reconstruction in patients with multiligament knee injury (MLKI).

METHODS

A retrospective cohort analysis of patients with MLKI from 2007 to 2019 was conducted. Patients who underwent a reconstructive surgical procedure with ≥12 months of postoperative follow-up were included. Patients were stratified into early reconstruction (<6 weeks after the injury) and delayed reconstruction (12 weeks to 2 years after the injury). Multivariable regression models with inverse probability of treatment weighting (IPTW) were utilized to compare the timing of the surgical procedure with the primary outcome (the Multiligament Quality of Life questionnaire [MLQOL]) and the secondary outcomes (manipulation under anesthesia [MUA], Kellgren-Lawrence [KL] osteoarthritis grade, knee laxity, and range of motion).

RESULTS

A total of 131 patients met our inclusion criteria, with 75 patients in the early reconstruction group and 56 patients in the delayed reconstruction group. The mean time to the surgical procedure was 17.6 days in the early reconstruction group compared with 280 days in the delayed reconstruction group. The mean postoperative follow-up was 58 months. The early reconstruction group, compared with the delayed reconstruction group, included more lateral-sided injuries (49 patients [65%] compared with 23 [41%]; standardized mean difference [SMD], 0.44) and nerve injuries (36 patients [48%] compared with 9 patients [16%]; SMD, 0.72), and had a higher mean Schenck class (SMD, 0.57). After propensity adjustment, we found no difference between early and delayed reconstruction across the 4 MLQOL domains (p > 0.05). Patients in the early reconstruction group had higher odds of requiring MUA compared with the delayed reconstruction group (24 [32%] compared with 8 [14%]; IPTW-adjusted odds ratio [OR], 3.85 [95% confidence interval (CI), 2.04 to 7.69]; p < 0.001) and had less knee flexion at the most recent follow-up (β, 6.34° [95% CI, 0.91° to 11.77°]; p = 0.023). Patients undergoing early reconstruction had lower KL osteoarthritis grades compared with patients in the delayed reconstruction group (OR, 0.46 [95% CI, 0.29 to 0.72]; p < 0.001). There were no differences in clinical laxity between groups.

CONCLUSIONS

Early reconstruction of MLKIs likely increases the likelihood of postoperative arthrofibrosis compared with delayed reconstruction, but it may be protective against the development of osteoarthritis. When considering the timing of MLKI reconstruction, surgeons should consider the benefit that early reconstruction may convey on long-term outcomes but should caution patients regarding the possibility of requiring an MUA.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Combined Anterior Cruciate Ligament/Medial Collateral Ligament Injuries: Surgeons Should Have a Low Threshold to Operate on the Medial Collateral Ligament

Combined anterior cruciate ligament/medial collateral ligament (ACL/MCL) injuries are relatively common, and multiple factors are involved in surgical decision-making, particularly when it comes to the MCL. Historically, most surgeons treated the MCL conservatively and performed staged MCL reconstruction after MCL reconstruction only if there was persistent medial instability. This was followed by a nonoperative approach for the MCL (when reconstructing the ACL) unless there was evidence of extreme (grade III or >1 cm) valgus instability, valgus malalignment, or mid-substance or tibial-sided injury, avulsion, or Stener lesion. However, the most recent research demonstrates that combined ACL/MCL injuries present a higher risk of ACL reconstruction failure and subsequent revision compared to ACL injuries alone. With growing biomechanical and clinical evidence, more surgeons are repairing or reconstructing the MCL in these combined injuries. Although there is no clear consensus, we recommend surgeons consider surgically treating the MCL to avoid not only excessive force on the ACL graft but also persistent valgus laxity, which can lead to ACL failure. For distal MCL avulsions, repairs have shown excellent midterm outcomes, especially if the tissue quality is pristine. If the tissue quality is not repairable, then we would advocate for repairing whatever tissue is repairable and augmenting with an MCL reconstruction. For mid-substance MCL injuries, if surgical intervention is required, we advocate for MCL reconstruction. For proximal tears, the same criteria used for distal tears apply with management based on tissue quality and joint stability after repair. The ACL is a secondary stabilizer to valgus loads, and MCL deficiency results in tremendous strain on ACL graft reconstructions. If the MCL is even mildly incompetent, we strongly advocate for treating the MCL surgically in this setting.

Tibiofemoral Dislocation Management in a Rural High School Football Scenario: Development of a Popliteal Artery Injury Suspicion Index

OBJECTIVE

This study evaluated the knowledge and preparedness of athletic trainers (ATs) for diagnosing and managing an anterior tibiofemoral knee dislocation in a rural or limited-resource high school football setting scenario. The study hypothesis was that more experienced ATs would display greater preparedness than less experienced ATs. A secondary objective was to develop evidence-based guidelines to help the AT provide better emergency triage care.

METHODS

This prospective cross-sectional study distributed a rural high school football game scenario survey electronically to a random sample of 2000 certified ATs to determine their perceptions of readiness to diagnose and manage an anterior tibiofemoral knee dislocation with signs or symptoms of possible popliteal artery injury.

RESULTS

A total of 249 surveys (12.5%) were completed. Years of athletic training experience were ≤5 years (n = 82, group 1) and ≥6 years (n = 167, group 2). Both groups perceived that they could not "rule out" an arterial injury and had similar "red flag" sign and symptom rankings. Group 2 perceived a more serious situation than group 1 (77.5 ± 15 vs 70.8 ± 14, P < 0.0001) and were more likely to activate the emergency action plan (74.5 ± 25 vs 64.4 ± 26, P = 0.005). Both groups were "neutral" about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that evidence-based guidance was needed.

