Multiligament Knee Injuries Research Articles

Contribution of the Medial Hamstrings to Valgus Stability of the Knee.

Multiligament knee injuries involving the medial side are common. When performing surgical reconstruction, use of the medial hamstrings (HS) as grafts remains controversial in this setting. To determine the role of the medial HS in stabilizing the valgus knee for different types of medial-sided knee injury. Controlled laboratory study. A biomechanical study on 10 cadaveric knees was performed. Valgus load (force moment of 10 N/m) was applied at 0°, 30°, and 60° of flexion, and the resultant rotation was recorded using an optoelectronic motion analysis system. Measurements were repeated for 4 different knee states: intact knee, superficial medial collateral ligament (sMCL) injury, deep medial collateral ligament (dMCL) injury, and posterior oblique ligament (POL) injury. For each state, 4 loading conditions (+ loaded; - unloaded) of the semitendinosus (ST) and gracilis (GRA) tendons were tested: ST+/GRA+, ST+/GRA-, ST-/GRA+, and ST-/GRA-. At 0° of flexion, combined unloading of the ST and GRA (ST-/GRA-) increased valgus laxity on the intact knee compared with the ST+/GRA+ condition (P < .05). For all medial-sided injury states (isolated sMCL; combined sMCL and dMCL; and combined sMCL, dMCL, and POL damage), ST-/GRA- increased valgus laxity at 0° and 30° of flexion versus ST+/GRA+ (P < .05 for all). The absolute value of valgus laxity increased with the severity of medial-sided ligament injury. Isolated ST unloading increased valgus laxity for the intact knee and the MCL-injured knee (combined sMCL and dMCL) at 0° of flexion (P < .05 vs ST+/GRA+). Isolated unloading of the GRA had no effect on valgus knee stability. The medial HS tendons contributed to the stabilization of the knee in valgus, and this was even more important when the medial side was severely affected (POL damage). This stabilizing effect was greater between 0° and 30°, in which the POL is the main valgus stabilizer. When deciding on graft selection for multiligament knee injury reconstruction, the surgeon should be aware of the effect of harvesting the medial HS tendon on valgus laxity.

Outcome of percutaneous reconstruction of chronic lateral collateral ligament rupture

PurposeMany techniques have been described for the reconstruction of chronic lateral collateral ligament (LCL) rupture with different autograft options. The advantages of percutaneous LCL reconstruction include small incisions, minimal soft tissue disruption, less postoperative pain, and speedy rehabilitation and recovery. The aim of this study was to report the functional outcome of percutaneous LCL reconstruction and overall patient satisfaction in Africans. MethodsThis prospective and interventional study involving 51 patients with chronic LCL rupture who had percutaneous LCL reconstruction using peroneus longus autograft was conducted between January 2021 and December 2022 in National Orthopaedic Hospital, Dala-Kano, Nigeria. The inclusion criteria were patients between the ages of 18 and 45 years with chronic isolated LCL and not more than 1 injury of knee ligament. Exclusion criteria were active infection, and multi-ligament knee injury requiring 2-staged surgery. The knee functions were assessed preoperatively, 3 months, 6 months, and 12 months postoperatively using the Lysholm scoring system. Patient satisfaction with the outcome of the treatment was assessed using a 5-point Likert scale. Relevant information was recorded into Microsoft Excel sheet and data was analyzed using SPSS version 23.0 for windows. The paired samples t-test was used to compare the clinical outcomes as continuous variables. Statistical significance was considered at p < 0.05. ResultsThe mean age of the patients was (30.10 ± 5.90) years. The median time from injury to surgery was 7 months (ranging from 3 to 28 months). The mean follow-up period was (14.07 ± 3.13) months. The mean preoperative and 1-year postoperative Lysholm scores were 44.33 ± 12.97 and 97.96 ± 1.23, respectively. ConclusionPercutaneous LCL reconstruction using peroneus longus autograft significantly improves patient knee function and results in excellent patient satisfaction.

Good long-term patients reported outcomes, return-to-work and return-to-sport rate and survivorship after posterior cruciate ligament (PCL)-based multiligament knee injuries (MLKI) with posteromedial corner tears as significant risk factor for failure

