Multiligament Injured Knee Research Articles

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review

ObjectiveTo map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs).DesignScoping review.Data sourcesPreferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey...

Diagnosis and treatment strategies of the multiligament injured knee : a scoping review protocol.

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI. This scoping review will address three aims: firstly, to map the current extent and nature of evidence for diagnosis and management of MLKI; secondly, to summarize and disseminate existing research findings to practitioners; and thirdly, to highlight gaps in current literature. A three-step search strategy as described by accepted methodology will be employed to identify peer-reviewed literature including reviews, technical notes, opinion pieces, and original research. An initial limited search will be performed to determine suitable search terms, followed by an expanded search of four electronic databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Web of Science). Two reviewers will independently screen identified studies for final inclusion. We will map key concepts and evidence, and disseminate existing research findings to the wider orthopaedic and sports medicine community, through both peer-reviewed and non-peer-reviewed literature, and conference and in-person communications. We will highlight gaps in the current literature and determine future priorities for further research.Cite this article: Bone Jt Open2022;3(11):894-897.

Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis

Background: Early surgery for acute ligamentous injuries has recently shown good clinical and functional outcomes. Purpose: To assess the advantages of early vs delayed surgery in patients undergoing isolated anterior cruciate ligament (ACL) or multiligament-injured knee (MLIK) surgery. Study Design: Meta-analyses of Level 1, 2, and 3 studies; Level of evidence, 4. Methods: A systematic search was performed via PubMed, EMBASE, and Cochrane for studies reporting outcomes of timing of surgery after isolated ACL injury or in the MLIK setting using accelerated rehabilitation protocols. Two analyses were conducted to differentiate early and delayed treatment (3- and 6-week cutoffs). Collected outcomes included meniscal or chondral lesions, failure and reoperation rates, range of motion (ROM) deficits, other complications, muscle strength, instrumented laxity, and functional outcomes. Outcomes were reported in risk ratios (RR) or mean differences with 95% CIs. Results: For timing of isolated ACL surgery, 16 studies were included with 2093 patients. High-grade evidence indicated that there were no differences in meniscal or chondral lesions, failure and reoperation rates, stiffness, ROM deficits, complications, muscle strength, instrumented laxity, and functional outcomes between patients treated early and late (all P > .05). When including only studies that set no preoperative criteria for early surgery, the findings were similar. Regarding MLIK surgery, 14 studies were included with 1172 patients. Low evidence was noted for the following: patients treated early had significantly fewer meniscal injuries (RR, 0.7; P = .04) and chondral injuries (RR, 0.5; P < .001), while no differences were found in reoperation rates, complications, stiffness, ROM deficits, muscle strength, instrumented laxity, and functional outcomes between the groups. Other than higher Lysholm scores in the early group for the 3-week analysis (mean difference, 6.8; P = .01), there were no differences between cutoff analyses. Conclusion: This systematic review with meta-analysis found no differences in clinical and functional outcomes between early and delayed surgery for isolated ACL injuries. For MLIK injuries, there were also no differences in surgical outcomes between early and delayed surgery.

National trends, 90-day readmission and subsequent knee surgery following multi-ligament knee reconstruction

Introduction/backgroundGiven the uncommon nature of the multi-ligament injured knee, a better understanding of its outcomes may be achieved by contemporary evaluation of a national administrative database. We aim to identify risk factors for 90-day major complications, 90-day readmissions, and subsequent knee surgery after a multi-ligament knee reconstruction. MethodsThe Humana Claims Database was queried for all patients undergoing a multi-ligament knee reconstruction procedure from 2007 to 2016 using International Classification of Diseases (ICD)-9 procedure codes and Current Procedural Terminology (CPT) codes. Outcomes of interest included Center of Medicaid and Medicare Services (CMS)- reportable 90-day complications, 90-day readmission and subsequent ligament reconstruction or total knee arthroplasty. Predictive factors studied included demographics (ie. age, sex, tobacco use) comorbidity burden and operative factors (ie. surgical setting, diagnosis of knee dislocation, concomitant meniscal repair or meniscectomy). Results588 multi-ligament knee reconstruction procedures were identified. The 90-day readmission rate 8.3%. The rate of subsequent ligament surgery was 7.1%. On multivariate regression analysis, a diagnosis of knee dislocation was associated with a four times greater likelihood of readmission and a two and a half greater likelihood of subsequent ligament surgery. Concomitant meniscectomy was associated with higher likelihood of subsequent total knee arthroplasty (9.1, 1.4–67.0) and outpatient setting of surgery compared to inpatient hospital setting was associated with reduced likelihood of readmission. ConclusionWhile uncommon, the patient population undergoing multi-ligament knee surgery is relatively diverse. Understanding common factors predisposing this population to adverse events following surgery may assist in improved outcomes.