CONCLUSIONS

More experienced ATs perceived a more serious situation than less experienced ATs and were more likely to activate the emergency action plan. Both groups were neutral about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that they would benefit from evidence-based guidance. Proposed guidelines provide the AT with a more measured, evidence-based index of suspicion for potential popliteal artery injury in anterior tibiofemoral dislocation cases. This will complement existing hospital emergency department-based management algorithms, decreasing the likelihood of this condition progressing to limb loss or death.

Increased Body Mass Index is Associated with Worse Mid- To Long-Term Patient Outcomes after Surgical Repair of Multiligamentous Knee Injuries

We evaluated the relationship between elevated body mass index (BMI) and mid- to long-term outcomes after surgical treatment of multiligamentous knee injury (MLKI). Records identified patients treated surgically for MLKI at a single institution. Inclusion criteria: minimum 2 years since surgery, complete demographics, surgical data, sustained injuries to two or more ligaments in one or both knees, and available for follow-up. Patients were contacted to complete patient-reported outcomes assessments and were classified according to mechanism of injury. Multivariate logistic regression analysis was used to predict the impact of BMI on outcome scores. A total of 77 patients (72.7% male) were included with a mean age at the time of injury of 29.4 ± 11.0 years and a mean BMI of 30.5 ± 9.4 kg/m2. The mean length of follow-up was 7.4 years. For each 10 kg/m2 increase in BMI, there is a 0.9-point decrease in Tegner activity scale (p = 0.001), a 5-point decrease in Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain (p = 0.007), a 5-point decrease in KOOS-ADL (p = 0.003), a 10-point decrease in KOOS-QOL (p = 0.002), and an 11-point decrease in KOOS-Sport (p = 0.002). There were no significant correlations with BMI and Pain Catastrophizing Scale or Patient Health Questionnaire scores. Increasing BMI has a negative linear relationship with mid- to long-term clinical outcomes including pain, ability to perform activities of daily living, quality of life, and ability to perform more demanding physical activity after MLKI. BMI does not appear to have a significant relationship with knee swelling and mechanical symptoms or patients' mental health.

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.

Association of Posterior Tibial Slope With Outcomes After Multiligamentous Knee Reconstruction for Knee Dislocation Grades 2 to 4

Background

Patients with isolated anterior cruciate ligament (ACL) reconstruction have demonstrated an increased risk of ACL graft failure and lower patient-reported outcome (PRO) scores when increased posterior tibial slope (PTS) is present. However, there is a paucity of literature evaluating the effect of PTS on outcomes after combined bicruciate multiligamentous knee reconstruction.

Purpose

To determine whether differences exist for graft failure rates or PRO scores based on PTS after combined bicruciate multiligamentous knee reconstruction.

Study Design

Cohort study; Level of evidence, 3.

Methods

All patients who underwent combined ACL and posterior cruciate ligament (PCL) reconstruction between 2000 and 2020 at our institution were identified. Exclusion criteria were age <18 years, knee dislocation grade 5 injuries, concomitant osteotomy procedures, and <2 years of clinical follow-up. Demographic and outcomes data were collected from our prospectively gathered multiligamentous knee injury database. Lysholm and International Knee Documentation Committee (IKDC) scores were analyzed in relation to PTS. Outcomes were compared for patients with a PTS above and below the mean for the total cohort, PTS >12° versus <12°, positive versus negative Lachman test at follow-up, and positive versus negative posterior drawer test at follow-up.

Results

A total of 98 knees in 98 patients were included in the study, with a mean clinical follow-up of 5.1 years (median, 4.6 years; range, 2-16 years). The mean PTS was 8.7° (range, 0.4°-16.9°). Linear regression analysis showed no significant correlation between PTS and IKDC or Lysholm scores. Patients with a PTS above the mean of 8.7° trended toward lower IKDC (P = .08) and Lysholm (P = .06) scores. Four patients experienced ACL graft failure and 5 patients experienced PCL graft failure. There were no differences in graft failure rates or PRO scores for patients with a PTS >12°. Patients with a positive Lachman test trended toward higher PTS (9.6° vs 8.5°, P = .15).

Conclusion

In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. Patients with a positive Lachman test were found to have a slightly higher PTS, although this did not reach statistical significance.

Perioperative outcomes in isolated versus multiligamentous anterior cruciate ligament reconstruction: a retrospective cohort analysis

PURPOSE

The outcomes of anterior cruciate ligament reconstruction in the setting of multiligamentous knee injury (M-ACLR) have not been well characterized compared to isolated ACLR (I-ACLR). This study aims to characterize and compare short-term outcomes between I-ACLR and M-ACLR.

METHODS

This is a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017. Current Procedural Terminology codes were used to identify and compare elective I- and M-ACLR patients, excluding patients undergoing concomitant meniscal or chondral procedures. Patient demographics and outcomes after I- and M-ACLR were compared using bivariate analysis. Multiple logistic regression analyzed if multiligamentous ACLR was an independent risk factor for adverse outcomes.

RESULTS

There was a total of 13,131 ACLR cases, of which 341 were multiligamentous cases. The modified fragility index-5 was higher in multiligamentous ACLR (p < 0.001). Multiligamentous ACLR had worse perioperative outcomes, with higher rate of all complications (3.8%, p = 0.013), operative time > 1.5 h (p < 0.001), length of stay (LOS) ≥ 1 day (p < 0.001), wound complication (2.1%, p = 0.001), and intra- or post-op transfusions (p < 0.001). In multiple logistic regression, multiligamentous ACLR was an independent risk factor for LOS ≥ 1 (odds ratio [OR] 5.8), and intra-/post-op transfusion (OR 215.1) and wound complications (OR 2.4). M-ACLR was not an independent risk factor for any complication, reoperation at 30 days, readmission, urinary tract infection (UTI), or venous thromboembolism (VTE).

