Multiligament Knee Injuries Research Articles

Factors predictive of poorer outcomes in the surgical repair of multiligament knee injuries.

To investigate the influence of injury and treatment factors on clinical/functional outcomes in multiligament knee injuries (MLKI). Thirty-nine consecutive patients with confirmed and surgically treated MLKI who met inclusion criteria were scheduled for a follow-up visit to obtain: SF-12 and subjective feeling of normalcy between the operated and healthy knee, and IKDC, active range of motion (ROM), and stability exam (Lachman test, posterior drawer, and dial test at 30°). A chart review was used to obtain data on injury and treatment factors. The postoperative mean (SD) outcomes were: IKDC score 62.7 (25.9), flexion-extension ROM 125° (29°), and percentage of normalcy 74% (20%). The postoperative normal/nearly normal stability exam was: Lachman test 36 (95%) patients, posterior drawer at 90° 38 (97%) patients, and dial test of 39 (100%) patients. There were 24 (61.5%) and 23 (59%) patients with complications and reoperations, respectively. The presence of bicruciate injuries was associated with worse Lachman (p = 0.03) and posterior drawer tests (p = 0.03). Presence of injury to meniscal structures was associated with worse Lachman test (p = 0.03), lower percentage of normalcy (p = 0.02) and extension lag (p = 0.04). Injury to cartilage structures was associated with worse IKDC scores (p = 0.04). IKDC was lower in cases of posterolateral corner reconstruction (p = 0.03) and use of allograft tendons for reconstruction (p = 0.02); ROM was lower in allograft reconstruction (p = 0.02) and need for meniscal repair (p = 0.01). Bicruciate reconstruction led to worst posterior drawer test (p = 0.006). The outcomes of MLKI might be negatively influenced by bicruciate ligament, meniscal, and cartilage injuries; with regards to treatment characteristics, need for posterolateral corner or bicruciate ligament reconstruction, use of allografts, or need for meniscal repair may similarly diminish outcomes. While surgical treatment provides good overall function, ROM and stability, it rarely results in a "normal" knee and the chances of complications and reoperations are high. Cross-sectional comparative study, Level III.

Socioeconomic Status Impacts Outcomes Following Anterior Cruciate Ligament Reconstruction Status

Objectives:Delays in pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) are associated with increased prevalence of concomitant knee injuries and worse post-operative outcomes. However, few studies have described the factors that may contribute to these delays and adverse events. This study seeks to determine the impact socioeconomic status has on outcomes following ACLR.Methods:Patients who underwent primary ACLR at a pediatric hospital between 2009 and 2015 were retrospectively reviewed. Variables included clinical outcomes and post-operative complications, as well as chronologic, demographic, and socioeconomic factors. Post-operative complication variables included graft failure, return to operating room, stiffness, and infection. Socioeconomic status was measured using health insurance type (commercial vs. government) and city block group level median household income levels derived from 2009-2015 U.S. Census Bureau data. Patients were excluded if they had multiligamentous knee injuries, prior ACLR, presented more than 365 days after injury, or had missing medical record data.Results:Overall, 127 patients (69 male, 58 female) were included in data analysis. The mean age at time of surgery was 15.0 ± 2.3 years (range = 9 to 21 years). There were 68 patients in the commercial insurance group and 59 patients in the government insurance group. Patients in the commercial insurance group had an average household median income of $87,767 (SD = $38,325) compared to $51,366 (SD = $25,330) in the government insurance group, p = < 0.0001. Patients in the government insurance group demonstrated greater delays in time from injury to first appointment (p = 0.0003), injury to MRI (p = 0.021), injury to surgery (p = < 0.0001), first appointment to surgery (p = 0.0036), and injury to return to play, p = 0.044 (Table 1). At time of surgery, 81% (48/59) of patients in the government insurance group presented with concomitant meniscal injuries compared 65% (44/68) of patients in the commercial insurance group, p = 0.034 (Odds Ratio = 2.38). Post-operatively, 22% (13/58) of patients in the government insurance group experienced decreased knee range of motion (“stiffness”) compared to 9% (6/68) in the commercial insurance group, p = 0.033 (Odds Ratio = 2.99). No significant differences were found between insurance types for rates of concomitant chondral injuries, graft failure, re-operation, or post-operative infection.Conclusion:Pediatric patients with government health insurance may experience delays in receiving definitive knee injury management and be at risk for complications and diminished outcomes. These delays are likely multifactorial, and may be attributed to decreased access to care, familial resources, and social support. Of note, our findings suggest a significant discrepancy in time to treatment as well as rates of concomitant knee injuries and post-operative complications between government and commercial insurance types.Table 1.Comparsion of insurance types by chronologic variables Commercial Government P Injury to First Appointment (days) 48.9 ± 57.196.5 ± 85.40.0003 Injury to MRI (days) 44.2 ± 83.385.9 ± 80.80.021 Injury to Surgery (days) 90.4 ± 83.7174.6 ± 122.2<0.0001 First Appointment to Surgery (days) 41.9 ± 65.278.1 ± 71.80.0036 Injury to Return to Play (days) 336.2 ± 130.4394.7 ± 153.60.044 Surgery to Return to Play (days) 255.7 ± 116.8238.9 ± 98.50.445

Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns.

The frequency of meniscal root tears in association with multi-ligament knee injury has not been established but adds to the complexity of surgical reconstruction and may have long-term consequences. Therefore, identifying root tears, on preoperative imaging, is important. The aim of this study was to identify the frequency of meniscal root tears, on preoperative magnetic resonance imaging, following multi-ligament injury and distinguish associated injury patterns that may aid detection. Cases were identified from a prospectively collected institutional database. The magnetic resonance imaging of 188 multi-ligament injuries [median age 31years (range 16-64)] was retrospectively reviewed by three musculoskeletal radiologists with the presence of meniscal injuries recorded alongside the ligament injury pattern and intra-articular fractures. Assessment of injury pattern was solely made on this imaging. 38 meniscal root injuries were identified in 37 knees (overall frequency = 20.2%; medial = 10.6%; lateral = 9.6%). The frequency of meniscal root tears was not increased in higher grade injuries (21.5% vs. 17.0%, n.s.). Valgus injury patterns were associated with lateral root tears (p < 0.05) and varus patterns were associated with medial root tears (p < 0.05). Further, fractures in the same compartment were associated with both medial and lateral root tears (p < 0.05). Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. Root tears can be predicted by ligament injury patterns and fractures sustained (suggestive of a compressive force). In multi-ligament cases, the preoperative magnetic resonance imaging can be used to detect these tears and associated patterns of injury. IV.

Nonoperative Treatment of PCL Injuries: Goals of Rehabilitation and the Natural History of Conservative Care.

To review the current practices of nonoperative management of posterior cruciate ligament (PCL) injuries, the natural history of conservative care, and the latest PCL rehabilitation strategies. PCL injuries often occur as part of a multiligamentous knee injury and occasionally occur in isolation. Although patients may be able to tolerate or compensate for a PCL-deficient knee, long-term outcomes after conservative care demonstrate a high rate of arthrosis in the medial and patellofemoral compartments resulting from altered knee kinematics and loads. Good subjective outcomes and a high rate of return to sport have been reported after nonoperative treatment of isolated PCL injuries. However, PCL laxity grade on objective exam does not typically correlate with subjective outcomes, nor does it correlate with the risk of developing osteoarthritis. Although more research is needed on the optimal PCL rehabilitation strategies, general principles include avoiding posterior tibial translation in the initial period to optimize ligament healing, followed by progressive range of motion and strengthening of the quadriceps and core musculature. At 12weeks, patients may begin an interval running program, followed by agility work and progressive sports-specific training to allow for return to sports. Nonoperative treatment of isolated PCL injuries results in good subjective outcomes and high rate of return to sport.

Return to Play After Multiligament Knee Injuries in National Football League Athletes

