Primary repair of multiligament knee injury with InternalBrace ligament augmentation

Multiligament injury of the knee usually occurs as a result of high-energy trauma causing tibiofemoral dislocation. These are rare but potentially limb-threatening injuries, frequently involving nerve or arterial damage and often leading to severe complex instability. Management generally favours surgical reconstruction of the affected ligaments, with controversy regarding optimal treatment. We present a severe multiligament knee injury (Schenk classification KD-IV involving both cruciate and both collateral ligaments) in a competitive showjumper. A combined arthroscopic/open technique of single-stage surgical repair and suture augmentation was used, repairing all affected ligaments. The patient made an excellent recovery, returning to work after 12 weeks and riding after 22 weeks. After 5-year follow-up, she has regained her previous level of competition without subsequent injury. Multiligament repair with suture augmentation is a viable approach to the management of knee dislocation injuries. We propose that this could provide superior outcomes to traditional reconstruction techniques using autograft or synthetic reconstruction.

Risk Factors Associated With Complications After Operative Treatment of Multiligament Knee Injury

Background: Many factors can affect clinical outcomes and complications after a complex multiligament knee injury (MLKI). Certain aspects of the treatment algorithm for MLKI, such as the timing of surgery, remain controversial. Purpose: To determine the risk factors for common complications after MLKI reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted on 134 patients with MLKI who underwent reconstruction between 2011 and 2018 at a single academic center. Patients included in the review had a planned surgical reconstruction of >1 ligament based on clinical examination and magnetic resonance imaging. Complications were categorized as (1) wound infection requiring irrigation and debridement, (2) arthrofibrosis requiring manipulation under anesthesia and/or lysis of adhesions, (3) deep venous thrombosis, (4) need for removal of hardware, and (5) revision ligament surgery. The potential risk factors for complications included patient characteristics, injury pattern categorized according to Schenck classification (knee dislocation [KD] I–KD IV), and timing of surgery. Significant risk factors for complications were analyzed by t test, chi-square test, and Fisher exact test. Results: A total of 108 patients met the inclusion criteria; of these, 29.6% experienced at least 1 complication. Smoking (odds ratio [OR], 3.20 [95% CI, 1.28-8.02]; P = .01) and planned staged surgery (OR, 2.71 [95% CI, 1.04-7.04]; P = .04) significantly increased the overall risk of complication, while increased time from injury to surgery (OR, 0.99 [95% CI, 0.98-0.998]; P < .01) significantly decreased the risk. Increasing time from injury to surgery (OR, 0.99 [95% CI, 0.97-0.998]; P = .02) also led to a slightly but significantly decreased risk for arthrofibrosis. Conclusion: The study findings suggest that smoking, decreased time from injury to initial surgery, and planned staged procedures may increase the rate of complications. Further studies are needed to determine which changes in the treatment algorithm are most effective to reduce the complication rate in patients.

Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

Result of single stage early surgical treatment of high-grade multiligamentous knee injuries (Schenck Type III, IV and V)

Introduction: The Multiligament Knee Injury is a complex knee problem and mostly associated with subluxation or dislocation of knee joint. Failure to diagnose and treat them appropriately can leads to devastating outcome particularly high-grade injury (Schenck Type 3,4 and 5). We favor single stage early surgical treatment of high grade Multiligament knee injury which leads to good functional outcome and return to work. Hypotheses: Single stage early surgical treatment of high grade Multiligament knee injury will leads to good functional outcome with higher IKDC and Lysholm score and helps the patients to in return early to work with higher satisfaction rate. Methods: From June 2013 to January 2020, 42 patients with age from 18 years to 56 years with acute (< 6 weeks) Multiligament knee injury included in surgical treatment. Patients with neurovascular injury were not included in study. From 42 patients, 28 patients was type 3,8 patients was type 4 and 6 patients was type 5 in this study. In all 42 patients, single stage treatment first Intraarticular ligament (anterior cruciate ligament ACL, posterior cruciate ligament PCL or both) reconstruction done by arthroscopic method then Extraarticular ligament (medial collateral ligament MCL, lateral collateral ligament LCL, Posterolateral corner PLC) treated with repair/augmentation/reconstruction depending upon status of ligaments by open method. We used only autograft (hamstring and peroneal longus tendon) of same limb or contralateral limb. Patient evaluation done with IKDC and Lyshlom score both in preoperative and postoperative period. Patient limb was kept in full extention in brace and started with aggressive physiotherapy with passive ROM at 2 weeks in post operative period . Follow up done at 2 weeks then every 6 weeks interval till 6 months then every 3 months interval. Partial weight bearing started at 6 weeks and full weight bearing usually between 10 weeks to 12 weeks. Results: Road traffic accident was the most common cause of Multiligament knee injury. Average follow up was 4 years (range 2 to 6.5 years) .40 % has excellent ,40% has good and 20% has average result. There was a significant improvement in both outcome scores as compared with the preoperative scores. Postoperatively average IKDC was 78 and Lyshlom was 86. Terminal restriction of knee movement was in 19% patients particularly those associated with medial side injury was the major complication in our study. Manipulation under anaesthesia was done in 4 cases and implant removal in 1 case and arthroscopic synovectomy and long term antibiotic in 1 case who develop early infection. Gade 1 posterior laxity and grade 1 varus stress was observed in 10 patints.Recovery after surgery takes 9 to 12 months of rehabilitation prior to returning to full activities. Conclusion: Proper evaluation and full diagnosis is key in Multiligament injury of knee. Failure to treat all injured structure can lead to change in knee kinematics and poorer outcome and increased risk for graft failure.Operative treatment with proper rehabilitation yields good functional and clinical outcome with early return to work and sports activity.

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

Neurologic Assessment and Management of the Multiple Ligament Injured Knee: A Review and Synthesis of Current Evidence

Knee dislocations are rare but devastating injuries that can often be associated with concomitant nerve injury, most often of the common peroneal nerve. Prompt diagnosis, investigation, and appropriate treatment are important in this subset of patients. This article provides an overview of relevant injury demographics, anatomy, diagnosis, and prognosis, and suggests a treatment algorithm for nerve injury associated with multiligament knee injury.