PurposeTo assess the survival rate and associated risk factors of a wide cohort of patient’s underwent surgical treatment for posterior cruciate ligament (PCL)-based multiligament knee injury (MLKI) at long-term follow-up and to investigate the long-term patient’s reported outcomes (PROMS) and functional activity.MethodsAll cases of PCL-based MLKI performed at one single sport-medicine institution were extracted and patient’s with a minimum 2 years of follow-up included. VAS, Lysholm, KOOS, Tegner Activity level scores, the incidence and time of return to sport (RTS) and return to work (RTW) were collected before, after surgery and at final follow-up. A multivariate logistic regression was performed to investigate the outcomes associated with the patient’s acceptable symptoms state (PASS) for each sub-score of the KOOS. The Kaplan–Meier method with surgical failure (re-operation to one of the reconstructed ligaments) as endpoint was used to perform the survivorship analysis for the entire cohort.ResultsForty-two patients were included and evaluated at an average of 10 years. All PROMS significantly improved from pre- to post-surgery (range ηp2 0.21–0.43, p < 0.05) except for the Tegner score which significantly improved from pre-surgery and to final follow-up (ηp2 = 0.67, p < 0.001). RTW was achieved in the 95.2% after 2.4 ± 1.9 months. RTS was achieved in 78.6% after 6.7 ± 5.0 months. The higher number of surgeries were the significant negative predictors of PASS for the KOOS sub-scales Sport (p = 0.040) and Quality of Life (p = 0.046), while the presence of meniscal lesions was a significant negative predictor of PASS only for the KOOS sub-scale of Sport (p = 0.003). Six patients (14.3%) underwent reoperation and were considered as surgical failures. The global survivorship was 95.2%, 92.6%, 87.1%, and 74.7% at 2, 5, 12, and 15 years, respectively. The survivorship in patient undergoing PMC reconstruction surgery was significantly lower (p = 0.004; HR 7.1) compared to patients without a PMC lesion.ConclusionGood-to-excellent PROMS could be obtained and maintained at long-term follow-up after surgery, with the higher number of surgeries and meniscal lesions as significant negative predictors of the PASS. Moreover, the presence of a PMC lesion significantly increases the risk of the PCL reconstruction failure.Level of evidenceIII.

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

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. 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. 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. 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 IV, therapeutic case series.

A Multifactorial Analysis of Patient Outcomes Following Multiligamentous Knee Injury

A Multifactorial Analysis of Patient Outcomes Following Multiligamentous Knee Injury

Comparison Of Physical Therapy Utilization And Motion-related Reoperations Between Isolated ACL And Multiligament Knee Injuries

Comparison Of Physical Therapy Utilization And Motion-related Reoperations Between Isolated ACL And Multiligament Knee Injuries

“New innovative QR code-based mobile audience response system (mARS) for panel discussion (PD) in a Indian Arthroscopy Society conference(IASCON) of 1102 registered delegates.” - A cross-sectional study

PurposeThe purpose is to determine the feasibility of Mobile based Audience response system (mARS) and the best time to get maximum delegate participation in panel discussion at a national Indian Arthroscopic Society conference(year-2022) with 1102 delegates by studying their engagement at various time schedules. MethodsOur institution-based software engineer set up mARS, and a separate URL, was purchased for recording the responses. 5 Panel discussions (PD) were moderated by senior national faculty, 3 were on knee topics, and 2 were on Shoulder topics. The audiences were engaged in ongoing PD discussion by displaying the multiple choice questions (MCQs) questions for 15–30 seconds & real-time response was collated, and poll results were declared in real-time during the conference. The data of each panel discussion was acquired from admin page & statistical analysis was done to determine the audience participation in Hall A (Knee) versus Hall B (Shoulder), Day 2 versus day 3 and pre-lunch session versus post-lunch session. ResultsMaximum number of delegates (252) participated in Multi-ligament knee injury (MLKI)PD (day 2); however, percentage of response was higher for Massive cuff tear PD (day 3). Audience response was better on day 2, for shoulder topics and pre-lunch session PD than on day 3, knee topics and post-lunch sessions & this was statistically significant (p < 0.001). ConclusionsmARS proves is an innovative and valuable resource, enhancing audience participation during PD at large gatherings. Real-time results aids not only active delegate engagement but also helps moderators/panellist in curating discussions to answer uncommon queries and unify the responses. The most suitable time for PD sessions utilizing mARS is the pre-lunch slot on day 2. Level of the evidenceLevel 3 (Decision Analysis- Observational cross-sectional study). Study designCross-Sectional Study. RelevanceThis article helps the organizers of larger meeting to time the panel discussion appropriately to obtain maximum audience participation and curate the discussion based on delegate centric responses. Key termsmobile Audience response system (mARS), Audience response system (ARS), Panel Discussion(PD), Indian Arthroscopic Society conference (IASCON), Indian Arthroscopy society (IAS). What is known about the subjectAudience response system (ARS) in the smaller meeting and webinars are well known entity to have active participation in on-going discussion. “What are the new findings?”Response and results of innovative QR code-based mobile Audience response system (mARS) for Panel discussion (PD) in larger arthroscopic conference with 1102 delegates showed delegates were more interested in Shoulder topics and pre-lunch session and Day 2 response were better.

Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries.

The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr). Between January 2012 and January 2022, 1,840 consecutive ACLrs were performed and included in a single-centre retrospective cohort. Exclusion criteria were partial tears, multiligament knee injuries, prior ipsilateral knee surgery, concomitant unicompartmental knee arthroplasty or high tibial osteotomy, ACL agenesis, and unknown date of tear. A total of 1,317 patients were included in the final analysis, with a median age of 29 years (interquartile range (IQR) 23 to 38). The median preoperative Tegner Activity Score (TAS) was 6 (IQR 6 to 7). Patients were categorized into four groups according to the delay to ACLr: < three months (427; 32%), three to six months (388; 29%), > six to 12 months (248; 19%), and > 12 months (254; 19%). Chondral injury was assessed during arthroscopy using the International Cartilage Regeneration and Joint Preservation Society classification, and its association with delay to ACLr was analyzed using multivariable analysis. In the medial compartment, delaying ACLr for more than 12 months was associated with an increased rate (odds ratio (OR) 1.93 (95% confidence interval (CI) 1.27 to 2.95); p = 0.002) and severity (OR 1.23 (95% CI 1.08 to 1.40); p = 0.002) of chondral injuries, compared with < three months, with no association in patients aged > 50 years old. No association was found for shorter delays, but the overall dose-effect analysis was significant for the rate (p = 0.015) and severity (p = 0.026) of medial chondral injuries. Increased TAS was associated with a significantly reduced rate (OR 0.88 (95% CI 0.78 to 0.99); p = 0.036) and severity (OR 0.96 (95% CI 0.92 to 0.99); p = 0.017) of medial chondral injuries. In the lateral compartment, no association was found between delay and chondral injuries. Delay was associated with an increased rate and severity of medial chondral injuries in a dose-effect fashion, in particular for delays > 12 months. Younger patients seem to be at higher risk of chondral injury when delaying surgery. The timing of ACLr should be optimally reduced in this population.

Injury Patterns in Posterolateral Corner Knee Injury.

Posterolateral corner (PLC) knee injuries associated with different injury mechanisms are not well known. This study sought to assess the patterns of associated injuries in the setting of PLC injury. The hypothesis was that there are recognizable injury patterns in PLC injuries that may correlate with injury mechanism. Cross-sectional study; Level of evidence, 3. Patients who sustained a multiligament knee injury were retrospectively reviewed. Patients who sustained an acute grade 3 PLC injury and underwent surgery were enrolled in this study. A description of the PLC injury (location of the injury of the fibular collateral ligament [FCL], popliteus tendon, and/or popliteofibular ligament) and reported concomitant injuries (biceps femoris tendon or meniscal tears, cartilage pathology and/or peroneal nerve palsy, or bone bruises) were collected and classified based on intraoperative and magnetic resonance imaging (MRI) findings. Of 135 patients reviewed, 83 did not have PLC involvement and 13 were excluded due to insufficient MRI scans available. Thus, 39 patients were included in this study. For both the anterior cruciate ligament (ACL)-PLC and ACL-posterior cruciate ligament-PLC injury patterns, the most frequent injury pattern entailed a bone bruise of the anteromedial (AM) femur and tibia, an FCL tear from the fibular head, the popliteus tendon avulsed off the femur, a biceps femoris tendon torn off the fibular head, and a common peroneal nerve palsy. Conversely, when no bone bruise occurred on the AM femur and tibia, the FCL was injured on the femoral side and the popliteus tendon, biceps femoris, and peroneal nerve were not injured. AM bone bruise was associated with a peroneal nerve injury in almost half of the patients, and peroneal nerve injury was not seen if there was no AM bone bruise.

Multiligament knee injuries in winter sports athletes

Multiligament knee injuries (MLKIs) are severe injuries that involve complete or partial tear to multiple ligaments of the knee, such as the cruciate ligaments, collateral ligaments, as well as structures such as the posteromedial and posterolateral corners. These injuries often occur as a result of high-energy trauma in motor vehicle accidents, but can also occur during sports activities such as a fall or collision while skiing or snowboarding. Diagnosis of an MLKI can be challenging due to the multifaceted nature of these injuries, and a comprehensive evaluation, including a thorough history, physical examination, and imaging studies, is necessary. Imaging methods, such as plain and stress radiographs and magnetic resonance imaging, are often used to confirm the diagnosis and assist in the establishment of a treatment plan. Treatment of MLKIs commonly involves surgical repair or reconstruction of torn ligaments and capsular structures, followed by lengthy rehabilitation focused on mobility, strength, and improving knee function. Return to sport is a concern, especially for those with many ligaments torn and those involving both cruciate ligaments and/or those involving the posterolateral corner. Prevention of MLKIs in skiing and snowboarding is important, and proper technique, equipment, risk awareness, and strengthening exercises can help reduce the risk of injury. While much is known about knee injuries in skiers, further research is needed to better understand MLKIs in ski and snowboard athletes, including the incidence, optimal management, and return to sport rates.