Background:Return to play (RTP) of National Football League (NFL) athletes after isolated anterior cruciate ligament (ACL) tears has been reported. However, no studies have reported on RTP of NFL athletes after multiligament knee injuries.Hypotheses:NFL athletes with multiligament knee injuries have lower RTP rates and longer recoveries than athletes with isolated ACL tears. Second, athletes with ACL and medial collateral ligament (MCL) injuries will have higher RTP rates and shorter time to RTP than athletes with an ACL tear and posterolateral corner involvement.Study Design:Retrospective cohort study.Level of Evidence:Level 4.Methods:Publicly available NFL injury data were reviewed for all multiligament knee injuries incurred between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited for reasons unrelated to the injury. Extracted data included type of injury, RTP, time to RTP (days), number and percentage of games played, and performance.Results:A total of 50 NFL athletes with multiligament knee injuries met inclusion and exclusion criteria. The overall RTP rate was 64.0%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, whereas athletes with ACL and posterior collateral ligament/lateral collateral ligament (PCL/LCL) tears had an RTP rate of 55.6% (P = 0.26). Mean time to RTP for all 50 athletes was 388.71 ± 198.52 days. The mean time to RTP for athletes with ACL/MCL injuries was 305.1 ± 58.9 days, compared with 459.2 ± 245.1 days (P = 0.004) and 609.3 ± 183.1 days (P < 0.0001) for those with combined ACL and PCL/LCL injuries and frank knee dislocations, respectively. Athletes with ACL/MCL injuries were more likely to return to prior performance level (43.5%) than those with ACL and PCL/LCL injuries (18.5%) (P < 0.001).Conclusion:The RTP rate for athletes with multiligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a greater likelihood of returning to prior performance than athletes with ACL and PCL/LCL tears.Clinical Relevance:Multiligament knee injuries significantly affect the ability of a football player to return to sport. ACL and MCL tears are associated with better RTP prognosis compared with ACL and PCL/LCL tears.

Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm.

Traumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation.

Epidemiology and outcomes of traumatic knee dislocations: Isolated vs multi-trauma injuries

Background and purposeTraumatic dislocation of the knee (TKD) is a rare injury, accounting for approximately 0.02% of orthopaedic injuries. They are a challenging entity for orthopaedic surgeons to manage, and can have devastating consequences.The aim of this study was to describe the epidemiology of traumatic knee dislocations (TKD'S) and contrast the incidence of neurovascular injury between isolated and multi-trauma dislocations as well as key patient reported outcomes achieved between these groups. Material and methodsPatients who had a traumatic disruption of the tibiofemoral articulation between March 1 2007 and February 31, 2015 were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data was cross-checked with medical records and radiological reports to confirm true multi-ligamentous dislocation. VOTOR collects information pertaining to orthopaedic injuries, treatment, complications and outcomes from four adult hospitals in Victoria, Australia, including the major trauma centers. Patient-reported outcomes are collected by VOTOR at 12 months post-injury including the EQ-5D-3L (EQ-5D) and Glasgow Extended Outcome Scores (GOS-E) and return to work status. Patient reported functional and quality of life outcomes at 12 months after injury were analysed. ResultsA cohort of 88 patients were identified that fit the inclusion criteria for the study, and at 12 months post-injury there was data available for 80 patients (90.9%). There were 38 (42.9%) patients who experienced an isolated traumatic knee dislocation and 52 (57.1%) who experienced a traumatic knee dislocation in association with another injury. Of the 88 patients identified as eligible for the study, two had bilateral knee dislocations, hence there were 90 multi-ligamentous knee injuries. Those who were injured at a higher velocity were more likely to have additional injuries. Dislocations that occurred at a lower velocity were shown to have better overall outcomes, as did dislocations that occurred in isolation. ConclusionsTraumatic knee dislocations that occur in isolation typically result in better outcomes than those that occur with associated injuries. TKD's are a rare but severe injury that requires further research in order for functional outcomes to be optimized.

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.

Short- to mid-term outcomes of anatomic MCL reconstruction with Achilles tendon allograft after multiligament knee injury.

Multiple techniques have been described in the literature for reconstruction of the medial collateral ligament. The purpose of this study is to describe functional outcome, range of motion, and knee stability following anatomic MCL reconstruction utilizing an Achilles tendon bone allograft after multiligament knee injury. A comprehensive search of a single-hospital multiligament knee injury (MLKI) procedural database was conducted to identify all patients that underwent reconstruction of the MCL utilizing an Achilles tendon bone allograft and with 2-year clinical follow-up. Medical charts were retrospectively reviewed to determine each patient's knee dislocation (KD) grade, final range of motion, stability on clinical examination, and the incidence of complications and reoperations. KOOS, IKDC, and Marx scores were also collected. Thirty-two knees in 32 patients (21 males and 11 females) with a mean age of 30years (range 15-51) were followed for an average of 40months (range 28-87months) following MCL reconstruction with Achilles tendon bone allograft. For patients with multiligament knee injuries, there were 14 KD-I (11 ACL/MCL; 3 MCL/PCL; 1 MCL/ACL/LCL; 1 MCL/PCL/LCL), 12 KD 3-M, and 3 KD-IV. One patient underwent isolated revision MCL reconstruction. At final follow-up, clinically significant valgus laxity was observed in only 1 patient (3%). All patients were able to achieve full extension of the knee and the average flexion was 121.1 ± 19.6. The average IKDC score was 67.6 ± 19.9 (range 27.7-98.9), the average KOOS score 77.1 ± 16.8 (range 31-100). The average Marx score was 4.9 (range 0-16, SD 5.2). Thirty-one of 32 (96%) patients reported being satisfied with results of the surgery. Knee dislocation grades were significantly correlated with post-operative outcome measures. In a series utilizing a modified Marx Achilles tendon, MCL reconstruction in the setting of MLKI demonstrated satisfactory clinical and functional outcomes, as well as patient satisfaction at short- to mid-term follow-up. Furthermore, knee dislocation grades were demonstrated to correlate with post-operative IKDC, KOOS, and Marx scores. Type IV.