Major concern in the multiligament-injured knee treatment: A systematic review

PurposeThe purpose of this systematic review was to address the treatment of multiligament knee injuries in three major aspects, specifically (1) surgical versus nonoperative treatment, (2) repair versus reconstruction of injured ligamentous structures, and (3) early versus late surgery of damaged ligaments. MethodsTwo independent reviewers performed a search on PubMed from 1966 to March 2016 using Levy’s review as a starting-point, and the same terms “knee dislocation,” “multiple ligament–injured knee,” and “multiligament knee reconstruction.” Study inclusion criteria were (1) levels I to IV evidence, (2) “multiligament” defined as disruption of at least 2 of the 4 major knee ligaments, (3) measures of functional and clinical outcomes, and (4) minimum of 12 months’ follow-up, with a mean of at least 24 months. ResultsTwo high-level studies compared surgical treatment with nonoperative treatment. There was a higher Lyshom scores (85 v 67) in surgically treated patients, as well as higher excellent/good IKDC scores (69% v 64%) and return to sport (41% v 18%). There were four studies comparing repair with reconstruction of damaged structures, with similar mean Lysholm scores (84 v 84) and excellent/good IKDC scores (63% v 63%). Nevertheless, repair of the posterolateral corner had a higher failure rate (39% v 8%) and a lower return to sport activities (25% v 51%). Similarly, repair of the cruciates achieved decreased stability and range of motion. There were six studies comparing early surgery (within 3 weeks) with delayed surgery. Early treatment resulted in higher mean Lysholm scores (89 v 82) and a higher percentage of excellent/good IKDC scores (57% v 41%), as well as higher mean ROM (129° v 124°). ConclusionsOur review suggests that the best treatment does not exist, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. Surgery must be performed within the first three weeks. Delayed ACL reconstruction allows to reduce arthrofibrosis rate.

Role of osteotomy in multiligament knee injuries

This article will outline the importance of the assessment of coronal and sagittal plane alignment when dealing with complex issues such as the multiligament injured knee. We will provide an overview of how alignment affects the forces transmitted across the joint during gait, and how these forces interact with knee ligaments following injury. Readers will be guided through the assessment of limb alignment, and an overview of methods to address coronal and sagittal deformity will be provided. In the acute multiligament injured knee, realignment osteotomy is rarely performed. However, in the patient with the chronic multiligament deficient knee presenting with instability, it is of utmost importance that limb alignment as assessed and any deformity corrected so as to optimize the biomechanical environment to achieve the best possible outcome for the patient.

The multiligament knee—not so complex to treat if the appropriate principles are respected

Even for experienced knee surgeons, the multiligament injured knee is a challenge.The challenge in these situations is to perform an accurate diagnosis in atimely manner and to establish the appropriate treatment for each patient. In contrast to common lesions such as an isolated anteriorcruciate ligament tear, patients with multiligamentinjured knees are very heterogenous and it is often not always possible tofollow an algorithm. The rationale for this special issueof Annals of Joint was to present an evidence-basedapproach from world leaders in the field regarding these injuries in orderguide knee surgeons in this difficult and long way for treatment.

Simultaneous Reconstruction of Anterior Cruciate Ligament with Autologous Tendon Grafts and Medial Collateral Ligament with Allograft

Objectives:Our objective is to show our surgical technique and experience in the combined reconstruction of ACL with autograft (either BTB or STGT) and MCL with allograft. (Aquiles Tendon)Methods:Twenty eight (28) patients, with an average age of 29,5, to whom an ACL and an MCL reconstruction with auto graft and allogeneic graft respectively was performed. These patients experienced residual internal instability after conservative treatment.Average follow-up was 19.6 months.Range of motion, joint laxity and subjective functionality were evaluated whit Lysholm scores and International Knee Documentation Committee (IKDC).Results:The Average Lysholm knee score was 93, while all the patients were classified A/B according to the IKDC and were able to return to their normal sport and daily activity.Conclusion:Nowadays various reconstructive techniques of anterior cruciate ligament (ACL) and of medial collateral ligament (MCL) are being utilized.Over the years the use of allografts have become common due to their safety, accesibility and satisfactory functional results.In multi-ligament injuries the single use of allografts or in combination with autologous grafts have become a valid resource.The lower risk of morbidity from the donor zone, the lower exposure of tissues, the lower postoperative pain with the MCL allogeneic graft at a low cost and greater security with ACL autologous graft have turned this surgical technique in a viable option for multi-ligament injured knee reconstruction.

