Multiple Ligament Reconstruction Research Articles

Anterior Cruciate Ligament Over-The-Top Plus Lateral Plasty and Minimally Invasive Double-Bundle Posteromedial Corner Reconstruction

The medial collateral ligament (MCL) and the posteromedial corner (PMC) of the knee are essential structures for maintaining medial knee stability. Chronic MCL instability is infrequent but can necessitate surgical intervention. Various surgical techniques have been described, but they often involve the use of tibial tunnels, which may complicate concurrent ligament reconstructions. This study aims to present a minimally invasive double-bundle PMC reconstruction technique that avoids the use of tibial tunnels. Knee evaluation was performed using standard clinical tests and 1.5-Tesla magnetic resonance imaging. Patients with grade III Hughston MCL injuries were considered for surgery. The technique employs either an autologous semitendinosus graft or a fresh-frozen allograft, usually tibialis anterior, to reconstruct both the superficial MCL and the posterior oblique ligament. The technique described avoids the use of tibial tunnels, preserving tibial bone stock for any future procedures. The graft is secured at the femoral and tibial insertions using bioabsorbable interference screws and titanium staples, respectively. Our minimally invasive double-bundle PMC reconstruction technique offers a feasible and effective solution for patients with chronic medial knee instability. It is particularly beneficial for patients requiring multiple ligament reconstructions, as it avoids tunnel collision and preserves tibial bone stock.

Novel technique of predicting the dimensions of 5-stranded hamstring grafts for anterior cruciate ligament reconstruction: A descriptive study

BackgroundPrediction of hamstring tendon autografts is essential when planning a ligament reconstruction surgery. This is especially important in cases of multiple ligament reconstruction surgeries. This study was designed to predict the dimensions of 5-stranded hamstring grafts from anthropometric parameters in patients undergoing anterior cruciate ligament (ACL) reconstruction surgery. Methods172 patients undergoing ACL reconstruction with hamstring autografts were included in the study. Preoperative parameters included age, gender, height, weight, body mass index (BMI), thigh length, thigh circumference, and tibia length; intraoperative parameters included semitendinosus (ST) and gracilis (G) length and diameter, final 5-stranded graft length and diameter. Pre-operative data was correlated with intra-operative data using tests of significance. ResultsHeight, tibia and thigh length were greater in males (p < 0.05) whereas BMI was greater in females (p < 0.05). G and ST length alongwith 5-stranded graft length and diameter were significantly greater in males (p < 0.05). The graft dimensions could be correlated with the pre-operative anthropometric parameters using specific equations. This was applicable to the lengths and diameters of ST, G and 5-stranded grafts. We also noted that an increase in age was associated with a reduction in graft dimensions except for the diameter of G graft in females and length of 5-stranded grafts in males. Conclusion5-stranded hamstring graft dimensions can be reliably predicted using anthropometric parameters and this eases surgical planning.

One-Stage Arthroscopic Multiple Ligament Reconstruction for Schenck IV Knee Dislocation.

Schenck IV knee dislocation patients have dissatisfactory knee function and return-to-sport rate with the existing treatment methods. The purpose of this study was to illustrate a one-stage arthroscopic multiple ligament reconstruction method for treating Schenck IV knee dislocations. A retrospective case series study was performed. All patients with a history of Schenck IV knee dislocation who underwent one-stage arthroscopic multi-ligament reconstruction from 2010 to 2018 were followed for 24months. The outcomes, including general patient data, Lysholm scores, International Knee Documentation Committee (IKDC) scores, visual analog scale (VAS) pain scores, knee active range of motion, and complications, were reviewed. The data was analyzed with paired-samples t-test. A total of 12 patients, comprising nine males and three females, were followed up and reviewed. The mean age at the time of the surgical procedure was 40.3 ± 9.0 (22-57) years. The mean body mass index (BMI) was 24.6 ± 4.9 (15.2-32.5) kg/m2 . The mean IKDC score and Lysholm score before surgery were 30.4 ± 6.1 (21-42) and 28.2 ± 6.2 (22-39), respectively. The average operation time was 121.8 minutes. The mean IKDC score and Lysholm score at the 24-month follow-up were 80.6 ± 6.5 (68-92) and 82.0 ± 7.5 (72-95), respectively. There were significant differences in the IKDC and Lysholm scores between the preoperative and 24-month postoperative time points (p < 0.01). The mean knee range of motion was 124.6° ± 6.6° (115°-135°) at the 24-month follow-up. No major complications occurred. The results of this retrospective study suggest that the new arthroscopic one-stage multi-ligament reconstruction technique is an effective way to treat Schenck IV knee dislocation with satisfactory postoperative knee function.

Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment

PurposeTo compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.MethodsThe MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ2 tests, and Fisher exact tests were used with an α level of .05 set as significant.ResultsWe identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group.ConclusionsSingle-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.Level of EvidenceLevel III, retrospective cohort study.

Surgical Principles for Medial and Posteromedial Knee Injuries

Injuries to the medial side of the knee are among the most common knee ligament injuries. Treatment of these injuries require a thorough clinical workup and an intricate knowledge of the anatomy and biomechanics involving this region of the knee. Low grade injuries and isolated injuries to the medial collateral ligament (MCL) are treated nonoperatively with bracing and functional rehabilitation. Surgical treatment is recommended for high grade (Grade III) posteromedial corner injuries, distal MCL tears, including Stener lesions, knee dislocations and multiple ligament knee injuries involving the posterolateral corner (PLC) because of high risk of residual instability if treated non-operatively. When indicated, surgical treatment should be performed in the acute phase followed by early protected range of motion and functional rehabilitation. Preoperative planning should include stress radiographs and MRI. Important considerations for surgical technique include avoiding graft tunnel convergence in the setting of multiple ligament reconstruction and anatomic placement of the tunnels to recreate the native kinematics of the medial compartment. Postoperative rehabilitation focusing on quadriceps activation and protected range of motion is recommended beginning postoperative day one to minimize the risk of arthrofibrosis. Anatomic reconstruction of the superficial medial collateral ligament and posterior oblique ligament have been shown to produce good subjective and objective patient outcomes. Further level one studies are recommended to reinforce these findings.

Management of Neglected Multiple Ligament Rupture of the Knee: A Case Report

Delayed or neglected multiple ligament injury of the knee is challenging or doctors and physiotherapists. We report on a 36-year-old army man who presented to the outpatient orthopaedic department with complaints of pain and deformity of his right knee and an inability to weight-bear on the right leg. The examination of the right knee revealed an unreduced posterior dislocation of the knee with instability in all planes and a limited range of motion (ROM) from 10° to 100°. Quadriceps wasting was noted. Roentgenograms revealed a posterior dislocation of the knee. Magnetic resonance imaging (MRI) showed complete rupture of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and the patellar tendon. A two-stage surgery was planned, involving soft tissue distraction with external fixation to restore the knee joint, followed by multiple ligament reconstruction. Three months after surgery, the patient could walk normally with ROM between 0° to 120°.

Anatomic Multiple Ligament Reconstructions of the Knee

Background: Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage. Indications: After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (&lt;3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis. Technique: We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary. Results: Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed. Discussion/Conclusion: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.