Outcomes of multiligament knee injury treated with versus without internal brace suture augmentation.

To compare the postoperative outcomes between Internal Brace (IB) and non-IB patients who underwent surgical management of multiple-ligament knee injuries (MLKI). Patients who underwent surgical management of MLKI at two institutions between 2010 and 2020 were identified and offered participation in the study via the collection of postoperative functional outcomes for MLKI; Lysholm Knee score, Multiligament Quality of Life (ML-QOL), Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT), Pain Interference (PI), Physical Function (PF), and Mobility instruments (MI). The postoperative outcomes and reoperation rates were compared between the IB group and non-IB group. One hundred and twenty-six patients were analyzed; 89 were included in the IB group (31.5% female; age 35.6 ± 1.4years), and 37 were included in the non-IB group (25.7% female; age 38.8 ± 2.4years). Mean follow-up time of the entire cohort was 37.9 ± 4.7months [IB: 21.8 + 1.63; non-IB: 76.4 ± 6.2, p < 0.001). The IB group achieved similar PROMIS CAT [PROMIS Pain (51.8 + 1.1 vs. 52.1 + 1.6, p = 0.8736), Physical Function (46.6 + 1.2 vs. 46.4 + 1.8, p = 0.9168), Mobility (46.0 + 1.0 vs. 43.7 + 1.6, p = 0.2185)], ML-QOL [ML-QOL Physical Impairment (36.6 + 2.5 vs. 43.5 ± 4.2, p = 0.1485), Emotional Impairment (42.5 + 2.9 vs. 48.6 ± 4.6, p = 0.2695), Activity Limitation (34.5 + 2.8 vs. 36.2 ± 4.3, p = 0.7384), Societal Involvement (39.1 + 3.0 vs. 41.7 + 4.2, p = 0.6434)] and Lysholm knee score (64.9 + 2.5 vs. 60.4 + 4.0, p = 0.3397) postoperatively compared the non-IB group, but the differences were not significant. In this cohort of patients with MLKI treated with versus without IB, outcomes and reoperation rates trended toward favoring IB, but the study was not sufficiently powered to reach statistical significance. Internal bracing could be useful in the management of MLKI.In the future, matched patient cohorts with more patients are warranted to further evaluate the clinical impact of the internal brace in MLKI.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis.

To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness. This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries. Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.). Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured. Level IV.

Poster 339: Long-Term Outcomes of Multiligament Knee Injuries in American Football Players from a Single Institution

Objectives: Multiligament knee injuries (MLKIs) can be devastating to an athlete’s career but can also negatively affect participation in recreational activities and daily tasks. A subset of athletes at significant risk of MLKIs are American football players. MLKIs with an associated anterior cruciate ligament tear (ACL-MLKI) are almost always surgically treated to restore stability to the athlete’s knee and to preserve knee-related function and joint health later in life. However, currently, there is a paucity of mid- and long-term outcomes data related to MLKIs and their surgical management. The objective of this study was to investigate &gt;2-year outcomes in American football players who had reconstruction of the anterior cruciate ligament (ACL) alongside any combination of additional knee ligament tears treated with repair or reconstructive surgery, constituting an ACL-MLKI, at a single institution. We hypothesized that greater than half of American football players who underwent surgical management for an ACL- MLKI would meet the International Knee Documentation Committee subjective knee form Patient Acceptable Symptomatic State (IKDC-PASS) cutoff, would be able to return to their pre-injury level of sport, and would be satisfied with their surgical treatment outcome. Methods: We utilized a single institution’s prospectively collected data repository to retrospectively- identify patients from 2001-2019 who were American football players, underwent surgical management for an ACL-MLKI, and were at least 2 years post-operative. We included patients with ACL reconstruction plus any additional combination of repair or reconstruction of the posterior cruciate ligament, medial or lateral collateral ligaments, or posterolateral corner. We excluded those with advanced osteoarthritis at the time of injury or morbid obesity. Follow-up for assessing patient-reported outcomes was performed using a web-based platform or via phone calls using 3 questionnaires: the IKDC, an institutionally developed surgical satisfaction questionnaire, and an institutionally-developed return-to-sport questionnaire. We calculated the proportions of patients meeting a previously published IKDC-PASS cutoff specific to isolated ACL reconstruction (IKDC³75.9) and calculated summary statistics for all outcomes data. As secondary analyses, we compared IKDC scores between 2-ligament and &gt;2-ligament groups using independent t-tests and evaluated the association between age at surgery and IKDC scores using linear regression (alpha&lt;0.05). Results: Outcomes data were successfully collected for 50 of 72 eligible patients (69%; mean follow-up time=7.9±4.0 years; Table 2). Of the 72 eligible patients, 55 (76%) had 2 ligaments surgically-treated, 16 (22%) had 3 ligaments surgically-treated, and 1 (2%) had 4 ligaments surgically-treated (Table 1). Among those with outcomes data (n=50), the mean IKDC score was 83.7, with 78% meeting the IKDC-PASS cutoff (Table 2). Only 7 patients (14%) did not return to sports participation due to limitations from their ACL-MLKI surgery, and 94% were either satisfied or very satisfied with their surgical outcome (Table 2). The 2-ligament and &gt;2-ligament groups did not differ in IKDC scores at follow-up (2-ligament: 84.0±15.4; &gt;2-ligament: 82.9±16.5; p=0.83). Age at surgery was not associated with IKDC score at follow-up (p=0.64). Conclusions: This study represents the largest cohort of American football players evaluated for mid- to long-term outcomes following ACL-MLKI surgery at a single institution. A high proportion of these athletes met the IKDC-PASS, successfully returned to sport, and were satisfied with their ACL-MLKI surgical treatment. [Table: see text][Table: see text]

