Revision Multi-ligament Knee Reconstruction: Treatment Algorithm and Outcomes

Abstract

The treatment of knee dislocations remains challenging, and there is limited evidence available to guide treatment after failed multi-ligament reconstruction. The purpose of this study is to (1) present an algorithm describing surgical decision-making in the setting of revision multi-ligament reconstruction, and (2) assess clinical outcomes of this algorithm at a minimum of two years after surgery. We identified patients from our prospective multi-ligament database that underwent revision of multi-ligament reconstruction between 1992-2013 for persistent instability after failed primary reconstruction and/or repair. Patient demographic information (age, gender, BMI), injury description (mechanism of injury, neurovascular status, specific ligaments injured, associated chondral or meniscal injury), surgical technique (repair vs. reconstruction, staged vs. non-staged, concomitant procedures), mechanism of failure, as well as IKDC and Lysholm scores were obtained. The cohort consisted of 19 patients (6 female, 13 male), with an average age of 31±12 years (range 17-59 years) who underwent revision of multi-ligament knee reconstruction with a mean follow-up of 47±27 months. Thirteen (70%) patients underwent at least one additional procedure (mean 1.2, range 0-4) to correct other underlying pathology in preparation for revision reconstruction. Five (26%) patients underwent staged revisions with bone grafting of the tibial/femoral tunnels. Two (11%) patients underwent staged osteotomies, one distal femoral and one proximal tibial. One (5%) patient underwent concomitant meniscal transplant at time of revision. For revision surgeries, 17 (89%) underwent reconstruction only, and 2 (11%) underwent combined repair/reconstruction. Average IKDC and Lysholm scores were 66±26 and 71±23 respectively. High-energy mechanism of injury (p=0.04) and increased age at primary surgery (p=0.03) are associated with lower Lysholm scores. This algorithm offers a systematic approach for treatment of failed multi-ligament knee reconstruction. Revision multi-ligament surgery can achieve modest outcomes in selected patients Non-modifiable risk factors associated with worse outcome include increased patient age and a high-energy injury.