Results of multiple ligament reconstruction after knee dislocation\u2014\u2014A prospective study with 95 patients and minimum 2-year follow up

BackgroundThere is still a lack of clinical data in arthroscopic treatment for treating multiple ligament injuries. This study aims to evaluate the clinical outcomes of patients with multiple ligament injuries undergoing treatment based on the classification stage and type of injury.MethodsA prospective, clinical trial on multiple ligament injuries was planned, which included 95 patients (58 men and 37 women; age: 42.8 ± 11.9 [range, 18–63] years) from October 2017 to June 2018. Injuries were classified into three stages (emergency stage < 24 h; acute stage: 24 h to 3 weeks, and chronic stage: > 3 weeks) and six types (KD I–VI) based on injuries time and structures, which indicated appropriate treatments. The clinical outcomes were evaluated at 2, 4, 6, 8, and 12 weeks and at 6, 9, 12 months and 24 months after surgery. The final choices in efficacy index included International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) score, and range of motion.ResultsDuring the follow-up, all patients exhibited statistically significant functional improvement in the injured limb compared with their preoperative situation. The mean postoperative scores of acute stage patients at 2-year follow-up were IKDC subjective score, 77.54 ± 11.53; Lysholm score, 85.96 ± 9.39; Tegner score, 4.13 ± 1.08; and VAS score, 1.21 ± 0.76. The mean postoperative scores of chronic stage patents at 2-year follow-up were IKDC subjective score, 74.61 ± 12.38; Lysholm score, 81.71 ± 10.80; Tegner score, 3.96 ± 1.14; and VAS score, 1.71 ± 0.60. The IKDC subjective score, Lysholm score, and Tegner score were significantly improved (P < 0.01) and the VAS score was significantly decreased (P < 0.01) at 2-year follow-up. Regarding the multiple ligament injuries classification, patients with more structural damage in stages V and VI showed less progress in functional recovery than those in stages I–IV.ConclusionsThis new classification with three stages and six types helps to identify the severity of injury and plan the management effectively. The outcomes were encouraging and the subjective functional results showed significant improvement at 2-year follow-up.Study designProspective clinical trial.Level of evidenceII

Knotless Webspace Reconstruction Technique for Central Metacarpal Ray Resections.

Ray amputations of the hand are procedures performed for traumatic injuries, infection, neoplasm, and certain deformities. When performed for the central digits, the gap created between the remaining digits can significantly impact hand function. Multiple deep transverse metacarpal ligament reconstruction techniques and bone transposition have been described to address this issue. The purpose of this case series is to describe a novel technique utilizing a knotless suture anchor reconstruction of the deep transverse metacarpal ligament after central digit ray amputation. We present a novel knotless suture anchor reconstruction technique through a single incision which allowed for an immediate range of motion. We present 2 cases where this technique was utilized with satisfactory cosmetic and functional outcomes. Knotless webspace reconstruction for central metacarpal ray resection reconstruction is technically simple and allowed for immediate motion with satisfactory cosmetic and functional patient outcomes. Level of Evidence: Level IV-therapeutic.

Multiple Ligament Reconstructions of the Knee and Posterolateral Corner

Injuries to the knee involving multiple ligaments occur in a variety of circumstances and require careful assessment and planning. A wide constellation of injuries can occur with causes sufficiently traumatic to produce bicruciate ligament deficiency, and this technical report will describe diagnosis, treatment and rehabilitation for a knee dislocation with lateral injury (KD-III-L on the Schenk classification). Reconstruction in the acute setting is preferred, with anatomic-based, single-bundle anterior cruciate ligament reconstruction, double-bundle posterior cruciate ligament reconstruction, and anatomic reconstruction of the posterolateral corner using two grafts for the 3 primary posterolateral corner stabilizers. Tunnel orientation to prevent convergence and sequence of graft tensioning and fixation are discussed as well. Successful outcomes have been achieved using these anatomic-based reconstruction techniques along with appropriate rehabilitation and bracing.