CONCLUSION

M-ACLR generally had worse outcomes than I-ACLR, including longer LOS, need for perioperative transfusions, and wound complications.

Open injuries and obesity as emerging risk factors for vascular injury in knee dislocations: A retrospective study

PURPOSE

Knee dislocations (KDs) are rare in orthopaedic trauma but can have devastating effects. Failing to diagnose a concomitant vascular injury can lead to amputation. Different methods are used for the diagnosis of a vascular injury and the best approach is under debate. This study aims to examine the risk factor(s) of vascular injury in patients with KDs, examine variables that differ between obese patients and non-obese patients with KDs, and analyse the modalities used to identify vascular injuries in the KD population.

METHODS

The electronic patient medical record system at a major trauma centre was retrospectively reviewed to identify knee dislocations from 2015 to 2022. These were stratified based on age, gender, BMI, mechanism of injury, vascular injury, non-vascular complications, and laterality. Co-variates were inputted into a univariable regression analysis, followed by a multivariable regression analysis to identify risk factors of vascular injury in patients with knee dislocations. Co-variates were also compared between obese and non-obese patients using two-tailed t-tests for continuous variables and chi-squared test for categorical variables.

RESULTS

Forty patients were identified with a KD, with twenty-eight males and twelve females. The average age was 42.9 years, seventeen patients had a BMI of thirty or over, and eleven patients (27.5%) had a vascular injury. Open injuries (OR: 2.21; 95% CI: 1.19-11.30; p = 0.038) and obesity (OR: 2.66; 95% CI: 1.45-18.69; p = 0.027) are risk factors for vascular injury in patients with knee dislocation. Compared to non-obese patients, obese patients had a higher rate of open injury (p = 0.028), vascular injury (p = 0.017), low-energy injuries (p = 0.014), non-vascular complications (p = 0.017), and amputation (p = 0.036).

CONCLUSION

Open injuries and obesity are risk factors for vascular injury in patients with KD. Compared to non-obese patients, obese patients have low-energy injuries and an increased rate of non-vascular complications, meaning that clinicians could err on the side of caution when investigating vascular injury.

LEVEL OF EVIDENCE

IV.

Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up

BACKGROUND

Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old.

METHODS

This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores.

RESULTS

Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012).

CONCLUSIONS

Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports.

LEVEL OF EVIDENCE

IV, Case series.

Long-term Outcomes After Surgical Reconstruction of Multiligamentous Knee Injuries: Results at Minimum 10-Year Follow-up

Background

Multiligamentous knee injuries (MLKIs) are devastating injuries with concomitant injuries that complicate treatment and recovery. Short-term studies have shown satisfactory patient outcomes after surgical treatment; however, evaluations of long-term outcomes remain scarce.

Purpose

To evaluate long-term outcomes after surgically reconstructed MLKIs and further investigate the relationship between patient age on clinical outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 55 knees (age, 36 ± 11 years; 24% female subjects) who underwent surgical reconstruction for MLKI between 1992 and 2013 met the study inclusion criteria and were evaluated with postoperative patient-reported outcomes (PROs) including International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) for pain, Forgotten Joint Score, subjective improvement ratings and surgery satisfaction, and Tegner activity scores. PRO scores, revision, and conversion to arthroplasty were analyzed using descriptive statistics, linear regression, Wilcoxon rank-sum, and Fisher exact tests.

Results

At final follow-up (mean, 15 ± 5 years; range, 10-31 years), 67% of the cohort reported subjective improvement in their knee, and 82% reported satisfaction with their surgery. Compared with preoperative scores, there were significant improvements in postoperative VAS pain at rest in the full cohort, age ≤30-year cohort, and age >30-year cohort (4 ± 1 vs 2 ± 2; 4 ± 1 vs 2 ± 3; 4 ± 1 vs 1 ± 2, respectively; P≤ .029 for all) but significant reductions in Tegner scores (6 ± 3 vs 4 ± 2; 7 ± 2 vs 5 ± 2; 5 ± 2 vs 3 ± 1; P≤ .003 for all). Younger patients had higher postoperative Tegner scores than older patients (5 ± 2 vs 3 ± 1, respectively; P = .003), but no other differences in PROs were observed based on age. At a mean 15-year follow-up, 3.6% of the cohort underwent revision ligament surgery and 10.9% required arthroplasty.

Conclusion

The majority of the cohort reported modest subjective improvement and were satisfied with their surgery. Gradual but expected age-related decreases in Tegner scores were observed, and some patients demonstrated continued symptomatic and functional limitations, but mean PRO scores remained satisfactory. Revision surgery and conversion to arthroplasty were not commonly required.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

Satisfactory Outcomes and Improved Range of Motion With Arthroscopic Lysis of Adhesions and Manipulation for Arthrofibrosis After Multiligamentous Knee Reconstruction

Purpose

To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient-reported outcomes at mid- to long-term follow-up.

Methods

We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side.

Results

In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5-9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°-129°), mean extension of 3.2° ± 5.2° (range, 0°-12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°-117°). At a mean follow-up of 7.0 ± 3.9 years (range, 2.4-16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° (P = .003), a significant increase in arc of motion of 51° (P = .002), and an increase in extension of 3° (P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow-up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery.

Conclusions

At mid-term follow-up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA.

Level of Evidence

Level IV, therapeutic case series.

Does Delayed Ligament Reconstruction Surgery Lead to Poor Outcomes in Patients With Multiligament Knee Injuries?