Poster 277: Return to Sport after Multi-Ligament Knee Injury in Young Athletes

Objectives: While return to sport (RTS) has been well studied in young athletes after anterior cruciate ligament (ACL) reconstruction, there is a paucity of literature on RTS following reconstructive surgery for multi-ligament knee injury (MLKI). The purpose of this study is to assess level of RTS following MLKI in athletes 23 years old or younger at the time of injury and evaluate the factors associated with RTS. Methods: This was a retrospective study. We identified 116 patients at our Level 1 referral center who sustained MLKI at an age of 23 years old or younger. All 116 patients underwent operative reconstruction. Patients were contacted via mail and then completed surveys by telephone if willing to participate. Our primary outcome variable was self-reported ability to return to sport at their preoperative level or higher following surgery. Secondary variables included 2000 International Knee Documentation Committee Subjective Form (2000 IKDC-SF), ACL Return to Sport After Injury (ACL-RSI), and Short-Form 12 (SF-12) physical and mental health scales. Dependent variables included age, participation in cutting sports, number of and specific ligaments injured, and any concurrent mental health diagnoses. Results: A total of 30 (25.9%) patients completed surveys at an average follow-up of 7.8 years postoperatively (24 male, 6 female, 18.1±2.5 years old at time of injury). Of this cohort, 90% of patients returned to sport at some level, while 43.3% returned to their preoperative level or higher. Participation in cutting sports was associated with significantly lower rate of RTS at the same level or higher (p=0.017). Higher 2000 IKDC-SF and ACL-RSI scores were associated with significantly higher rate of RTS at the same level or higher (p=0.001 and 0.002, respectively). Patients who participated in higher level of sport preoperatively demonstrated a higher odds ratio (OR) of returning to their same athletic level or higher following MLKI (OR=3.516 [1.034-11.955]; p=0.044). Number of ligaments injured, age at time of injury, concurrent mental health diagnosis, and SF-12 scores were not associated with a statistically significant change in RTS at the same level or higher. Patients with concurrent ACL and MCL injuries trended toward higher rate of RTS at the same level or higher than two- or three-ligament injuries involving the ACL and PCL and/or LCL, but this was not statistically significant (50% vs. 25%, p=0.225). Conclusions: While a high percentage of young athletes return to some level of sport following MLKI, less than half return to their previous level. Those participating in cutting sports were significantly less likely to return to their pre-injury level of sport following MLKI. Participation in higher level of sport preoperatively was associated with a higher OR of return to sport at the same level or higher. Those who returned to the same level or higher reported significantly higher scores on the ACL-RSI and the 2000 IKDC-SF. There was no significant difference in those returning to sport at their previous level or higher based on SF-12 physical or mental scores, number of ligaments injured, presence of a mental health diagnosis, or age at injury. Future studies will focus on larger cohorts and any modifiable variables to obtain a functional return to sport. [Table: see text][Table: see text][Table: see text][Table: see text]

Poster 308: Clinical Outcomes After Multi-ligamentous Knee Injuries in Patients Over 40-Years-Old at Average 4-Years Follow-Up