Influence of Posterior Tibial Slope on Clinical Outcomes and Survivorship After Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts: A Minimum of 10-Year Follow-Up

To investigate the influence of medial and lateral posterior tibial slope (PTS) on long-term clinical outcomes and survivorship after anterior cruciate ligament (ACL) reconstruction using hamstring autografts. A total of 232patients (mean age, 28.2 ± 8.9 years) who underwent primary ACL reconstruction from October 2002 to July 2007 were retrospectively reviewed. Patients with multiple ligament reconstruction, total meniscectomy, contralateral knee surgery before ACL reconstruction, open growth plate, and less than 10-year follow-up were excluded in the study. The medial and lateral PTS were measured from preoperative magnetic resonance imaging. Based on Li etal.'s previous study, the patients were divided into 2 groups according to their medial PTS (≤5.6° vs >5.6°) and lateral PTS (≤3.8° vs >3.8°), respectively. Clinical outcomes (clinical scores, stability tests and failure rate) were compared between the groups at the last follow-up. Furthermore, survival analysis was performed using the Kaplan-Meier method. All clinical scores (International Knee Documentation Committee subjective, Lysholm, and Tegner activity scores) and stability tests (physical examinations and side-to-side difference in Telos stress radiographs) were insignificantly different between the 2groups classified based on medial or lateral PTS. However, the failure rate was significantly higher in patients with medial PTS >5.6° (16.1% vs 5.1%, P= .01) or lateral PTS >3.8° (14.5% vs 4.7%; P= .01). The odds ratios of graft failure due to increased medial and lateral PTS were 3.18 (95% confidence interval, 1.22-8.28; P= .02) and 3.43 (95% confidence interval, 1.29-9.09; P= .01), respectively. In addition, the 10-year survivorship was significantly lower in patients with medial PTS >5.6° (83.9% vs 94.9%, P= .01) or lateral PTS >3.8° (85.5% vs 96.0%; P= .01). Increased medial (>5.6°) and lateral (>3.8°) PTS were associated with higher failure rate and lower survivorship at a minimum of 10-year follow-up after primary ACL reconstruction using hamstring autografts. Level III, retrospective comparative trial.

Anterolateral Ligament Reconstruction Improves Anteroposterior Stability As Well As Rotational Stability in Revision Anterior Cruciate Ligament Reconstruction with High-Grade Pivot Shift.

This study aimed to investigate the effect of anterolateral ligament reconstruction (ALLR) in revision anterior cruciate ligament reconstruction (ACLR) with high-grade pivot shift. The hypothesis was that revision ACLR combined with ALLR (RACLR with ALLR group) would show superior clinical outcomes to those of isolated revision ACLR. We retrospectively evaluated consecutive patients who underwent revision ACLR (RACLR) combined with ALLR between October 2015 and January 2017. The indication for combination of ALLR with revision ACLR was failed ACLR with ≥G2 pivot-shift instability. The control group included patients who underwent isolated revision ACLR (isolated RACLR group) for the same indication between July 2013 and September 2015. Exclusion criteria were ≤G1 pivot-shift instability, multiple ligament reconstruction, bilateral ligament injury, double-bundle reconstruction, insufficient medical records, postoperative infection, and follow-up loss at postoperative 2 years. Clinical scores, stability tests, and failure rates were compared between groups at the 2-year follow-up. The RACLR with ALLR group had 18 patients (mean age, 32.9 ± 10.8 years) and the RACLR group had 21 patients (mean age, 29.6 ± 10.2 years). Clinical scores at the 2-year follow-up showed no significant differences between groups. However, the RACLR with ALLR group showed better stability in the Lachman test (p = 0.005), pivot-shift test (p = 0.030), and side-to-side difference in stress radiographs (3.9 ± 3.0 mm vs. 5.9 ± 2.8 mm, p = 0.018) than the isolated RACLR group. The RACLR with ALLR group had two failures (11.1%), and the RACLR group had three failures (14.3%). In conclusion, ALLR in revision ACLR with high-grade pivot shift improves anteroposterior stability as well as rotational stability at 2-year follow-up. Therefore, ALLR is recommended with revision ACLR, especially in patients with high-grade pivot shift. This is a Level III, retrospective cohort review.