Background and objective Multiligament knee injuries (MLKIs) are difficult to treat, and poor outcomes have been reported after conservative management. Controversy exists as to how to surgically manage these complex injuries. The aim of our study was to evaluate the midterm patient-reported outcomes after delayed multiligament knee reconstruction. Methods This was a review of a prospectively kept database of all patients undergoing surgery for multiligament reconstruction at a single institution. A total of 51 patients were included in the study, with a median follow-up of 48 months. In addition to the patient-reported outcomes, we also looked at other factors that could potentially affect the outcomes. Results At the final follow-up, there was no significant difference between the range of motion (ROM) of the injured knee compared to that of the healthy knee. Patients having surgery >6 months after injury had similar outcomes when compared to those having surgery <6 months post-injury. Female patients and patients with a BMI >30 had inferior outcomes. Conclusion Good midterm results can be expected after delayed multiligament knee reconstruction. Patients with a BMI >30 and female patients were observed to have inferior outcomes.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries

Background

Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal.

Purpose/Hypothesis

The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction.

Study Design

Cohort study; Level of evidence, 3.

Methods

The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts.

Results

In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001).

Conclusion

Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes

PURPOSE

The purpose of the study is to assess return to play rate and timing of elite athletes treated for multi-ligament knee injuries with modern surgical techniques.

METHODS

A retrospective review was performed of all professional or national/international level athletes treated for a multi-ligament knee injury by the senior author in the period from February 2001 to October 2019, with a minimum of 2-year follow-up. The study cohort consisted of 136 elite athletes who underwent surgery of two or more knee ligaments. Outcomes measures were return to play (RTP), defined as return to elite level sport, return to play time, and further surgical procedures.

RESULTS

One hundred and twenty (88.2%) athletes returned to elite level sport at an average of 12.8 months from operation. In unicruciate injuries, ACL and PCL-based injuries had similar return to play rates (89.1% vs. 87.5% respectfully, n.s.) although mean RTP time was longer in those with PCL-based injuries (15.2 vs. 11.9 months, p < 0.01). Bicruciate injuries had longer RTP times compared to unicruciate injuries (mean RTP 16.0vs. 12.4 months, p < 0.05) but were able to return at a similar rate (83.3% vs. 88.9%, n.s.). Medial and lateral sided injuries had similar RTP rates (89.3% vs. 87.9%, n.s.) though lateral sided injuries took longer before returning to play (13.4 vs. 11.6 months, p < 0.05). Further surgery was required in 54 (39.9%) patients including 25 (18.4%) manipulations under anaesthesia. Four (2.9%) of the athletes underwent revision ligament surgery.

CONCLUSION

Modern surgical techniques used in the treatment of multi-ligament knee injuries can lead to high return to play rates in elite athletes.

LEVEL OF EVIDENCE

IV.

The Top 50 Articles on Knee Posterolateral Corner Injuries

Purpose

To identify and characterize the most cited publications in orthopaedic research related to posterolateral corner (PLC) injuries of the knee.

Methods

The Science Citation Index Expanded was queried for PLC injury articles. The 50 most-cited studies from 1976 to 2021 were selected. Article characteristics, including number of citations, citation density, year of publication, source journal, country of origin, article type, article subtype, and level of evidence, were analyzed.

Results

The number of citations for individual articles ranged from 47 to 205. The 50 most cited articles were published in 16 journals. Eleven of the 50 articles (22%) were published in Arthroscopy-The Journal of Arthroscopic and Related Surgery. The largest proportion of the articles (n = 22, 44%) were classified as clinical, with the rest classified as reviews (n = 15, 30%), and basic science research (n = 13, 26%). The most common level of evidence for clinical articles was IV (14/22, 63.6%). Nine countries contributed to the top 50 articles, with the majority published in the United States (n = 35, 70%).

Conclusions

In the last 20 years, papers published on the diagnosis and surgical management of PLC injuries have a high citation frequency. Future high-quality research is needed to establish best-practice guidelines for the management of PLC injuries due to the low overall level of evidence of existing clinical studies.

Clinical Relevance

This research provides a comprehensive list for practitioners and may help educators identify articles to include in the curriculum for residents and fellows.

Complex Repair and Cruciate Ligament Reconstruction in KDs III and IV Multiligamentous Knee Injuries-Results of Mid-Term Follow-up

The purpose of the present study was to describe the longitudinal outcomes of acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament for knee dislocations (KDs) III and IV multiligamentous knee injuries. Forty-seven patients with an acute KD III or IV were treated with one-stage management within 9.2 days. Forty-five KDs III and IV with a follow-up at a mean of 53.2 months were evaluated. The mean International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score were 81.5 ± 0.7, 89.6 ± 1.2, and 6.8 ± 0.5, respectively. Comparing preoperative data with those at the latest follow-up, significant improvements in IKDC score (p < 0.01), Lysholm score (p < 0.01), and Tegner score (p < 0.01) were noted in all groups. Comparing contralateral knee stability, no statistical differences were found including the varus/valgus (0 degree/30 degrees) and Telos stress radiography. So, acute repair of extra-articular structure and anatomical reconstruction of cruciate ligament resulted in satisfactory outcomes for KDs III and IV multiligamentous knee injuries.

Long-term functional outcomes of multiligament knee reconstructions with lateral injuries

INTRODUCTION

Multiligament knee injuries are a rare but serious injury, affecting functional prognosis. The objective of this study was to assess the long-term clinical and laximetric outcomes of acute or chronic multiligament knee reconstructions, with lateral impairment, using autografts.

HYPOTHESIS

Autograft reconstructions give good long-term clinical and laximetric results.

MATERIAL AND METHOD

A retrospective monocentric consecutive study was conducted in patients who had multiligament knee reconstructions. The criteria for inclusions were cruciate ligament lesions associated with lateral injuries, reconstructed using autografts, regardless of the time to surgery. A minimum follow-up of 5-years was required. Twenty-nine patients were analysed. The average age at surgery was 30.2±13 years. The patients were clinically reviewed at the last follow-up. Differential residual laxity was objectively assessed with comparative dynamic X-rays. Functional IKDC, Lysholm and KOOS scores were analyzed.

