Abstract
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.
Highlights
Acute multiligament knee injuries are uncommon injuries, if not recognized and managed appropriately, they can have devastating consequences [1]
The number of surgeons working in private sectors was higher (n = 28, 41.8%, p > 0.05) for the developed economic nations (DEN) group, while a significantly higher number of surgeons (n = 32, 45.1%, p < 0.05) worked in the public sector hospitals in the emerging markets and developing nations (EMDN) group (Supplementary Fig. 1)
Twenty surgeons (29.9%) who completed the questionnaire from the DEN group were subspecialized knee surgeons, compared to only 9 (12.7%)
Summary
Acute multiligament knee injuries (aMLKIs) are uncommon injuries, if not recognized and managed appropriately, they can have devastating consequences [1]. The popliteal artery is injured in 1.6% [2] to 40% [3] of cases and vascular assessment forms a crucial, yet controversial part of the initial assessment. The treatment of knee dislocations has been inconsistent, surgical treatment has become the preferred option [10] and high-volume centers in the developed world recommend early single-stage arthroscopic ligament reconstruction with. For resource-constrained settings in low-income countries, there are no evidence-based guidelines that are adapted to local challenges, such as access to surgical time, sub-specialist surgeons, arthroscopic equipment, allograft, and physiotherapy
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