Development of heterotopic ossification after multiple-ligament reconstruction of the knee joint: Incidence and explanatory factor analysis

BackgroundThe development of heterotopic ossification (HO) might nullify any benefit of multiple-ligament reconstruction of the knee joint. The purpose of this study was to investigate the incidence and the specific explanatory factors for the development of HO after multiple-ligament reconstruction of the knee joint. MethodsFrom January 2011 to June 2016, 72 consecutive patients with knee dislocations received multiple-ligament reconstructions, of which 57 (79%) were available for a minimum follow up of 12 months and were included in this study. Anteroposterior (AP) and lateral radiographs were reviewed for all patients. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparisons. In addition, the HO group was divided into three subgroups based on a modified quadrant grading system introduced by the senior author for further evaluation. Multivariate logistic regression analysis was then performed to identify specific explanatory factors predicting development of HO in patients after multiple-ligament reconstructions of the knee joint. ResultsAmong the 72 consecutive patients, 57 (79%) were available for the clinical evaluations with an average period of 28.4 months (range, 12–51 months). Twenty-one patients (37%) showed radiological evidence of HO. The HO group (n = 21) showed significantly inferior results of knee flexion angle compared with the non-HO group (n = 36) (HO group vs. non-HO group: 124 ± 13° vs. 132 ± 5°; P<0.01). According to the quadrant grading system, there were seven patients with grade I, nine with grade II, and five with grade III HO. Subgroup analysis further revealed that higher HO grade would lead to lower knee flexion angle. In addition, multivariate regression analysis showed that concomitant posterior cruciate ligament reconstruction was the only independent explanatory factor predicting the development of HO after multiple-ligament reconstruction of the knee joint (P=0.018; odds ratio, 8.75; 95% confidence interval, 1.69–39.7). ConclusionIn this cohort of knee dislocations, the incidence of HO development following multiple-ligament reconstruction was 37%, with grade III HO showing the most inferior range of motion outcome. Moreover, concomitant posterior cruciate ligament reconstruction was the only independent predictor for the development of HO.

The incidence and risk factor of deep venous thrombosis after arthroscopically assisted anterior cruciate ligament reconstruction

PurposeTo retrospectively analyze the incidence and risk factors of deep venous thrombosis (DVT) detected by ultrasonography after arthroscopically assisted Anterior Cruciate Ligament Reconstruction (ACLR). MethodsWe retrospectively reviewed medical records of arthroscopically assisted ACLR surgery performed at our institution between 2012 and 2015. Revision ACLR, bone patella tendon bone (BTB) graft reconstruction, and concomitant multiple ligament reconstructions were excluded. We performed a standardized double-bundle reconstruction procedure using hamstrings graft for ACLR. All patients routinely received DVT screening by using venous ultrasonography on postoperative day 7 from 2012 to 2013, and postoperative days 7 and 14 from 2014 to 2015. The prevalence of DVT was calculated and clinical factors such as age, gender, Body Mass Index (BMI), operative time, and duration of tourniquet application were evaluated in relation to the risk factor of DVT. ResultsTwo hundred and fifty-six patients (129 men and 127 women) with a mean age of 28.9 were enrolled. Sixteen patients (6.6%) were detected with DVT on postoperative day 7. Among 146 patients who received venous ultrasonography on both postoperative days 7 and 14, DVT were detected in five additional patients on postoperative day 14. In a total of 21 patients who were diagnosed with DVT, two were proximal, the remaining 19 were distal, and no patient had progressed to pulmonary embolism (PE). In terms of predisposing factors for developing DVT on postoperative day 7, only age ≥30 showed a statistically significant higher risk of DVT (P = 0.03). ConclusionIncidence of DVT after ACLR detected by ultrasonography on postoperative day 7 was 6.6%. Patients aged ≥30 years have a potentially higher risk for developing DVT. Great care for DVT should be taken if prolonged immobilization is applied after ACLR surgery. Level of evidenceLevel Ⅳ

A Hamstring-Based Anatomic Posterolateral Knee Reconstruction With Autografts Improves Both Radiographic Instability and Functional Outcomes