RESULTS

The average follow-up was 7.5±1.7 years. The lesions were divided into 12 KD-I, 16 KD-IIIL and 1 KD-IV, including 16 acute lesions (time to surgery <30-day) and 13 chronic lesions. At the last follow-up, the objective IKDC identified: 3 stage A, 15 stage B and 11 stage C. The average scores were: subjective IKDC 70.1±16, Lysholm 76.8±14 and KOOS: pain 71.6±20, symptoms 83.6±22, activity 90.6±20, sport 58.8±23, quality of life 60.0±30. Dynamic X-rays showed an average differential laxity of 2.8±2.6mm anteriorly, 5.0±2.2mm posteriorly, and 2.0±2.5mm in varus. Four cases required surgery: 3 arthrolysis procedures for stiffness and 1 joint lavage for sepsis.

DISCUSSION

With an average follow-up of 7.5 years, multiligament knee reconstructions using autografts with lateral involvement provide good long-term control of frontal and sagittal laxities. A comparison with allograft reconstructions is necessary to be able to potentially overcome the morbidity associated to donor sites.

LEVEL OF EVIDENCE

IV; monocentric retrospective descriptive study.

Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques

Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m², mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.

Estudo epidemiológico das lesões multiligamentares do joelho

Objective  The present paper aims to describe multiligament knee injuries and to associate their features with the profile of the patients and trauma mechanisms.

Methods  This is a cross-sectional study evaluating 82 patients with multiligament knee injuries from September 2016 to September 2018. Evaluated parameters included age, gender, mechanical axis, affected side, range of motion, trauma mechanism, associated injuries, affected ligaments, and absence from work.

Results  The sample included patients aged between 16 and 58 years old, with an average age of 29.7 years old; most subjects were males, with 92.7% of cases. The most common trauma mechanism was motorcycle accident (45.1%). The most injured ligament was the anterior cruciate ligament (80.5%), followed by the posterior cruciate ligament (77.1%), the posterolateral corner (61.0%), and the tibial collateral ligament (26.8%). The most frequent type of dislocation was KD IIIL (30.4%). Only 1 patient had a vascular injury, and 13 (15.9%) presented with neurological injuries. Most subjects took medical leave from work (52.4%).

Conclusion  There is a big difference between patients with multiligament lesions in Brazil compared with international studies. Thus, it is advisable to carry out more specific studies on the topic with our population to improve the treatment of these patients.

Arthroscopically reduced, irreducible patella dislocation

Acute patella dislocations account for approximately 2%-3% of knee injuries and are therefore a relatively common presentation in the accident and emergency department. The majority of patella dislocations can be reduced with simple manoeuvres or even spontaneously and can be managed conservatively by bracing and rehabilitation. The aim of this study is to identify and review the main causes of the unique and unexpected event of irreducible patella dislocation and their characteristic presentations. Irreducible patella dislocations can happen but are very rare. Currently, a limited number of case reports are available, prompting for a need for research on this topic. This case study can shed light on the possible pathogenesis and pathognomonic features of irreducible patella dislocations and provide insight on the available therapeutic approaches.

Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

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.

Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial

BACKGROUND

Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion.

QUESTIONS/PURPOSES

(1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score?

METHODS

Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed.

RESULTS

With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year.

CONCLUSION

With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Postoperative Rehabilitation of Multiligament Knee Reconstruction: A Systematic Review

BACKGROUND

Multiligamentous knee injuries (MLKIs) are rare, and heterogeneous in presentation and treatment options. Consequently, optimal postoperative rehabilitation of MLKI remains unclear.

OBJECTIVE

To summarize the latest evidence for postoperative rehabilitation protocols following multiligamentous knee reconstruction (MLKR).

PATIENTS AND METHODS

A multidatabase search was conducted with the aid of a health sciences librarian. Blinded reviewers conducted multiple screenings of studies evaluating postoperative rehabilitation protocols following MLKR. All included studies were then graded based on level of evidence, and data concerning patient demographics and rehabilitation protocols were extracted.

RESULTS

MLKR rehabilitation protocols differ widely in terms of weightbearing, bracing, initiation, and types of physical therapy, yet several established protocols were referenced frequently throughout the literature. Such protocols resulted in good outcomes, with patients returning to running in 6 to 12 months and returning to sport in 8 to 12 months.

CONCLUSION

The rare nature of MLKI hinders the ability to create a standardized rehabilitation protocol. However, early postoperative physical therapy and range of motion consistently lead to improved outcomes. Randomized studies are needed to determine optimal postoperative rehabilitation following MLKR.

Multi-ligament reconstructions as a risk factor for adverse outcomes in arthroscopic surgery

PURPOSE

Multi-ligament knee injuries are a serious consequence of knee dislocation with a poorly evaluated post-operative complication profile due to low incidence. The aim of this study is to assess the risk of adverse post-operative events associated with operative management of multi-ligament knee injuries.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing surgical procedures for multi-ligament knee injuries from 2006 to 2016 using Current Procedural Terminology codes. We evaluated data on patient demographics and used a propensity score algorithm to adjust for baseline differences in these patients and developed univariate and multivariate logistic regression models to assess effects on minor and severe 30-day post-operative complications.