Objectives: Multi-ligamentous knee injuries (MLKIs) are typically caused by high-energy mechanisms that warrant complex clinical decision-making and operative management to achieve optimal outcomes for patients. There is limited literature regarding these rare presentations, with even less information examining the clinical outcomes with respect to the age at which the injury was sustained. The purpose of this study is to investigate clinical outcomes following surgical treatment of MLKIs in patients who were at least 40-years-old at the time of their injury. Methods: The study design was a multi-center retrospective cohort study. Forty-four patients who underwent surgical repair for MLKI from May 2013 to August 2021 and were at least 40-years-old at the time of their injury were identified from two separate institutions. Patients-reported outcomes assessed included International Knee Documentation Committee Subjective Knee (IKDC) Subjective Knee Form, the Lysholm Knee Score, the Tegner Activity Scale (TAS), return-to-sport and return-to-work surveys, and Visual Analogue Scale (VAS) for pain and satisfaction. A multiple regression model was used to quantify the impact of various factors related to the initial injury, including age, sex, BMI, time of follow-up, history of dislocation with injury, and mechanism of injury on the assessed outcome measures. Results: The mean age of the cohort was 48.1 ± 7.0 years old. The mean overall follow-up was 60.8 months ± 36.3 (range 12-167)]. This cohort reported the following: mean IKDC of 63.4 ± 23.5, mean Lysholm score of 72.6 ± 23.6, and mean Tegner scores of 6.3 ± 2.2 before injury and 4.0 ± 2.0 at the time surveyed. These scores align similarly to the literature, indicating mediocre daily functional status. There were 18 patients that reported engagement in sports, with only 5 returning at a mean of 55.5 (± 26.2) weeks. The multiple linear regression model found dislocation to have a coefficient of -22.17 in relation to IKDC (p = 0.009), indicating that prior dislocation would predict a significant functional detriment as measured by the IKDC. A similar regression model with the Lysholm score as the outcome variable found dislocation to have a coefficient of -19.18 (p=.053), approaching significance. None of the other included variables were found to be significantly predicative of poorer outcome measures (p &gt; 0.05), including age. Conclusions: These results demonstrate that age may not be a significant factor to consider with respect to operative management in patients over 40 years old. Instead, dislocation status was found to be a much more significant predictor of clinical outcomes following operative management of MLKIs. Further research should be directed toward understanding which predisposing factors affect the long-term outcomes of MLKI injuries, given the often random nature of their presentation.

Techniques for Fixing Anterior Cruciate Ligament Tibial Avulsion Fractures in Multiligament Knee Injuries

Background: In patients with multiligament knee injuries, anterior cruciate ligament (ACL) tears are often reconstructed. Recent studies have shown good results when the ACL tibial avulsions are repaired. The advantages of ACL tibial avulsion repair are the preservation of the native anatomy, reduction in donor site morbidity, and lower risk of tunnel convergence. Indications &amp; Technique Description: We show 2 techniques for repairing ACL tibial avulsion fractures. The first case describes the use of hybrid fixation (screw and suture), with staged repair and reconstruction in a patient with high-energy knee fracture-dislocation. The second case describes the use of suture ACL repair via tunnels in a patient with a low-energy knee dislocation and an ACL tibial avulsion fracture. When repairing ACL tibial avulsion fractures, screw fixation is recommended for larger tibial fragments. In smaller comminuted fragments, tying sutures passed through the ACL via tibial tunnels may be more appropriate. Results: Several studies have demonstrated good postoperative results in patients following the fixation of ACL tibial avulsion fractures. Both screw and suture fixation are effective methods of repairing ACL tibial avulsion fractures and have similar postoperative outcomes. It has been found that screw fixation is associated with a higher risk of subsequent surgery and implant removal than suture fixation. Conclusion: The repair of ACL tibial avulsion fractures in multiligament knee injuries is an alternative to ACL reconstruction that demonstrates excellent postoperative patient outcomes, good patient satisfaction, and good return to sports. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Poster 306: Examining Preoperative Magnetic Resonance Imaging for Medial Meniscal Ramp Lesions in Patients Surgically Treated for Acute Grade III Combined Posterolateral Corner Knee Injuries