To report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstring-based anatomic posterolateral corner (PLC) reconstruction technique using autografts. An outcome study of patients with a chronic complete tear of all ligamentous structures of the PLC (>5mm of varus gapping at 30o, ≥10° of external tibial rotation during the dial test, ≥4mm of increased lateral compartment opening during varus stress radiographs) was performed. The patients were evaluated subjectively with Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores and objectively with varus stress radiographs at 20° of knee flexion, IKDC objective scores, and recurvatum evaluation. Institutional review board approval: CEP/UNIFESP n: 1251/2016. Twenty-nine of 33 patients were available for follow up at an average of 31.9 ± 12.3months (range, 24-59months) postoperatively. Twenty-five patients underwent multiple-ligament reconstruction without prior osteotomy. No patient had an isolated PLC knee reconstruction. The average comparative preoperative and postoperative outcomes were, respectively: Lysholm: 49.7 ± 10.3, 81.2 ± 12.8, P < .001, 89.7% met minimal detectable change; IKDC: 36.7 ± 8.3, 70.4 ± 19.8, P < .001, 82.8% met minimal clinically important difference; Tegner, 6.6 ± 1.3, 5.5 ± 1.6, P<.001; and varus stress radiograph: 7.1 ± 3.1mm, 1.8 ± 1.8mm, P < .001. A significant improvement, P < .001, was found between preoperative and postoperative IKDC objective scores for varus opening at 0° and 30° and external rotation measured by the dial test at 30°. Recurvatum was also improved: preoperatively, 52% had a low-grade and 48% had a high-grade recurvatum, whereas postoperatively, 100% were classified as low grade, P < .001. The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls. Level IV, therapeutic caseseries.

The Influence of Graft Tensioning Sequence on Tibiofemoral Orientation during Bicruciate and Posterolateral Corner Knee Ligament Reconstruction: A Biomechanical Study

Objectives:During a multiple knee ligament reconstruction, the graft tensioning order may influence the final tibiofemoral orientation and corresponding knee kinematics. Therefore, the objective of this study was to biomechanically evaluate the effect of different graft tensioning sequences on knee tibiofemoral orientation following multiple knee ligament reconstruction in a bicruciate ligament (anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) with posterolateral corner [PLC] injured knee.Methods:Ten non-paired, fresh-frozen human cadaveric knees were utilized for this study. Following reconstruction of both cruciate and posterolateral corner ligaments and proximal graft fixation, each knee was randomly assigned to each of four graft tensioning order groups: (1) PCL → ACL → PLC, (2) PCL → PLC → ACL, (3) PLC → ACL → PCL and (4) ACL → PCL → PLC. The tibiofemoral orientation after graft tensioning was measured and compared to the intact states.Results:Tensioning the ACL first (tensioning order 4) resulted in posterior displacement of the tibia at 0° by 1.7 ± 1.3 mm compared to the intact state (p=0.002) (Figure 1). All tensioning orders resulted in significantly increased anterior tibial translation compared to the intact state at higher flexion angles ranging from 2.7 mm to 3.2 mm at 60° and 3.1 mm to 3.4 mm at 90° for tensioning orders 1 and 2 respectively (all p<0.001). There was no significant difference in tibiofemoral orientation in the sagittal plane between the tensioning orders at higher flexion angles. All tensioning orders resulted in increased internal tibial rotation (all p<0.001). Tensioning and fixing the PLC first (tensioning order 3) resulted in the most increases in internal rotation of the tibia; 2.4° ± 1.9°, 2.7° ± 1.8° and 2.0° ± 2.0° at 0°, 30° and 60° respectively (Table 1).Conclusion:None of the tensioning orders restored intact knee tibiofemoral orientation. Tensioning the posterolateral corner first should be avoided in bicruciate knee ligament reconstruction with a concurrent posterolateral corner reconstruction because it significantly increased tibial internal rotation. We recommend that the PCL be tensioned first, followed by the ACL to avoid posterior translation of the tibia in extension where the knee is primarily loaded with most activities and finally the PLC.Figure 1:Mean changes from intact in tibial displacement in the anteroposterior (AP) direction after different tensioning sequences compared to the intact state (error bars represent ± 1 SD). The magnitude demonstrates changes after each tensioning sequence with intact subtracted. Positive values denote anterior translation, and negative values denote posterior translation of the tibia. * = significantly different from intact, native state (p < .05).0Table 1:Pairwise comparison of internal and external tibial rotation between the different tensioning orders with the intact, and between the tensioning orders at different angles (0°, 30°, 60°, 90°, respectively) for the zero force state. Angles are given in degrees, and the differences between the states are in degrees. Numbers in the top row denote tensioning order * denotes significant difference for that comparison. PP: passive path with minimal forces on the knee.Pairwise comparison of internal and external tibial rotation between the different tensioning orders1 vs Intact2 vs Intact3 vs Intact4 vs Intact2 vs 13 vs 14 vs 13 vs 24 vs 24 vs 31.6*1.8*2.4*1.7*0.30.90.10.6-0.1-0.72.1*2.3*2.7*2.3*0.20.60.20.40-0.41.7*1.9*2.0*1.6*0.20.3-0.10.1-0.3-0.41.92.1*2.0*1.40.30.1-0.4-0.2-0.7*-0.5