RESULTS

We identified 444 patients in this database who underwent multi-ligament knee reconstructions between 2006 and 2016. After propensity matching, minor and major adverse post-operative events were more frequent in patients with multi-ligament knee injuries (1.4% vs 0.2%, p < 0.001 and 2.7% vs 1.1%, p = 0.002, respectively). Patients with multi-ligament knee injuries experienced a 55-fold increase risk of need for transfusion (p < 0.001) and a fivefold increased risk of pulmonary embolism (p = 0.025), with most occurring in bicruciate reconstructions (Schenck Classification KD-III and KD-IV injuries).

CONCLUSION

The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse event over arthroscopic ACL reconstruction. These patients are most at risk for post-operative blood transfusion requirement, and pulmonary embolism, with patient's undergoing surgery for bicruciate ligament injuries at particularly high risk of complication.

LEVEL OF EVIDENCE

IV.

Clinical studies of single-stage combined ACL and PCL reconstruction variably report graft tensioning, fixation sequence, and knee flexion angle at time of fixation

PURPOSE

In single-stage ACL-PCL reconstruction, there is uncertainty regarding the order of graft tensioning and fixation, as well as the optimal knee flexion angle(s) for graft fixation. A systematic review of clinical studies of single-stage combined ACL-PCL reconstruction was performed to determine whether a particular fixation sequence and/or knee flexion angle is associated with superior outcomes.

METHODS

A systematic review was performed according to PRISMA guidelines. All levels of evidence were included. All outcome measures were extracted, including physical examination values, radiographic measurements, and objective and subjective outcomes.

RESULTS

Of the 19 included studies, 17 tensioned and fixed the PCL before the ACL. Only four studies reported the methods/forces used for graft tensioning. Across studies, the ACL was fixed at variable knee flexion angles, from full extension to 70°. Conversely, 3 studies fixed the PCL at a knee flexion angle < 45°, while the remaining 16 studies fixed the PCL at a flexion angle > 70°. Patient-reported outcomes were qualitatively similar between groups.

CONCLUSIONS

This systematic review found considerable variability in graft tension, fixation sequence, and knee flexion angle at the time of fixation, with insufficient evidence to support specific surgical practices. Most commonly, the PCL is fixed before the ACL graft, with fixation occurring at a knee flexion angle between 70° and 90° and near full extension, respectively. The methodology for quantifying the forces applied for graft tensioning is rarely described. Given this clinical equipoise, future studies should consistently report these surgical details. Furthermore, prospective, randomized studies on the treatment of multiligament knee injuries are needed to improve outcomes in patients.

LEVEL OF EVIDENCE

IV.

Risk Factors Associated With Complications After Operative Treatment of Multiligament Knee Injury

Background:

Many factors can affect clinical outcomes and complications after a complex multiligament knee injury (MLKI). Certain aspects of the treatment algorithm for MLKI, such as the timing of surgery, remain controversial.

Purpose:

To determine the risk factors for common complications after MLKI reconstruction.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A retrospective review was conducted on 134 patients with MLKI who underwent reconstruction between 2011 and 2018 at a single academic center. Patients included in the review had a planned surgical reconstruction of >1 ligament based on clinical examination and magnetic resonance imaging. Complications were categorized as (1) wound infection requiring irrigation and debridement, (2) arthrofibrosis requiring manipulation under anesthesia and/or lysis of adhesions, (3) deep venous thrombosis, (4) need for removal of hardware, and (5) revision ligament surgery. The potential risk factors for complications included patient characteristics, injury pattern categorized according to Schenck classification (knee dislocation [KD] I–KD IV), and timing of surgery. Significant risk factors for complications were analyzed by t test, chi-square test, and Fisher exact test.

Results:

A total of 108 patients met the inclusion criteria; of these, 29.6% experienced at least 1 complication. Smoking (odds ratio [OR], 3.20 [95% CI, 1.28-8.02]; P = .01) and planned staged surgery (OR, 2.71 [95% CI, 1.04-7.04]; P = .04) significantly increased the overall risk of complication, while increased time from injury to surgery (OR, 0.99 [95% CI, 0.98-0.998]; P < .01) significantly decreased the risk. Increasing time from injury to surgery (OR, 0.99 [95% CI, 0.97-0.998]; P = .02) also led to a slightly but significantly decreased risk for arthrofibrosis.

Conclusion:

The study findings suggest that smoking, decreased time from injury to initial surgery, and planned staged procedures may increase the rate of complications. Further studies are needed to determine which changes in the treatment algorithm are most effective to reduce the complication rate in patients.

The management of acute knee dislocations: A global survey of orthopaedic surgeons' strategies

Purpose: Great variety and controversies surround the management strategies of acute multiligament knee injuries (aMKLIs) and no established guidelines exist for resource-limited practices. The aim of this study was to compare the management approach of acute knee dislocations (AKDs) by orthopedic surgeons from nations with different economic status. Methods: This descriptive cross-sectional scenario-based survey compares different management strategies for aMLKIs of surgeons in developed economic nations (DEN) and emerging markets and developing nations (EMDN). The main areas of focus were operative versus non-operative management, timing and staging of surgery, graft choice and vascular assessment strategies. The members of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT) were approached to participate and information was collected regarding their demographics, experience, hospital setting and management strategies of aMLKIs. These were analyzed after categorizing participants into DEN and EMDN based on the gross domestic product (GDP) per capita. Results: One-hundred and thirty-eight orthopedic surgeons from 47 countries participated in this study, 67 from DEN and 71 (51.4%) from EMDN. DEN surgeons had more years of experience and were older (p < 0.05). Surgeons from EMDN mostly worked in public sector hospitals, were general orthopedic surgeons and treated patients from a low-income background. They preferred conservative management and delayed reconstruction with autograft (p < 0.05) if surgery was necessary. Surgeons from DEN favored early, single stage arthroscopic ligament reconstruction. Selective Computerized Tomography Angiography (CTA) was the most preferred choice of arterial examination for both groups. Significantly more EMDN surgeons preferred clinical examination (p < 0.05) and duplex doppler scanning (p < 0.05) compared to DEN surgeons. More surgeons from EMDN did not have access to a physiotherapist for their patients. Conclusions: Treatment of aMLKIs vary significantly based on the economic status of the country. Surgeons from DEN prefer early, single stage arthroscopic ligament reconstruction, while conservative management is favored in EMDN. Ligament surgery in EMDN is often delayed and staged. EMDN respondents utilize duplex doppler scanning and clinical examination more readily in their vascular assessment of aMLKIs. These findings highlight very distinct approaches to MLKIs in low-resource settings which are often neglected when guidelines are generated.

