Acute Versus Delayed Surgical Intervention in Multiligament Knee Injuries: A Systematic Review

Background: The optimal timing of surgical intervention for multiligament knee injuries remains controversial. Purpose: To review the clinical and functional outcomes after acute and delayed surgical intervention for multiligament knee injuries. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a search of the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to September 2020. Eligible studies reported on knee dislocations, multiligament knee injuries, or bicruciate ligament injuries in adult patients (age, ≥18 years). In addition to comparing outcomes between acute and delayed surgical intervention groups, we conducted 3 subgroup analyses for outcomes within isolated knee injuries, knee injuries with concomitant polytrauma/fractures, and high-level (level 2) studies. Results: Included in the analysis were 31 studies, designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n = 20). These studies reported on 2594 multiligament knee injuries sustained by 2585 patients (mean age, 25.1-65.3 years; mean follow-up, 12-157.2 months). At the latest follow-up timepoint, the mean Lysholm (n = 375), International Knee Documentation Committee (IKDC) (n = 286), and Tegner (n = 129) scores for the acute surgical intervention group were 73.60, 67.61, and 5.06, respectively. For the delayed surgical intervention group, the mean Lysholm (n = 196), IKDC (n = 172), and Tegner (n = 74) scores were 85.23, 72.32, and 4.85, respectively. The mean Lysholm (n = 323), IKDC (n = 236), and Tegner (n = 143) scores for our isolated subgroup were 83.7, 74.8, and 5.0, respectively. By comparison, the mean Lysholm (n = 270), IKDC (n = 236), and Tegner (n = 206) scores for the polytrauma/fractures subgroup were 83.3, 64.5, and 5.0, respectively. Conclusion: The results of our systematic review did not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes. Although previous evidence has supported acute surgical intervention, future prospective randomized controlled trials and matched cohort studies must be completed to confirm these findings.

Imaging Review of the Posterior Cruciate Ligament

Posterior cruciate ligament (PCL) injuries can often be missed on physical examination, especially in multiligament knee injuries. Therefore, a comprehensive approach to imaging the PCL should be implemented whenever history and examination findings indicate relative risk. Radiography, including a posterior-stress view, and magnetic resonance imaging, when available, provide consistently accurate diagnosis of PCL pathology and common knee comorbidities. Computed tomography and ultrasonography can be useful modalities with potential advantages with respect to availability and access, specific comorbidities, and/or cost-effectiveness.

High Incidence of Osteoarthritis Observed in Patients at Short- to Midterm Follow-Up after Delayed Multiligament Knee Reconstruction

The aim of this study was to evaluate the incidence of knee osteoarthritis, failure rate of reconstruction, and clinical outcomes of patients with chronic multiligament knee injuries subjected to surgical treatment. Sixty-two patients with chronic knee dislocation subjected to multiligament reconstruction between April 2008 and July 2016 were evaluated, with a minimum follow-up of 24 months. Anteroposterior and lateral radiographs were performed in the pre- and last postoperative evaluation; the progression of degenerative changes according to the Kellgren-Lawrence classification (KL) was assessed. The Schenck classification, Knee Injury and Osteoarthritis Outcome Score (KOOS), time between injury and surgery, type of postoperative rehabilitation protocol (brace vs. external fixator), and physical examination for ligament instability were also evaluated. Univariate and multivariate analysis were performed, p <0.05 was considered significant. Fifty-two (83.9%) patients were men and 16.1% (n = 10) were women, with a mean age of 38.8 ± 1.3 years. The time from injury to surgery was 31.1 ± 6.1 months, and the follow-up time was 6.1 ± 0.5 years. The mean final KOOS was 79.3 ± 10.4 and the overall reconstruction failure occurred in 25.8%. Of all patients, 64.5% (n = 40) presented a KL classification of ≥2 and were defined as having radiographic osteoarthritis (OA). As 11.7% (n = 7) also presented arthritis in the contralateral knee, in 53.2% (n = 33) the progression was most likely due to the initial injury. The failure of ligament reconstruction or residual instability was present in 15 (35.7%) of patients with OA, and only one patient (4.5%) without OA. In the multivariate analysis, only reconstruction failure was an independent predictor of OA (odds ratio = 13.2 [p = 0.028]). There is a high incidence of knee OA following ligament reconstruction for chronic multiligament knee injuries. Ligament reconstruction failure was the only independent predictor for the development of OA in our study.

Treatment of Partial Posterior Cruciate Ligament Injuries with Platelet-Rich Plasma in Growth Factors (PRGF) Intraligamentous Infiltration and a Specific Knee Brace

Posterior cruciate ligament (PCL) injuries are not as common as other knee ligament injuries, but may present a challenging scenario for even skilled knee surgeons. Complete PCL tears are typically encountered in the setting of multiligament knee injuries and require surgical treatment. Isolated complete PCL injuries are uncommon and the best treatment is debated, and likely depends on the degree of symptoms and objective instability. However, many PCL injuries will be partial tears (grade I or II). The purpose of this chapter is to describe our treatment of choice for partial PCL injuries through a conservative approach. Level of evidence Level IV.

Low-Energy Multiligament Knee Injuries Are Associated With Higher Postoperative Activity Scores Compared With High-Energy Multiligament Knee Injuries: A Systematic Review and Meta-analysis of the Literature

Background: Multiligament knee injuries (MLKIs) can result from high-energy injury mechanisms such as motor vehicle accidents or low-energy injury mechanisms such as activities of daily living or sports. Purpose/Hypothesis: The purpose was to conduct a systematic review on postoperative patient-reported outcomes after MLKIs and to conduct a meta-analysis of comparable outcome variables based upon high- versus low-energy injury mechanisms. It was hypothesized that MLKIs with low-energy injury mechanisms would demonstrate significantly improved subjective clinical outcome scores compared with high-energy injuries. Study design: Meta-analysis and systematic review. Methods: A systematic review was performed with the inclusion criteria of postoperative MLKI outcomes based upon high-versus low-energy mechanisms of injury with a minimum 2-year follow-up. Outcome scores included were the Lysholm knee scoring scale, Tegner activity scale, and the International Knee Documentation Committee (IKDC) score. High-energy mechanisms included motor vehicle accidents or falls from a height >5 feet; low-energy mechanisms included sports-related injuries, activities of daily living, or falls from <5 feet. A meta-analysis was performed comparing the outcome scores of high- versus low-energy mechanisms of MLKIs. Results: Overall, 1214 studies were identified, 15 of which were included in the systematic review and meta-analysis. Thirteen studies included surgical reconstructions of all injured ligaments. A total of 641 patients with 275 high-energy and 366 low-energy injuries were grouped for comparison in the meta-analysis. No significant differences in Lysholm scale (78.6 vs 78.0) or IKDC scores (69.0 vs 68.4) were found between high- and low-energy groups at a minimum of 2 years (range, 2-10 years) postoperatively ( P > .05). The low-energy injury group demonstrated significantly higher Tegner activity scale scores (5.0 vs 3.9; P = .03). There was no significant difference in failure rates between groups (3.5% vs 2.0%; P = .23). Conclusion: We found in this systematic review and meta-analysis that patients with low-energy mechanisms of MLKI surgery had improved postoperative Tegner activity scores compared with those patients with high-energy mechanisms after MLKI surgery. However, there were no differences in Lysholm score, IKDC score, or failure rates between high- and low-energy MLKI patients at an average of 5.3 years postoperatively.