The Influence of Graft Tensioning Sequence on Tibiofemoral Orientation During Bicruciate and Posterolateral Corner Knee Ligament Reconstruction: A Biomechanical Study

Background: During multiple knee ligament reconstructions, the graft tensioning order may influence the final tibiofemoral orientation and corresponding knee kinematics. Nonanatomic tibiofemoral orientation may result in residual knee instability, altered joint loading, and an increased propensity for graft failure. Purpose: To biomechanically evaluate the effect of different graft tensioning sequences on knee tibiofemoral orientation after multiple knee ligament reconstructions in a bicruciate ligament (anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) with a posterolateral corner (PLC)–injured knee. Study Design: Controlled laboratory study. Methods: Ten nonpaired, fresh-frozen human cadaveric knees were utilized for this study. After reconstruction of both cruciate ligaments and the PLC and proximal graft fixation, each knee was randomly assigned to each of 4 graft tensioning order groups: (1) PCL → ACL → PLC, (2) PCL → PLC → ACL, (3) PLC → ACL → PCL, and (4) ACL → PCL → PLC. Tibiofemoral orientation after graft tensioning was measured and compared with the intact state. Results: Tensioning the ACL first (tensioning order 4) resulted in posterior displacement of the tibia at 0° by 1.7 ± 1.3 mm compared with the intact state (P = .002). All tensioning orders resulted in significantly increased tibial anterior translation compared with the intact state at higher flexion angles ranging from 2.7 mm to 3.2 mm at 60° and from 3.1 mm to 3.4 mm at 90° for tensioning orders 1 and 2, respectively (all P < .001). There was no significant difference in tibiofemoral orientation in the sagittal plane between the tensioning orders at higher flexion angles. All tensioning orders resulted in increased tibial internal rotation (all P < .001). Tensioning and fixing the PLC first (tensioning order 3) resulted in the most increases in internal rotation of the tibia: 2.4° ± 1.9°, 2.7° ± 1.8°, and 2.0° ± 2.0° at 0°, 30°, and 60°, respectively. Conclusion: None of the tensioning orders restored intact knee tibiofemoral orientation. Tensioning the PLC first should be avoided in bicruciate knee ligament reconstruction with concurrent PLC reconstruction because it significantly increased tibial internal rotation. We recommend that the PCL be tensioned first, followed by the ACL, to avoid posterior translation of the tibia in extension where the knee is primarily loaded during most activities. The PLC should be tensioned last. Clinical Relevance: This study will help guide surgeons in decision making for the graft tensioning order during multiple knee ligament reconstructions.

