Novel classification for multi-ligament knee injury including both tibiofemoral joint factor and patellofemoral joint factor (193)

Objectives: Multi-ligament knee injury (MLKI) shows very varied symptoms which was depended on the combination of injured ligaments. Schenck`s knee dislocation classification which was one of useful classifications for surgeon in decision making. However, Schenck`s classification is only referred to the factors of cruciate ligament and collateral ligament. It is well known that knee joint consists of two important structure; tibiofemoral joint and patellofemoral joint. Knee extensor structure is one of important factors of knee function. Dislocation of patella, quadriceps or patella tendon rupture are sometimes occurred in the knee trauma and provided severe instability or disability of knee function. Of course, these injuries were also target for consideration of treatment. Moreover, knee extensor structure disruption was sometimes combined with other knee ligaments such as cruciate or collateral ligament. Unfortunately, the case of combined cruciate or collateral ligament with knee extensor structure disruption could not classified in the previous classifications. Therefore, we proposed new classification for MLKI which contains both femorotibial factor and patellofemoral factor. We established and defined several categories in accordance with number of injured ligaments, combination of injured ligaments, and additional combined injury such as fracture, nerve injury, vascular injury. It was hypothesized that all cases at least two ligaments involved situation not only combination of tibiofemoral factor, but also including patellofemoral factor, could classify and divide into the new established classification. Methods: The present study was conducted in 2019, involving patient who was diagnosed MLKI at our institute. The study followed both retrospective and prospective observational design including data collected from Apr 2007 to Aug 2020. The experimental design was reviewed and approved (Accession No. 0-0602) by the Ethics Committee of our institute. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Inclusion criteria were the cases of two or more injured ligaments diagnosed clinically and by MRI testing and dynamic X-ray testing. Detail of ligament around knee joint were defined as follows; ‘cruciate ligaments` which contains ACL and PCL; ‘collateral ligaments` which contains MCL and posterolateral corner (PLC) certainly include lateral collateral ligament, and; ‘patellofemoral joint factor` which contains medial patellofemoral ligament (MPFL), quadriceps tendon and patellar tendon. Exclusion criteria was any prior knee surgery cases. Total 65 MLKI cases were met the inclusion criteria and were enrolled in this study. We focused on the number of injured ligaments, combination of the injured ligaments, and complication such as fracture, neurovascular injury. Based on the number of injured ligaments, 2 injured ligaments case was categorized as Type A, 3 injured ligaments case was as Type B, 4 ligaments case was as Type C, and 5 ligaments case was as Type D, respectively. We defined that injured ligament counting was follows; cruciate ligament group; ACL and/or PCL, collateral ligament group; MCL and/or PLC, and PF joint group; one of the MPFL or patellar tendon or quadriceps tendon. Depended on the combination of injured ligaments, each case was subdivided into 1 to 5 in Type A and B, into 1 to 3 in Type C. Additional injuries with MLKI were also subdivided as follows; MLKI with fracture case was defined as X, with neurovascular injury case was as Y, and both fracture and neurovascular injury case was as Z. (Table 1, 2, 3, and 4). For each case, final decision of injured ligament was recorded under clinical examination and image evaluation. MLKI cases were divided into both Schenk’s KD classification and the present new established classification. Results: Fifty-seven of 65 cases were divided into Schenck’s KD classification as follows; 19 cases of ACL+MCL and 13 cases of ACL+PLC and 9 cases of PCL+PLC and 2 cases of PCL+MCL as KD-?, 4cases of ACL+PCL as KD-? and one case of ACL+PCL with fracture as KD-?2, 6 cases of ACL+MCL, 2 cases of ACL+PCL+PLC as KD-?, and 1 case of ACL+PCL+MCL+MCL with fracture as KD-?5, respectively. Eight cases (12.3%) could not be divided into Schenk’s KD classification. Combination of these 8 cases were follows; 2 cases of PLC+MPFL, and single case of ACL+MCL+PLC, ACL+PCL+MCL+PLC+MPFL, ACL+MPFL, PCL+PLC+MPFL+ fracture, ACL+MCL+MPFL, and PCL+ patella tendon, respectively. Seven of 8cases contained PF joint factor injury. At the established new classification for MLKI, all 65 cases were divided into each category, successfully. PLC+MPFL was divided into Type-A5, ACL+MCL+PLC was Type-B2, ACL+PCL+MCL+PLC+MPFL was Type-D, ACL+MPFL was Type-A4, PCL+PLC+MPFL was Type-B3-X, ACL+MCL+MPFL was Type-B3, and PCL+ patella tendon was Type-A4. Conclusions: Several classification systems have been reported for diagnosis of MLKI cases. Kennedy `s classification and the French Society of Orthopedic Surgery and Traumatology 2008 classification were focused on the mechanism and direction of dislocation. These classifications were available for understanding comprehension mechanism of injured knee. However, previous classifications including Schenck’s classification were lack of PF joint factor. It is very important for knee surgeon that understanding injured mechanism as well as number of injured ligaments and combination of injured ligaments for decision making for surgery. The present classification was useful for MLKI case which contains both tibiofemoral factor and patellofemoral factor.