CLINICAL OUTCOMES AFTER TWO-STAGE BICRUCIATE KNEE LIGAMENT RECONSTRUCTION

Objective:

To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction.

Methods:

The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02).

Results:

With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36).

Conclusion:

Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.

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

Background

The purpose of this study is to compare the outcomes of acute primary repair of extraarticular ligaments with staged surgery for acute knee dislocations (KDs) and multiligament knee injuries (MLKIs).

Materials and methods

Between January 2005 and May 2018, 61 consecutive patients diagnosed with MLKI or KD were referred to or visited our institution. Of these, 31 patients who underwent acute repair of extraarticular ligaments within 3 weeks of injury were included in this study. These patients were retrospectively classified into two groups: those who underwent only primary repair (repair group) and those who underwent staged reconstructive surgery (staged group). Follow-up examination included range of motion (ROM), knee joint stability (Lachman test, posterior drawer test, and varus and valgus stress test), Lysholm knee score, Tegner activity scale, and Knee Injury and Osteoarthritis and Outcome Score (KOOS).

Results

Twelve of the 31 patients did not need or desire further surgery and were included in the repair group. No significant difference was observed in demographic data between the repair and staged groups. Although staged surgery decreased positive posterior drawer test results, no significant difference was observed between the two groups regarding ROM, other knee joint stability tests, Lysholm scores, Tegner scale, or KOOS.

Conclusions

In this series, all patients returned to their activities of daily living and preinjury occupation levels. Acute primary repair of extraarticular ligaments provides essential knee stability without varus/valgus instability and may reduce the need for subsequent cruciate ligament reconstruction.

Level of evidence

Level IV, retrospective observational study.

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes

BACKGROUND

Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts.

HYPOTHESIS

MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes.

METHODS

Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters.

RESULTS

Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis.

CONCLUSIONS

Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level.

LEVEL OF EVIDENCE

Level IV, case series.

Surgical Treatment of Combined ACL, PCL, and Lateral Side Injuries

A knee dislocation that involves at least 2 of the 4 major ligament groups-such as the anterior cruciate ligament, the posterior cruciate ligament, or the posterolateral corner-is a catastrophic event for an athlete or trauma patient. Careful evaluation of these patients is needed to avoid disastrous outcomes. Surgeons must be cognizant of a number of key treatment concerns-such as tunnel crowding, controversies over graft fixation methods, and sparsity of level I clinical data-to make proper ligament repair decisions. This manuscript will review treatment principles that govern high-quality care of this complex injury.

Knee Ligament Anatomy and Biomechanics

An understanding of knee ligament anatomy and biomechanics is foundational for physicians treating knee injuries, especially the more rare and morbid multiligamentous knee injuries. This chapter examines the roles that the cruciate and collateral anatomy and morphology play in their kinematics. Additionally, the biomechanics of the ACL, PCL, MCL, and LCL are discussed as they have surgical and reconstructive implications.

Combined ACL-PCL-Medial and Lateral Side Injuries (Global Laxity)

The multiple ligament injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurological status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends upon the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.

Promising clinical and magnetic resonance imaging results after internal bracing of acute posterior cruciate ligament lesions in multiple injured knees

PURPOSE

The purpose of this study was to evaluate the clinical and radiological outcomes of acute posterior cruciate ligament (PCL) lesions in multiple injured knees that were surgically treated with internal bracing.

METHODS

Acute complete PCL lesions in multiple injured knees with subsequent internal-bracing treatment within 21 days between 2014 and 2016 were eligible for inclusion. At final follow-up, patients were assessed with Tegner, Lysholm, and IKDC scores. PCL stability and healing were verified with KT-2000, stress radiography and magnetic resonance imaging (MRI).

RESULTS

Fourteen patients [mean age 37.4 (± 17.8; SD) years] were evaluated after a mean follow-up of 19.9 (± 7.7; SD) months. Thirteen patients suffered complete lesions of the PCL with concomitant ligamentous injuries (Schenck I: six cases, Schenck III M: five cases, Schenck IV N: one case, Schenck V: one case). Median Tegner, mean Lysholm and mean IKDC scores at follow-up were 4 (2-7; interquartile range), 69.1 (± 16.6; SD) and 68.9 (± 18.1; SD) respectively. Posterior translation averaged 5.8 (± 2.2; SD) mm with the KT 2000 and stress radiography showed a mean posterior tibial translation of 5.5 (± 4.1; SD) mm in the side to side comparison. MRI showed adequate PCL healing.

CONCLUSIONS

Internal bracing as treatment for acute PCL ruptures in multiple injured knees showed adequate restoration of posterior tibial translation in a single-centre study including 14 cases.

LEVEL OF EVIDENCE

IV.

