Surgical Outcomes of Medial Versus Lateral Multiligament-Injured, Dislocated Knees.

PURPOSE: To compare clinical and functional outcomes of surgically treated medial and lateral knee dislocations. METHODS: A retrospective review of the medical records of patients who presented with knee dislocations was conducted. We identified patients who underwent surgical treatment of KDIII-M (anterior cruciate ligament/posterior cruciate ligament/medial collateral ligament) or KDIII-L (anterior cruciate ligament/posterior cruciate ligament/lateral collateral ligament) knee dislocation as documented by the Schenck classification. Minimum 2-year follow-up with Lysholm and International Knee Documentation Committee (IKDC) outcome scores was required for inclusion. Postoperative range of motion, ligamentous examination, and conversion to total knee arthroplasty were also collected. Data were analyzed using univariate and multivariate statistical models with P < .05 considered significant. RESULTS: A total of 56 patients met the inclusion criteria, 24 with the KDIII-M injury pattern (43%) and 32 with the KDIII-L injury pattern (57%), with a mean age of 34 years (range, 16 to 62 years) and a mean follow-up of 6.5 years (range, 2 to 20 years). Patients undergoing medial repairs had worse outcomes for both the Lysholm score (P = .008) and IKDC score (P = .003). In addition, female sex was linked to worse outcomes (Lysholm score, 58.8 ± 21.5 v 77.8 ± 21.1, P < .01; IKDC score, 54.9 ± 23.7 v 75.2 ± 20.2, P < .01). No differences in outcome were found between patients with and patients without peroneal nerve injury (Lysholm score, P = .81; IKDC score, P = .77). No difference in laxity testing was found between the 2 groups. CONCLUSIONS: In patients undergoing multiligament knee reconstruction, our data suggest that those who undergo medial repair for knee dislocations are not as likely to achieve positive results as those who undergo reconstruction or lateral reconstruction/repair, regardless of the status of the peroneal nerve. In addition, medial reconstruction had comparable outcomes to those in patients treated with lateral reconstruction/repair. Lastly, female patients showed less favorable clinical outcomes than male patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Are meniscal tears and articular cartilage injury predictive of inferior patient outcome after surgical reconstruction for the dislocated knee?

PURPOSE: A paucity of data exists on the effects of articular cartilage and meniscal injury in the setting of knee dislocations. The purpose of this study is to determine whether concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation are associated with inferior outcomes. METHODS: The records of patients who underwent surgical treatment for multiligament knee injury between 1992 and 2012 were retrospectively reviewed. Patients included had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. A logistic regression model was used to determine whether articular cartilage injuries (grade 2 involving ≥50 % of the condylar width or greater, or any grade III/IV lesions) and meniscus tears are predictors of IKDC outcome scores collected at a minimum of 2 years postoperatively. RESULTS: Of the 121 patients who met inclusion criteria, 2-year minimum follow-up was available on 95 patients (79 %). The cohort was 77 % male and had a median age of 32 years (16-62) at the time of surgery and was followed for an average of 6 years. Articular cartilage injury was present in 40 % of knees: medial femoral condyle (20 %); medial tibial plateau (9 %); lateral femoral condyle (5 %); lateral tibial plateau (4 %); patella (18 %); trochlear (5 %). Meniscal injury was present in 56 % of patients (isolated medial, 22 %; isolated lateral, 22 %; combined, 12 %). IKDC scores were significantly lower for patients with any cartilage damage (p = 0.03), combined medial and lateral meniscus tears (p = 0.02), medial-sided articular cartilage damage (p = 0.03), medial femoral condyle (p = 0.04) and trochlear (p = 0.03) lesions. CONCLUSION: Articular cartilage damage and meniscus tears are frequently associated with a knee dislocation. This study showed IKDC scores were significantly lower for patients with cartilage damage or combined medial and lateral meniscus tears at mid-term follow-up of 6 years. LEVEL OF EVIDENCE: IV.

Nonoperative Management of Minimally Displaced Patellar Sleeve Fractures.