How to avoid tunnel convergence in a multiligament injured knee

Multiligament knee injuries are challenging to diagnose and treat. For knee dislocations surgical treatment of the torn ligaments has been demonstrated to be superior to non-operative management. Furthermore, reconstruction of the torn ligaments has been demonstrated to be superior to repair of the torn ligaments. Repair of knee ligaments is associated with higher failure and reoperation rates compared to reconstruction; therefore, anatomic reconstruction of the torn ligaments is recommended. It is imperative to perform anatomic reconstructions to restore both the anatomy and the biomechanics of the knee. When reconstructing several knee ligaments, there is a risk of tunnel confluence in both the femur and the tibia. Prior to and during surgery, thorough planning of tunnel placement and orientation is important.

Tricks and tips for physical examination of the multiligament injured knee: what we can not forget

The multiligament knee injury may present some challenges in its evaluation during the physical examination. Due to the wide range of lesion patterns and instabilities, a systematic approach to physical examination is essential in such cases. The initial evaluation by inspection and palpation, followed by with the specific tests for each structure, with the evaluation of the cruciate ligaments, then the lateral and medial ligaments in an organized way allows a more accurate diagnosis. It is very important the ability to recognize the meaning of the result of each physical examination test and its variations, to avoid common misinterpretation. This article aims to present the physical examination of the multiligament injured knee in an organized way, pointing out the tips and tricks for the best diagnosis and correct treatment.

Use of external fixator pre- and post-reconstruction in the multiligament injured knee

Multiligament knee injury (MLKIs) is a rare condition, making up the 0.02% of the orthopedic injuries, but are potentially devastating to patients. The management of such lesions mandates a clear knowledge of the anatomy on all sides of the joint.

Imaging evaluation of the multiligament injured knee

Knee dislocation (KD) is an uncommon and complex injury with potentially limb threatening outcome. Injury to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) rarely occurs in isolation and is often part of a multiligamentous knee injury. There is a growing interest in the diagnosis and treatment of injury to the secondary supporting structures of the knee. Magnetic resonance imaging (MRI) is invaluable for evaluating the knee joint and its peripheral corners. Therefore, detailed knowledge of the normal MRI knee anatomy and the patterns of injury are crucial for the correct diagnosis and appropriate management of KD. As low impact KD often resolve spontaneously, the radiologists can be the first to consider the diagnosis of KD in a patient. In this article, we will focus on the MRI assessment of the normal and injured knee with emphasis on the peripheral corners. For detailed anatomic illustration we will use high resolution turbo spin echo MRI.

Multiligament Repair With Suture Augmentation in a Knee Dislocation With Medial-Sided Injury

Knee dislocations often result in a severe multiligament injured knee (MLIK) with complex instability. Multiligament reconstruction can successfully restore knee stability and is commonly recommended, although surgical morbidity is induced by graft harvesting and tunnel drilling, and convergence of multiple tunnels can complicate the surgery. Therefore, as an alternative, primary repair of knee ligaments is currently reconsidered. The main advantages of primary repair consist of tissue preservation and decrease of surgical morbidity, which might improve knee functionality. Techniques in which avulsed ligaments are reapproximated to their anatomic origin have resulted in good clinical outcomes in selected patients over the past decade. More recently, repaired ligaments have been augmented with suture tape, to protect them from excessive stretch, which can improve healing and allows early rehabilitation. The surgical technique of primary repair in the multiligament injured knee has not yet been described. The purpose of this Technical Note is to explain suture augmented primary repair in KDIII-M injury, including the anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament.

Posterolateral Corner Reconstruction Using the Anatomical Two-Tailed Graft Technique: Clinical Outcomes in the Multiligament Injured Knee.