Objectives: While medial meniscocapsular tears ( ramp lesions) are commonly associated with isolated anterior cruciate ligament (ACL) injuries, there are limited descriptions of these meniscal injuries in multi-ligament knee injuries (MLKIs). The purposes of this study were: (1) To retrospectively evaluate preoperative MRIs for the presence of ramp lesions in patients surgically treated for acute grade III combined posterolateral corner knee injuries and (2) To determine if a preoperative posteromedial tibia plateau (PMTP) bone bruise is associated with the presence of preoperative ramp lesions on MRI in these same patients. Methods: Data on consecutive patients at a Level I trauma center with MLKIs between 2001 and 2021 were retrospectively reviewed. Only patients with acute grade III combined PLC injuries who received a magnetic resonance imaging (MRI) scan within 30 days of injury were assessed. Two musculoskeletal radiologists retrospectively reviewed each patient’s preoperative MRI for evidence of ramp lesions and bone bruises (Figure 1). Intra-class correlation coefficients (ICCs) were used to calculate reliability among the reviewers. Multivariate analysis was used to evaluate the relationship between bone bruising patterns and the presence of a ramp lesion on MRI. Results: Sixty-eight patients (79.4% male; mean age, 36.2 ± 13.7 years) with an acute grade III combined PLC injury were included in the study (Table 1). On MRI, the ICC for detection of ramp lesions and PMTP bone bruising were 0.921 and 0.938, respectively. Medial meniscal ramp lesions were diagnosed in 18/68 (26.5%). 11/18 (61.1%) patients with ramp lesions also showed evidence of PMTP bruising, while 13/50 (26.0%) patients without ramp lesions had PMTP bruising (P=0.008) (Table 2). When controlling for age and sex, PTMP bruising was significantly associated with the presence of a ramp lesion in combined PLC injuries (OR, 4.62; P=0.012) (Table 3). Conclusions: Preoperative medial meniscal ramp lesions were diagnosed on MRI in 26.5% of patients with acute grade III combined PLC injuries. In addition, PMTP bone bruising was significantly associated with the presence of a ramp lesion in patients with a grade III combined PLC injury. These findings demonstrate the need to assess for potential ramp lesions at the time of multi-ligament reconstruction. [Table: see text][Table: see text][Table: see text]

Poster 266: Outcomes of Surgical Stabilization for Recurrent Patellar Instability in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 6 years Mean Follow Up

Objectives: The purpose of this study was to assess return to play (RTP), patient-reported outcomes (PRO), and reoperation rates following patellofemoral stabilization surgeries (PSS) for recurrent patellar instability (RPI) in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of an RPI and subsequent PSS at a single institution between 2000 and 2020 were identified. Primary PSS ranged from MPFL reconstruction (n = 31; 50%) or MPFL repair (n = 22; 33.5%), and other PSS (n = 9; 14.5%) in the form of tibial tubercle osteotomy (TTO), lateral retinaculum release (LRR), and medial retinaculum reefing (MRR). Exclusion criteria included revision PSS, or concomitant anterior cruciate ligament reconstruction or multi ligament knee injury. All patients were contacted for determination of reinjury rates, current sport status, and PROs. Surgical failure defined as subsequent patellar dislocation despite operative management or need for secondary PSS. Results: Ultimately, 62 knees in 56 wrestlers were included at a mean follow-up time of 6.6 years (range, 2.0 – 18.8 years). RTP occurred in 55.3% of wrestlers at a mean of 8.8 ± 6.7 months. Among the PSS no differences were observed between rates of RTP (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). Recurrent patellar instability was the most common complication in 21% of knees. Among PSS types, MPFL reconstruction had the lowest rate of RPI (6.5% vs. 27.3% vs. 55.6%; P = .005), and surgical failure (9.7% vs. 31.8% vs. 55.6%; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared to MPFL repair and other PSS up to 10 years after the index surgery (90.3% vs. 64.1% vs. 27.8%; P = .048). Conclusions: Recurrent patellar instability remains a concern for competitive wrestlers after PSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared to other PSS up to 10 years after surgery. [Table: see text]

Poster 257: Decreased time between injury and surgery and increased injury severity predict motion loss after multi-ligament knee injury, but are only part of the picture