Patellar sleeve fractures primarily occur in the adolescent population from a rapid contraction of the quadriceps with the knee in a flexed position. Several small case reports describe operative reduction and fixation for displaced fractures. However, there is sparse literature on nonoperative management of these injuries. Retrospective review and prospective follow-up of all patients diagnosed with patellar sleeve fracture between 1991 and 2014 at a single institution. Patients with superior pole avulsion fractures, history of prior knee surgery, and fractures managed operatively were excluded. Patients with a clinical diagnosis without support of advanced imaging were also excluded. Radiographs and magnetic resonance imaging (MRI) were reviewed for initial fracture displacement, time until fracture union, and the presence of patellar tendon ossification. Outcome was assessed using the Tegner's activity scale, Kujala's Score and the International Knee Documentation Committee (IKDC) subjective knee evaluation score at final follow-up. Eighteen nonoperatively treated distal patellar pole sleeve fractures were identified, while five patients had advanced imaging to support their diagnosis. All were males with a mean age of 15.1 (range: 12-18). Traumatic and sport-related injuries were noted in the majority of patients. Only one patient had any appreciable displacement, but still < 2 mm. Final radiographic evaluation revealed fracture healing without patellar tendon ossification in all patients. All five patients had full terminal knee extension and symmetric range of motion. Mean IKDC score was 96.4 (range: 82-100) mean Tegner's activity score was 60 (range: 5-8), and mean Kujala's score was 89.7 (range: 63-100) at final follow-up. Of the five cases, three patients presented in a delayed fashion, and all went on to have surgical treatment. Two required arthroscopic loose body removal, while the other had an open patellar debridement and platelet-rich plasma (PRP) injection. Minimally displaced patellar sleeve fractures can be successfully managed nonoperatively with excellent clinical outcomes. However, delayed in presentation may be associated with worse outcome. This study of case series reflects level of evidence IV.

All-Inside Posterior Cruciate Ligament Reconstruction: GraftLink Technique.

Posterior cruciate ligament (PCL) injuries account for nearly 20% of knee ligament injuries. PCL injuries can occur in isolation or, more commonly, in the setting of multiligamentous knee injuries. Isolated PCL disruptions are commonly treated nonoperatively; however, symptomatic grade III injuries, as well as PCL injuries found in multiligamentous injuries, are frequently treated surgically. Several reconstructive techniques exist for the treatment of PCL deficiency without a clear optimal approach. We describe our preferred operative technique to reconstruct the PCL using an all-inside arthroscopic approach with a quadrupled tibialis anterior or peroneus longus allograft with both tibial and femoral suspensory fixation.

Posterolateral Reconstruction of the Knee: Two-Tailed Surgical Techniques.

Reconstruction of the posterolateral corner of the knee using two-tailed techniques involved grafts originating from the femur and inserting on the proximal tibia and fibular head. This method reconstructs the fibular collateral ligament, popliteofibular ligament, and popliteus tendon using anatomically placed grafts. This article describes the history, anatomy, indications, and authors' preferred technique for a two-tailed posterolateral corner reconstruction. In addition, biomechanical and clinical outcomes of this technique will be compared.

Open Anatomic Reconstruction of the Medial Collateral Ligament and Posteromedial Corner.

Injuries to the medial collateral ligament (MCL) and posteromedial corner can occur in isolation or in the setting of multiligamentous knee injuries. Reconstruction of the MCL and posteromedial corner is indicated in the setting of a multiligamentous knee injury. Isolated cases failing nonoperative treatment may also undergo surgical treatment. Our preferred technique for anatomic medial-sided knee reconstruction is an open anatomic MCL reconstruction using an Achilles tendon allograft along with direct repair of all associated medial and posteromedial structures.

Treatment of Patellofemoral Cartilage Lesions in the Young, Active Patient.

Articular cartilage lesions of the patella and trochlea are commonly encountered in the young and active patient. These defects can be classified as chondral or osteochondral, and then further described according to size, location, and etiology. Early surgical intervention is often indicated for traumatic injuries resulting in osteochondral damage, including acute patellofemoral dislocation. For chronic lesions, initial treatment involves exhaustive nonoperative measures, and surgery is reserved for patients with persistent symptoms. A thorough history, physical examination, and imaging are essential to select the best surgical option. Cartilage restoration procedures are combined with optimization of background factors such as patellofemoral alignment and congruity to achieve success. Cell-based therapies have evolved into a reliable strategy for management of these lesions.

Anterior horn lateral meniscus tear, repair, and meniscectomy.

The purpose of this study was to describe the effect of anterior horn of the lateral meniscus (AHLM) tears on tibiofemoral contact pressures and the ability to restore normal parameters with repair. Eight fresh-frozen cadaveric knees were used. The specimens were subjected to a load of 1,000 N at 0 and 30 degrees of flexion and peak pressure, force and contact area were recorded. The test was repeated for four different instances. Peak force in the lateral compartment was significantly increased at 0 degrees of knee flexion from 37 N intact to 47 N after the tear and 56 N postmeniscectomy. At 0 degrees of knee flexion, the peak pressure of the lateral meniscus was significantly increased from 1.1 MPa in the intact state to 1.9 MPa after meniscectomy. The peak pressure in the nontraumatized medial compartment was significantly increased after partial lateral meniscectomy (p < 0.05). This cadaveric study demonstrated a significant increase in tibiofemoral peak forces in both the medial and lateral compartments with a tear of the AHLM. It also showed an increase in peak contact pressure after meniscectomy. With repair, the preinjury condition peak forces were restored to normal, suggesting the importance of repairing tears of the AHLM.