Surgical Management of the Multiple-Ligament Knee Injury

The management of multiligament knee injury is a complex process starting with the adequate identification of the injury. A detailed physical and radiographic examination with a thorough understanding of knee anatomy is crucial to assess all damaged structures: anterior cruciate ligament, posterior cruciate ligament, posteromedial corner including the medial collateral ligament, and posterolateral corner including the lateral collateral ligament. Several surgical techniques have been developed throughout the years to adequately address these ligament insufficiencies. In this surgical technique description, we describe a reproducible method for the assessment and surgical management of a knee dislocation (KDIV) injury. Our approach includes using anatomic single-bundle cruciate ligament reconstructions with modified Bosworth technique for medial-side injuries and a combination of Müller popliteal bypass and Larson figure-of-8 techniques for posterolateral corner injuries. The orders of surgical steps is described concisely, and technical controversies such as graft choice, tunnel positioning, and sequence of graft fixation are discussed in detail.

Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population—A 2-Year Follow-up Study

To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction in young and middle-aged Asians. A retrospective study was performed using prospectively collected data from a tertiary institution ACL registry. All Asian patients with ACL tears who underwent primary arthroscopic ACL reconstruction by a single surgeon between 2008 and 2014, with minimum 2-year follow-up, were included. Patients with previous knee surgery or multiligamentous knee injuries were excluded. Two groups were formed: young patients (YP) (age <30) and middle-aged patients (MP) (age >40). They were compared preoperatively and 6months, 1year, and 2years postoperatively for demographics, knee range of motion, anterior laxity, Tegner level, Lysholm and International Knee Documentation Committee grade, ability to return to preinjury level of activity, and patient satisfaction. YP (n=84) and MP (n= 22) had differences in mean age (YP= 23.1years, range 18-29years; MP= 46.4years, range 41-59years, P < .001), preinjury Tegner level (YP= 7.4, MP= 6.4, P= .005), and preoperative Lysholm scores (YP=65.3, MP= 53.0, P= .034). The incidence of meniscal and chondral injuries was similar. Two years postoperatively, both groups had comparable knee range of motion and anterior laxity. The Tegner score was different (YP= 6.3, MP=5.2, P= .028), but the proportion of patients returning to preinjury Tegner level (YP= 45.2%, MP= 46.9%, P=.812), Lysholm scores (YP= 92.5, MP= 93.8, P= .794), proportion of patients with knees rated International Knee Documentation Committee A/B (YP= 77.4%, MP= 81.8%, P= .777), and satisfaction levels (YP= 98.5%, MP= 94.1%, P= .370) were similar. There were no graft ruptures or reoperations. In an Asian, predominantly male population, the clinical outcomes of arthroscopic ACL reconstruction in YP and MP are equally good at 2-year follow-up. MP can benefit as much as younger patients from ACL reconstruction in terms of restoration of knee function and return to preinjury activity level, are equally satisfied with outcomes, and should not be excluded from surgery on the basis of age alone. Level III, retrospective comparative study.

Physical therapy management of a rare multi-ligamentous knee injury following dislocation with a focus on gait training and therapeutic strengthening

Abstract Background: Knee dislocation is a traumatic but relatively rare injury that generally results in damage to multiple major stabilizing ligaments of the knee and, at times, vascular and neural compromise.