Tranexamic Acid has no Effect on Post-Operative Hemarthrosis or Pain Control Following ACL Reconstruction Using Bone Patella Tendon Bone Autograft: A Double-Blind Randomized Controlled Double-Blind Trial (169)

Objectives: Tranexamic acid (TXA) is a commonly used medication in orthopaedic procedures, reducing perioperative bleeding and need for transfusion. The purpose of this double-blind randomized controlled study was to evaluate if IV TXA for primary anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone (BTB) could reduce perioperative blood loss or postoperative intra-articular hemarthrosis without postoperative drains. Methods: A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR). Results: There was no significant difference in perioperative blood loss between the experimental and control groups (32.5ml v. 35.6ml, p=0.47). The experimental group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or pre- nor post-operative TCR (p > 0.05 for all). Conclusions: IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation.

Soft tissue extensor mechanism tendon ruptures of the knee

Ruptures of the extensor mechanism of the knee are serious injuries requiring prompt diagnosis and treatment. They can be divided into soft tissue and bony causes. Soft tissue tendon injuries can be either partial or complete. Rupture of the quadriceps tendon is an uncommon injury and is more frequent in patients over the age of 40 years. Patella tendon ruptures are even rarer and are more frequent in patients under the age of 40 years. Causes can be direct or indirect. Complete ruptures of the quadriceps tendon or patella tendon benefit from early surgical management, while partial ruptures may be managed non-operatively. This article gives an overview of the presentation, assessment and management of soft tissue extensor mechanism tendon ruptures for core surgical, acute care common stem and emergency medicine trainees.

Patellofemoral Joint Auto-fusion after Patella Tendon Repair: A Case Report

Introduction: Post-traumatic patellofemoral auto fusion is poorly described in the literature and its etiology may be multifactorial. Management options are not well published and this case report addresses a rare and complex case of patellofemoral autofusion after a patellar tendon repair with a description of our surgical approach and ultimately improvement in patient outcome and satisfaction. Case Presentation: A 59-year-old African American female suffered an acute traumatic patellar tendon rupture that was treated with a primary repair that resulted in sequelae leading to a subsequent open procedure revealing an osseous bridge between the patella and trochlea. After osteotomy of this bridge, the patient’s range of motion improved. Conclusion: For the appropriate management of arthrofibrosis surgeons should focus on modifiable risk factors including close follow-up with patients, patient expectation management, and consider surgical intervention such as techniques described below in recalcitrant cases to evaluate for post-traumatic sequelae including bone bridge formation. Keywords: Patella tendon, arthrofibrosis, tendon repair.

SURGICAL TREATMENT OF OSGOOD-SCHLATTER DISEASE IN ADOLESCENT ATHLETES

Background: Osgood-Schlatter disease is an apophysitis of the tibial tubercle causing pain and difficulty kneeling. A majority of cases resolve spontaneously at skeletal maturity when the tibial tubercle apophysis fuses. Treatment is symptomatic when the physis is open. Adolescent athletes with closed physes and continued symptoms can benefit from surgery. Purpose: The purpose of this study is to report the outcomes of ossicle excision and tubercleplasty for unresolved Osgood-Schlatter disease that has failed conservative treatment. Methods: A retrospective review was performed on 6 athletes who underwent ossicle excision and tibial tubercleplasty for unresolved Osgood-Schlatter disease. Data collected include age at onset of symptoms, age at surgery, gender, laterality, radiographic findings, sports played, time to return to sport, length of follow up, and complications. Surgery involved an open ossicle excision, tubercleplasty, and repair of the patella tendon to bone using a suture anchor. A longitudinal incision was made over the antero-lateral aspect of the patella tendon. The patella tendon was reflected medially to gain access to the ossicle and bump. A direct anterior incision was avoided to minimize post-operative pain with kneeling. Post-operatively, patients were allowed to fully weight bear in an extension knee brace for 4 weeks, and then allowed to gradually resume activity. Results: 4 males and 2 females were studied. The right knee was involved in 3 cases and the left knee in 3. The average age at onset of symptoms was 15.8 (range 12-18). The average age at surgery was 17.3 (range 17-18). Radiographic findings included a large bump in 3 cases, an ossicle in 2 cases, and free fragments at the tendon insertion in 3 cases. Sports played included basketball, football, running, and dancing. All patients returned to sports at an average of 23.9 weeks post-surgery (range 5-56). The average length of follow up was 14.2 weeks (range 5-27). No patients reported post-operative pain with kneeling, limp, need for a cane, locking sensations, giving way sensations, pain, swelling, difficulty climbing stairs or difficulty squatting. No patients needed additional surgery. Conclusion: Surgical treatment of unresolved Osgood-Schlatter disease was successful in 100% of adolescent athletes in this series. For symptomatic patients after closure of the growth plate, we recommend removal of the ossicle and adjacent bursae, smoothing down the bump with a burr, and repairing the reflected patella tendon to bone using suture anchors. The outcomes were excellent in all patients with no complications.