Objectives: Postoperative motion loss is the most common complication following multiple ligament knee injuries (MLKIs). MLKIs are often associated with concomitant musculoskeletal and neurovascular injuries and complex surgical treatment; however, factors that increase the risk of postoperative motion loss remain largely unknown. The purpose of this study was to identify predictors of motion loss following MLKI. We hypothesized that injury classification (Knee Dislocation [KD] grade), and shorter time between injury and surgery would be independent predictors of postoperative motion loss. Methods: This was a multicenter retrospective review of 773 MLKIs that occurred between 2011 and 2015. MLKI was defined as a complete tear of two or more ligaments where at least 1 ligament was repaired or constructed. Individuals with a MLKI defined as a complete tear (grade III tear) of two or more ligaments that underwent surgical repair or reconstruction of at least one ligament were included. Cases with loss of motion were identified from review of follow-up documentation or the need for subsequent manipulation under anesthesia and/or lysis of adhesions. A multivariable logistic regression with forward variable entry (p&lt;0.05) was performed to determine if any of the following variables were predictive of motion loss after MLKI: biological sex, KD grade, number of days between injury and surgery, graft type, use of external fixation, if staged procedures were performed, and associated vascular, nerve or tendon injury. Results: Of the 773 patients identified in the multicenter review, 562 (72.7%) had complete data for inclusion in the current analyses with 65 (11.6%) having postoperative motion loss (Table 1). Of the 562 patients (76.0% male, age=30.7±12.9 y, BMI=29±6.8 kg/m2), the median number of days between injury and surgery was 59 days (IQR=22-192 days). KD I injuries were the most common (59.6%) with 3.6% having KD II, 14.4% KD III-M, 13.9% KD III-L, 5.3% KD IV, and 3.2% KD V injuries. External fixation was used in 8.2% and 6.8% of the patients underwent staged procedures. Multiple graft combinations were used (all allograft = 37.5%, all autograft = 11.4%, combination = 48.9%, all repairs = 2.1%). Associated nerve injuries occurred in 19.8%, tendon injuries in 15.8%, and vascular injuries in 4.1%. Regression analysis identified decreased time between injury and surgery (OR=0.998, 95%CI[0.997-1.00]) and increased injury severity (KDIII OR=2.31, 95%CI[1.19-4.48], KDV OR=5.42, 95%CI[1.84-15.98]) as independent predictors of motion loss after MLKI (p &lt; 0.001, Nagelkerke R2=0.08). Conclusions: While KD grade and time between injury and surgery are predictive of motion loss after MLKI, these variables only explain 8% of the variability in motion loss. This confirms that clinicians should be cognizant that decreased time between injury and surgery and more severe injuries may increase this risk of motion loss; however, postoperative factors not measured in this secondary analysis might more heavily impact motion loss after surgical treatment for MLKI. Future studies are necessary to identify other factors such as pre-operative ROM, the postoperative inflammatory state of the knee, utilization of physical therapy and/or psychosocial factors that might influence motion loss after MLKI reconstruction to better inform postoperative care. [Table: see text]

Paper 25: The Impact of Posterior Tibial Slope on Meniscal Injury in Acute ACL Ruptures: A Large, Retrospective Registry Study

Objectives: Increased posterior tibial slope has previously been associated with an elevated risk of anterior cruciate ligament (ACL) rupture. Recent studies have suggested there may be a relationship between posterior slope and meniscal tears in ACL ruptures, however, these studies have either included chronic ACL injuries, revision ACL reconstructions or an overall low number of study participants. The goal of this study is to leverage a large ACL registry to assess the impact of posterior tibial slope on meniscal tears in acute ACL ruptures. Methods: A large, single-institution knee registry was consulted to identify all patients between the age of 18 and 45 who underwent primary ACL reconstruction between Jan 2019 and July 2022 for acute, noncontact ACL rupture, defined as undergoing surgery within 90 days of injury. Patients with pre-existing meniscal pathology, chronic ACL reconstructions, revisions, multi-ligament knee injuries and nonoperatively managed ACL injuries were excluded. Preoperative MRIs were used to measure lateral and medial posterior tibial slope for all patients. Meniscal injury seen in-situ during arthroscopy was recorded based on operative reports. Demographics data, including age, sex, and body mass index, was also recorded. Independent cohorts were created based on the presence or absence of any meniscal injury. Two-tailed student’s t tests were used to compare average medial and lateral posterior tibial slopes between these groups. Separate analyses were also performed to assess the impact of posterior slope on medial and lateral meniscus tears independently. Multiple logistic regression was carried out to determine risk factors for meniscal injury in this population. Results: 1059 patients ultimately met inclusion criteria. The average age was 29.5 and there were 532 (50%) women. There were 253 (24%) patients with isolated lateral meniscus tears, 152 (14%) patients with isolated medial meniscus tears and 93 (9%) patients with both medial and lateral tears. The average lateral and medial posterior tibial slopes were 5.54 (-4.2 to 13.4) and 5.67 (0 to 15.7), respectively. Increased lateral tibial slope was associated with a statistically significant increase in rate of any meniscal tear (p=.0022). Lateral slope was also associated with a higher rate of lateral meniscal tears, specifically (p=.0009). Multiple logistic regression identified elevated BMI and male sex as independent risk factors for meniscal injury in this population. Conclusions: Increased lateral posterior tibial slope is associated with a higher rate of meniscus injury in acute ACL ruptures and should be considered when devising treatment algorithms for patients in this population. [Table: see text][Table: see text][Table: see text][Table: see text]