Revision Multiligament Knee Reconstruction: Clinical Outcomes and Proposed Treatment Algorithm

To (1) assess clinical outcomes of revision multiligament knee injury (MLKI) reconstruction at a minimum of 2years' follow-up and (2) present a standardized treatment algorithm used in treating revision MLKI patients. A retrospective review of our institution's MLKI database was performed to identify all patients who underwent revision MLKI reconstructions (≥2 ligaments reconstructed) after implementation of a standardized treatment algorithm in 2000 and had a minimum of 2years' follow-up. Patient demographic information, injury description (mechanism of injury, neurovascular status, knee dislocation grade, associated chondral or meniscal injury), surgical technique (repair vs reconstruction, staged vs nonstaged, concomitant procedures), mechanism of failure, knee stability, and range of motion, as well as International Knee Documentation Committee and Lysholm scores, were obtained. We assessed 23 patients (8 female and 15 male patients), with an average age of 26.7 ± 11.5years at primary surgery and 30.8 ± 11.0years at revision surgery. The mean follow-up period was 7.5 ± 5.3years. Of the 23 patients, 10 (43.4%) underwent staged revision procedures: isolated bone grafting in 3, osteotomy in 4, hardware removal with osteochondral allograft in 1, hardware removal with bone grafting in 1, and meniscus repair for a locked knee in 1. The average International Knee Documentation Committee and Lysholm scores were 74.5 ± 22.3 and 79.4 ± 20.2, respectively. High-energy injury and increasing age at revision surgery were the only risk factors found to be associated with significantly worse outcomes (P < .05). Patients with recurrent instability after MLKI reconstruction present with many concomitant pathologies, including limb malalignment, bone tunnel widening, retained hardware, meniscal incompetence, and cartilage defects. Revision MLKI reconstruction can provide these patients with modest functional outcomes when a standardized treatment algorithm is used focusing on identification and treatment of the concomitant pathology, often in a staged manner. Level IV, case series.

Pain and the unstable knee

Causes of knee pain in the unstable knee can be multifactorial and complex and often misdiagnosed. Commonly ligamentous injury, such as anterior cruciate ligament (ACL) tears can lead to knee pain that can be secondary to hemarthrosis, articular injuries, meniscal pathology and/or patellofemoral pain. Controversy exits regarding the role bone bruising plays in ACL injured and knee instability patients. Patient factors such as sex, age, BMI, and type of sport play a role as well. When ligamentous reconstruction is chosen, prehabilitation is essential to decrease the risk of arthrofibrosis which is a common cause of post-operative knee pain. Autograft donor site pain, as well as painful hardware, also is relevant. Post-operative therapies are critical as well. Posterior cruciate ligament (PCL) injury can lead to asymptomatic instability which also can be a cause of pain. As with the ACL, this instability can lead to further cartilage damage and osteoarthritis and subsequently to knee pain. Further, multi-ligamentous knee injuries are complex and causes of knee pain are even more numerous. Special attention must be paid to the vascular and neurologic status of the patient as conditions such as complex regional pain syndrome can be devastating. Commonly, injury and surgical complications, and arthrofibrosis can cause acute and chronic pain and no superior treatment scheme has been well established. The authors recommend an individualized approach with a thorough exam, appropriately indicated treatments, and post-operative care to prevent further injury and debilitating pain to allow the best outcomes.

Poly-traumatic multi-ligament knee injuries: is the knee the limiting factor?

Multi-ligament knee injuries (MLKI) from a high-velocity accident are rare but potentially devastating. This matched cohort analysis compares knee functional outcomes after multiple ligament reconstruction in poly-trauma patients to those that occurred in isolation. Sixty-two patients with MLKI that occurred either as a component of polytrauma or had occurred in isolation were matched according to age, sex, and knee dislocation grade. Functional outcomes and knee physical examination were assessed at a 2-year follow-up. New Injury Severity Score (NISS) was calculated based on the poly-traumatic injury pattern. Risk factors for worse outcomes in the poly-trauma cohort were analyzed. The mean IKDC, Lysholm, and NISS scores in the polytrauma cohort were 57.2 ± 21.9, 62 ± 22, and 40.9 ± 20.4, respectively, at a mean of 67months (range 24-220). The isolated knee injury group was followed for a mean of 74months (range 24-266) with mean IKDC and Lysholm scores of 71.1 ± 26.5 and 78 ± 23, respectively. Patients in the control cohort had significantly higher IKDC (p = 0.01) and Lysholm scores, (p = 0.003). There were no major differences between the two groups in regards physical examination findings at final follow-up. None of the analyzed risk factors was predictive of poor outcome. When comparing knees with similar multi-ligament and neurovascular injury patterns, patients who sustained their injury as a result of poly-trauma demonstrated significantly lower functional scores following reconstruction. This is despite restoration of similar knee stability and range of motion. The functional outcomes following MLKI reconstruction in poly-traumatized patients are influenced by factors other than the knee including concomitant injuries and psychosocial factors. Therapeutic Level III.