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.

Surgical management of posterior knee dislocation associated with extensor apparatus rupture

ObjectiveThe purpose of this study was to report the clinical and functional results of patients who underwent surgical management for posterior knee dislocation associated with extensor apparatus rupture. IntroductionPosterior knee dislocations associated with extensor apparatus ruptures are defined as rare but complicated injuries, which are difficult to return to the level of activity prior to the injury. The study demonstrated a hypothesis that good knee stability and early gain of range of motion could be achieved with deliberate design of the treatment protocol and proper application of the instruments. MethodsFifteen patients with posterior knee dislocations associated with extensor apparatus ruptures were evaluated after reduction and repair of extensor apparatus. Following that, multiple-ligament reconstruction in association with use of a lateral knee-spanning external fixator was applied for at least six weeks. Ligament reconstructions were performed using allografts. Range of motion and knee stability were both measured at each follow-up evaluation at a mean time of 36months. The assessment was made using the Lysholm Knee Scoring Scale. ResultsThe mean Lysholm scale score was 87.6 (range 73–95), with excellent in 11 cases, good in two, and fair in two. In the final evaluation, the range of motion was a mean range of 123.4° (range 100–135). ConclusionThe use of a lateral knee-spanning external fixator ensured the safety of repaired vessels, knee stability after reduction, and early rehabilitation with range of motion.

Multiple Ligament Reconstruction Femoral Tunnels: Intertunnel Relationships and Guidelines to Avoid Convergence

Background: Knee dislocations often require multiple concurrent ligament reconstructions, which involve creating several tunnels in the distal femur. Therefore, the risk of tunnel convergence is increased because of the limited bone volume within the distal aspect of the femur. Purpose: To assess the risk of tunnel convergence and determine the optimal reconstruction tunnel orientations for multiple ligament reconstructions in the femur. Study Design: Descriptive laboratory study. Methods: Three-dimensional knee models were developed from computed tomography scans of 21 patients. Medical image processing software was used to create tunnels for each of the primary ligamentous structures, replicating a surgical approach that would be used in multiple ligament reconstructions. Thereafter, the tunnel orientation was varied in surgically relevant directions to determine orientations that minimized the risk of tunnel convergence. The orientation of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tunnels was held constant throughout the study, while the orientation of the fibular collateral ligament (FCL), popliteus tendon (PLT), superficial medial collateral ligament (sMCL), and posterior oblique ligament (POL) tunnels was varied to avoid convergence. Results: A high risk of tunnel convergence was observed between the FCL and ACL tunnels when the FCL tunnel was aimed at 0° in the axial and coronal planes. Aiming the FCL tunnel 35° anteriorly minimized convergence with the ACL tunnel. No tunnel convergence was observed for the PLT tunnel aimed 35° anteriorly and parallel to the FCL tunnel. To avoid convergence between the sMCL and PCL tunnels, the sMCL tunnels should be aimed 40° proximally in the coronal plane and 20° to 40° anteriorly. During concomitant POL reconstruction, the sMCL should be aimed 40° proximally and anteriorly and the POL 20° proximally and anteriorly. The PLT and POL tunnels aimed at 0° in both the coronal and axial planes had an increased risk of violating the intercondylar notch. Conclusion: Femoral tunnel orientations during multiple ligament reconstructions need to be adjusted to avoid tunnel convergence. On the lateral side, aiming the FCL and PLT tunnels 35° anteriorly eliminated convergence with the ACL tunnel. On the medial side, tunnel convergence was avoided by orienting the sMCL tunnel 40° proximally and anteriorly and the POL tunnel 20° proximally and anteriorly. The POL and PLT tunnels aimed at 0° in the axial plane had an increased risk of violating the intercondylar notch. Clinical Relevance: The risk of tunnel convergence with the ACL and PCL femoral tunnels can be reduced by adjusting the orientation of the FCL and PLT tunnels and the sMCL and POL tunnels, respectively.