Arthroscopic Posterior Cruciate Ligament Primary Repair

Injury to the posterior cruciate ligament (PCL) is most commonly seen in the setting of a multiligamentous injured knee, and isolated PCL tears are rare. PCL injuries are generally treated either conservatively or by PCL reconstruction using a graft. If a proximal or distal tear is present, the injured ligament can also be treated by primary repair, in which the ligament is reattached to the tibial or femoral insertion. This has the (theoretical) advantages of preserving the native tissue, maintaining proprioception, and can be performed in a less invasive way when compared with reconstruction surgery. In this review, the appropriate patient selection, surgical indications, surgical techniques, and outcomes of primary repair of proximal and distal PCL tears will be discussed. Primary repair may be an alternative treatment for PCL reconstruction if appropriate patient selection is applied.

From the central pivot to the peripheal knee injuries in the skier: a narrative review

The improvement in the technology in the last 20 years has showed its main effect on the increase of the speed in the curves, thus leading to a rise of knee injuries. In fact, the most injured zone of the body was the knee (35,6 %) and the distal part of the lower body (11,5%), with ACL lesion as the most frequent diagnosis (49% of all the injuries to the knee) due to a trauma in valgus and external rotation in most of cases. The MCL is involved in the 15-20% of the cases while the LCL in only the 4,2% of the patients. Unique epidemiology and distinct mechanisms of injuries are peculiar for skier’s knee while evaluation and treatment is similar to evaluation and treatment of knee injuries in other athletes. In this narrative review we aimed to highlight the current evidences in skiers’ traumatology with special focus on the treatment nowadays proposed in the international literature and to the return to sport. (www.actabiomedica.it)

Long-term clinical and radiological outcomes after multiligament knee injury using a delayed ligament reconstruction approach: A single-center experience

PURPOSE

To present long-term clinical and radiological results of patients treated with delayed reconstruction of multiligament knee injuries.

METHODS

Clinical data from 26 patients (21 men, five women, mean age 27.44 years) were retrospectively reviewed. Patients were evaluated at final follow-up with the use of: The International Knee Documentation Committee score (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity level, Lysholm Knee Scoring Scale, EuroQol subjective knee evaluation form, and KT-2000 arthrometer. Mean follow-up time was 105.38 months. Both knees were radiographically evaluated for osteoarthritis according to the Kellgren-Lawrence classification.

RESULTS

No patient required mobilization under anesthesia for adhesion lysis at the immediate or later postoperative duration. There was no statistically significant difference in range of motion between the healthy and operated sides (P = 0.713). Mean time to final range of motion regain was 2.1 ± 0.4 months. Average KT-2000 side-to-side (operated vs. normal) difference was 2.03 ± 1.1 mm, and the difference was statistically significant (P = 0.007). The mean IKDC, KOOS, Lysholm, Tegner, and Euroqol-5D postoperative scores were 82.13 ± 17.5, 84.59 ± 16.8, 90.6 ± 6.4, 4.3 ± 1.3, and 80 ± 11.74, respectively. Multiple regression analysis showed that age and follow-up time had significant effects on each clinical score, except for the Lysholm and Tegner scores. Progression of osteoarthritic changes of the reconstructed knee and its contralateral side was significantly different (P = 0.003).

CONCLUSION

Excellent clinical results were reported from this center's long-term experience with delayed ligament reconstruction, and osteoarthritic changes of reconstructed knees were recorded.

Knee and Leg Injuries

Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.

Critical Evaluation of the Methodologic Quality of the Top 50 Cited Articles Relating to Knee Dislocation and Multiligamentous Knee Injury

Background:

Many studies have evaluated the management of knee dislocations (KDs) and multiligamentous knee injuries (MLKIs). However, no study to date has analyzed the quality of the most cited articles in this literature.

Hypothesis:

There is a positive correlation between the number of article citations in the KD and MLKI literature and their methodologic quality.

Study Design:

Systematic review.

Methods:

The Web of Science online database was searched to identify the top 50 cited articles in KD and MLKI care. Demographic data were recorded for each study. The Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS) were used to analyze the methodological quality of each article. Spearman correlation coefficients (r_s) were then calculated.

Results:

The articles identified were published between 1958 and 2015 in a wide variety of peer-reviewed journals (n = 16). The majority of study level of evidence (LOE) was of low quality (level 5, 16%; level 4, 54%; level 3, 16%; level 2, 14%). There were no studies of level 1 evidence. The mean MCMS and MINORS scores were 29.0 (SD, 19.1; range, 3-72) and 6.1 (SD, 3.7; range, 0-14), respectively. No significant correlation was identified between the number of citations and the publication year, LOE, MCMS, or MINORS (r_s = 0.123 [P = .396]; r_s = 0.125 [P = .389]; r_s = 0.182 [P = .204]; and r_s = 0.175 [P = .224], respectively). Positive correlations were observed between improved MCMS and MINORS scores and more recent year of publication (r_s = 0.43 [P = .002]; r_s = 0.32 [P = .022]) as well as improved study LOE (r_s = 0.65 [P < .001]; r_s = 0.67 [P < .001]).

Conclusion:

The top 50 cited articles on KD and MLKI care consisted of low LOE and methodological quality, with no existing level 1 articles. There was no significant correlation between the number of citations and publication year, LOE, or study methodological quality. Positive correlations were observed between later publication date and improved methodological quality.

Non-surgical management of a tibiofemoral knee dislocation in a patient with sarcoidosis

This case presents a patient who sustained a knee dislocation, and who due to her diagnosis of sarcoidosis, other comorbidities, and prolonged use of corticosteroids, external fixation and physical therapy were implemented versus soft tissue reconstruction/repair. Research indicates worse functional outcomes with non-surgical treatment, and guidelines on optimising outcomes in this population are lacking. Integrated care of the patient-even when complex injuries and comorbid medical conditions are present-can lead to positive functional recovery, despite previous data. Evidence from related injuries can be successfully adapted in non-surgical management of these injuries, providing general treatment guidelines.