Unusual combined PCL and PLC pediatric multiligamentous knee injury treated with ligament repair procedure.

Unusual combined PCL and PLC pediatric multiligamentous knee injury treated with ligament repair procedure.

The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies.

The posteromedial corner of the knee encompasses five medial structures posterior to the medial collateral ligament. With modern MRI systems, these structures are readily identified and can be appreciated in the context of multiligamentous knee injuries. It is recognized that anteromedial rotatory instability results from an injury that involves both the medial collateral ligament and the posterior oblique ligament. Like posterolateral corner injuries, untreated or concurrent posteromedial corner injuries resulting in rotatory instability place additional strain on anterior and posterior cruciate ligament reconstructions, which can ultimately contribute to graft failure and poor clinical outcomes. Various options exist for posteromedial corner reconstruction, with early results indicating that anatomic reconstruction can restore valgus stability and improve patient function. A thorough understanding of the anatomy, physical examination findings, and imaging characteristics will aid the physician in the management of these injuries.

Low Incidence of Neurovascular Complications After Placement of Proximal Tibial Traction Pins.

Skeletal tibial traction is a temporizing measure used preoperatively for femoral fractures to improve the length and alignment of the limb and provide pain relief. The goal of this study was to identify possible neurovascular morbidity associated with the use of bedside skeletal tibial traction to treat femur fractures. All femoral fractures treated with proximal tibial traction during a 10-year period at an urban level I trauma center were retrospectively reviewed. The medical record was reviewed to determine whether a pin-related complication had occurred. Records also were reviewed to identify ipsilateral multi-ligamentous knee injuries that were not diagnosed until after the application of traction. In total, 303 proximal tibial traction pins were placed. A total of 7 (2.3%; 95% confidence interval, 0.60%-4.0%) pin-related neurologic complications and zero vascular complications were noted. All complications involved motor and/or sensory deficits in the distribution of the peroneal nerve. Of the 7 complications, 6 resolved fully after surgery and removal of the pin. After traction placement, 6 (2.0%) ipsilateral multiligamentous knee injuries were diagnosed. None of these patients had a neurovascular complication. This study suggests that bedside placement of proximal tibial traction for femoral fractures is associated with a low incidence of neurovascular complications and that traction can be safely placed at the bedside by residents. A thorough neurovascular examination should be performed before insertion, and care should be taken to identify the proper starting point and reduce soft tissue trauma during pin placement. [Orthopedics. 2017; 40(6):e1004-e1008.].

Practice Guidelines for the Management of Multiligamentous Injuries of the Knee.

Background:Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts.Materials and Methods:Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury.Results:Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries.Conclusion:Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.

Arthroscopic Primary Posterior Cruciate Ligament Repair With Suture Augmentation

Isolated posterior cruciate ligament (PCL) injuries are relatively rare and PCL injuries most commonly occur in the setting of multiligamentous knee injuries. PCL injuries can be treated with primary repair, which has the advantages of preserving the native tissue, maintaining proprioception, and minimal invasive surgery when compared with reconstruction surgery. Historically, primary repair of PCL injuries was performed in all tear types using an open approach, and, although the subjective outcomes were relatively good, patients often had residual laxity. Modern advances and increasing knowledge could improve the outcomes of PCL repair. With magnetic resonance imaging patients with proximal tears and sufficient tissue quality can be selected, and with arthroscopy and suture anchors minimal invasive surgery with direct fixation can be performed. Furthermore, with suture augmentation the healing of the repaired PCL can be protected and the residual laxity can be prevented. In this Technical Note, we describe the surgical technique of arthroscopic primary repair of proximal PCL tears with suture anchors and suture augmentation. The goal of arthroscopic primary repair is the preservation of the native PCL using a minimally invasive method and subsequent protection of this repair using suture augmentation.