Injury to the posterolateral corner (PLC) of the knee can lead to both varus and rotational instability. Multiple PLC reconstruction techniques have been described, including one-tailed graft (fibula-based constructs) or two-tailed graft (combined fibula- and tibia-based constructs). The purpose of our study was to evaluate the clinical outcomes of anatomical two-tailed graft reconstruction of the PLC in the setting of multiligament knee injuries (MKLIs) with grade III varus instability. Patients were identified through a prospective MLKI database between 2004 and 2013. Patients who received fibular collateral ligament and PLC reconstructions using a two-tailed graft and had a minimum follow-up of 2 years were included. Patients were assessed for clinical laxity grade, range of motion, and functional outcomes using Lysholm and International Knee Documentation Committee (IKDC) scores. Twenty patients (16 male, 4 female) with a mean age of 30.7 (range: 16-52) and a mean follow-up of 52.2 months (range: 24-93 months) were included. Knee dislocation (KD) grades included: 4 KD-1, 10 KD 3-L, 5 KD-4, and 1 KD-5. No patients had isolated PLC injuries. Mean IKDC and Lysholm score were 73.1 ± 25.8 and 78 ± 26, respectively. Mean range of motion was -1.1 to 122.8. In full extension, two patients (10%) had grade 1 laxity to varus stress. In 30 degrees of knee flexion, five (25%) patients had grade 1 laxity, and two (10%) had grade 2 laxity. Anatomical two-tailed PLC reconstruction can reliably restore varus stability when performed on patients with MLKIs and type C posterolateral instability with hyperextension external rotation recurvatum deformity. Satisfactory functional outcome scores were achieved in the majority of patients. This study supports the use of an anatomical two-tailed PLC reconstruction in the multiligament injured knee. The level of evidence is IV, case series.

Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions.

The purpose of this study was to analyse the clinical outcomes of multiligament injured knees with respect to the medial collateral ligament and posteromedial corner (PMC) repair or reconstruction versus the posterolateral corner (PLC) reconstruction in patients operated according to a codified surgical protocol. Patients were divided into two groups depending on whether PMC or PLC was injured. Cruciate ligaments as well as PMC or PLC were reconstructed/repaired in a one-stage procedure. At minimum of 1-year follow-up, objective and subjective International Knee Documentation Committee (IKDC) forms, Lysholm score and sports activity level were recorded. Thirty-nine patients with a median follow-up time of 57months (range 12-129) were reviewed. No significant difference was found for functional scores between acute PMC and PLC subgroups. In Group PLC, subjective outcomes tend to be better in the acute than in chronic reconstruction subgroup. A one-stage protocol with early surgery rather than delayed reconstruction produced better clinical outcomes whatever the injured collateral ligament, medial or lateral. In the future, early and chronic reconstructions as well as each injury pattern should be considered as separate entities in studies on multiple ligament injured knees to reach a better level of evidence. IV.

Arthroscopic Primary Repair of Posterior Cruciate Ligament Injuries

Posterior cruciate ligament (PCL) injury can present either as an isolated tear or in the setting of a multiligament-injured knee. Most PCL injuries are midsubstance tears and 10%-40% of tears are either bony avulsion or soft tissue avulsion of the femur or tibia. PCL reconstruction is the mainstay for treatment of midsubstance tears, but primary arthroscopic PCL repair can be considered for avulsion tears. Although the literature on PCL injuries and especially PCL repair is scarce, some studies show good results with primary repair techniques. In this article, we describe the surgical technique of arthroscopic primary PCL repair by passing Bunnel-type stitches into the ligament using a reloadable suture passer. Sutures are then fixed either to bone with a suture anchor technique or by passing the sutures through drill holes at the femoral footprint and tying them over a bony bridge or button. Patient selection and surgical indications, including radiographic assessment, are critical to successfully using this technique. The areas of concern and most common pitfalls of this technique are discussed, as well as the postoperative care regimen and reported clinical results to date. When these steps are carefully optimized, successful patient outcomes can be achieved. Although this technique is not meant to be the mainstay of surgical PCL treatment, we believe that the arthroscopic primary PCL repair technique is quite useful in select clinical situations, and should be in the armamentarium of every surgeon treating multiligament-injured knee or isolated PCL injuries.

Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting?

Treatment of posterolateral corner (PLC) injury in the multiligament-injured knee is still controversial. The aim of this study was to investigate the clinical outcome of acute or sub-acute surgical repair of Type 1 and 2 PLC peel-off lesions in a multiligament setting. Mini-open direct repair of the PLC was performed in 13 patients. Combined PCL, ACL and MCL injuries were simultaneously managed. Telos valgus and varus stress radiographs at 30° of flexion with 150N load were used to investigate medial and lateral joint opening. Posterior stress radiograph with 150N load was used to investigate the function of the PCL. External rotational laxity was assessed with a dial test at 30° of knee flexion, and photographs were taken to measure angles. Anterior displacement was examined using the manual maximum test performed with a KT-1000 arthrometer. A statistically significant reduction between pre- and postoperative laxity values was achieved for every test. Particularly, lateral joint opening side-to-side difference reduced from 10.3±4.0 to 1.0±3.2mm and external rotation reduced from 15±8° to 0°±6° more than that of the contralateral uninjured knee. The medial joint opening side-to-side differencereduced from 11.5±5.6 to 2.6±2.7mm in the 7 patients surgically managed for MCL lesion. The anterior tibial displacement side-to-side difference reduced from 14.0±5.0 to 3.0±5.0 mm in the 9 patients surgically managed for ACL lesion. The posterior tibial translation side-to-side difference reduced from 11.1±5.1 to 4.4±3.9mm in the 11 patients treated for PCL lesion. The main finding of the current study is that acute repair of Type 1 and 2 PLC peel-off injury proved to be an effective procedure to restore PLC function in a multiligament-injured knee. These data enabled the current literature with an effective treatment option to face such a complex and various scenarios such as multiligament-injured knee. IV.

Simultaneous reconstruction of anterior cruciate ligament (ACL) with autologous graft and of medial collateral ligament (MCL) with allograft

Introduction:Over the last years, the incidence of multiple ligament injuries has increased significantly due to the rising number of traffic accidents in relation to their kinetics and due to higher sports demands. Among their various combinations, one of them is the lesion of anterior cruciate ligament (ACL) which is associated to medial collateral ligament responsible for them in a 13 %.Nowadays several techniques to the reconstruction of Anterior Cruciate Ligament (ACL) and Medial Collateral Ligament (MCL) are applied. Therefore, for the last three years, we have carried out the simultaneous reconstruction of ACL with autologous graft and of MCL with allograft. Benefits include avoidance of morbidity in multiple donor areas, a safe bone-to-bone fixation in the case of Achilles tendon grafting; tiny incisions in the skin , and anatomical reconstruction.Throughout the years, the use of allografts has been very frequent. This is due to their safety factors, accessibility and their functional outcomes in the long term.Objectives:Show our surgical technique and experience in the combined reconstruction of anterior cruciate ligament with autologous graft and of medial collateral ligament with allograft.Methods:Fourteen (14) patients, with an average age of 29, were evaluated after they had undergone a reconstruction of ACL and MCL with autologous graft and allograft respectively. Average follow-up was 19.6 months.With respect to the surgical technique, it comprises two small incisions placing the anatomical femoral and tibial insertion for the MCL, and arthroscopically the anatomical location of the LCA. Later, some corresponding holes are made to be fixed with blunt Titanium screws following the same procedure. Mobility, joint laxity and subjective functionality were evaluated by means of Lysholm scores and International Knee Documentation Committee (IKDC).Results:The Average Lysholm knee score was 93, while all the patients were classified A/B according to the IKDC and were able to return to their normal sport and daily activity. Their range of motion remained stable.Conclusion:In multiple ligament knee injury, the use of allografts or in combination with autologous graft has become a valid resource. The lower risk of morbidity from the donor zone, the lower exposure of tissues, the lower postoperative pain with the MCL allograft at a low cost and greater security with ACL autologous graft have turned this surgical technique in a viable option for multi-ligament injured knee reconstruction.

Reply to the Letter to the Editor: Is Stability of the Proximal Tibiofibular Joint Important in the Multiligament-injured Knee?

To the editor, Thank you for your insightful questions. One of the goals of our paper was to bring recognition to a possible associated injury in the setting of a multiligament injured knee. As previously mentioned, the frequency of proximal tibiofibular joint instability in this group of patients is truly unknown, and associated injuries in our cohort of patients, including fractures, also were common. There have been numerous techniques described [2–5] to surgically stabilize an unstable proximal tibiofibular joint as mentioned in our paper. We do not necessarily believe that our technique is better than any other, and certainly further studies may help answer the question of what technique offers the best clinical results. The decision to use screw fixation to stabilize the proximal tibiofibular joint in our group of patients was made partly due to the availability of the hardware. On many occasions, the diagnosis was not made until the time of surgery. Moreover, similar techniques have been used to stabilize the distal tibiofibular joint with good results [1, 6, 7]. To date, we have not experienced any known screw breakage, and have removed the screw in two patients due to local pain around the screw. Both patients have not experienced any further issues.