Autograft Versus Allograft in Posterolateral Corner Reconstruction: A Systematic Review and Meta-analysis.

Background: Several approaches to surgical techniques and graft types exist in posterolateral corner (PLC) reconstruction. The literature lacks knowledge regarding outcomes after autograft versus allograft reconstruction for PLC injuries. Purpose: To comprehensively review the current literature on PLC reconstruction and compare outcomes between autograft and allograft tissues. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed and Scopus online databases were searched with the terms "PLC,""posterolateral knee,""posterolateral corner," and "reconstruction" in varying combinations. Patient characteristics, graft type, graft failure, surgical techniques, functional outcome scores, and varus laxity on stress radiographs were reviewed and compared between PLC reconstruction with autografts versus allografts. Results: Included were 22 studies comprising 33 cohorts: 16 autografts (n = 280 knees) and 17 allografts (336 knees). There were 69 isolated PLC reconstructions (58 allografts and 11 autografts) and 493 multiligament reconstructions (269 autografts and 224 allografts). There was no difference in the mean patient age (30.5 vs 33.5 years, respectively; P = .11) or mean follow-up (39.5 vs 37.7 months, respectively; P = .68) between the autograft and allograft groups. There was no evidence to suggest a difference in graft failures between graft types (pooled mean autograft vs allograft: 0.44 vs 0.41 failures; P = .95). There was a significant difference in the mean postoperative Lysholm scores for autografts versus allografts (89.6 vs 85.5, respectively; P = .04). There was no difference between the cohorts in preoperative or postoperative International Knee Documentation Committee (IKDC) scores or postoperative varus laxity. Conclusion: Our review and meta-analysis indicated no significant differences in graft failure rates or objective outcomes after PLC reconstruction based on graft type alone. There was a significant difference in postoperative Lysholm scores in favor of the autograft group and no significant difference in IKDC subjective scores.

Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up.

BACKGROUND: Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. PURPOSE: To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. RESULTS: A total of 42 patients (25 male, 17 female) were assessed at a mean 6.5-year follow-up (range, 2.1-10.7 years). Twenty patients (47.6%) were found to have a documented KD; they reported significantly lower IKDC (49.9 vs 63.0; P = .043), Lysholm (59.8 vs 74.5; P = .023), and Tegner activity level (2.9 vs 4.7; P = .027) scores than the patients without documented dislocation. VAS pain was not significantly different between groups (36.4 vs 33.5; P = .269). The incidence of neurovascular injury was greater among those with documented dislocation (45.0% vs 13.6%; P = .040). Subgroup analysis found that patients with KD3-L injuries experienced a greater deficit in Tegner activity level than patients with KD3-M injuries (Δ: -3.4 vs -1.2; P = .006) and had an increased incidence of neurovascular injury (41.7% vs 11.1%; P = .042). Documented dislocation status was predictive of poorer IKDC (ß = -2.15; P = .038) and Lysholm (ß = -2.85; P = .007) scores. CONCLUSION: Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.

Perioperative outcomes in isolated versus multiligamentous anterior cruciate ligament reconstruction: a retrospective cohort analysis.

PURPOSE: The outcomes of anterior cruciate ligament reconstruction in the setting of multiligamentous knee injury (M-ACLR) have not been well characterized compared to isolated ACLR (I-ACLR). This study aims to characterize and compare short-term outcomes between I-ACLR and M-ACLR. METHODS: This is a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017. Current Procedural Terminology codes were used to identify and compare elective I- and M-ACLR patients, excluding patients undergoing concomitant meniscal or chondral procedures. Patient demographics and outcomes after I- and M-ACLR were compared using bivariate analysis. Multiple logistic regression analyzed if multiligamentous ACLR was an independent risk factor for adverse outcomes. RESULTS: There was a total of 13,131 ACLR cases, of which 341 were multiligamentous cases. The modified fragility index-5 was higher in multiligamentous ACLR (p < 0.001). Multiligamentous ACLR had worse perioperative outcomes, with higher rate of all complications (3.8%, p = 0.013), operative time > 1.5 h (p < 0.001), length of stay (LOS) ≥ 1 day (p < 0.001), wound complication (2.1%, p = 0.001), and intra- or post-op transfusions (p < 0.001). In multiple logistic regression, multiligamentous ACLR was an independent risk factor for LOS ≥ 1 (odds ratio [OR] 5.8), and intra-/post-op transfusion (OR 215.1) and wound complications (OR 2.4). M-ACLR was not an independent risk factor for any complication, reoperation at 30 days, readmission, urinary tract infection (UTI), or venous thromboembolism (VTE). CONCLUSION: M-ACLR generally had worse outcomes than I-ACLR, including longer LOS, need for perioperative transfusions, and wound complications.

Long-term Outcomes After Surgical Reconstruction of Multiligamentous Knee Injuries: Results at Minimum 10-Year Follow-up.

Background: Multiligamentous knee injuries (MLKIs) are devastating injuries with concomitant injuries that complicate treatment and recovery. Short-term studies have shown satisfactory patient outcomes after surgical treatment; however, evaluations of long-term outcomes remain scarce. Purpose: To evaluate long-term outcomes after surgically reconstructed MLKIs and further investigate the relationship between patient age on clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: A total of 55 knees (age, 36 ± 11 years; 24% female subjects) who underwent surgical reconstruction for MLKI between 1992 and 2013 met the study inclusion criteria and were evaluated with postoperative patient-reported outcomes (PROs) including International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) for pain, Forgotten Joint Score, subjective improvement ratings and surgery satisfaction, and Tegner activity scores. PRO scores, revision, and conversion to arthroplasty were analyzed using descriptive statistics, linear regression, Wilcoxon rank-sum, and Fisher exact tests. Results: At final follow-up (mean, 15 ± 5 years; range, 10-31 years), 67% of the cohort reported subjective improvement in their knee, and 82% reported satisfaction with their surgery. Compared with preoperative scores, there were significant improvements in postoperative VAS pain at rest in the full cohort, age ≤30-year cohort, and age >30-year cohort (4 ± 1 vs 2 ± 2; 4 ± 1 vs 2 ± 3; 4 ± 1 vs 1 ± 2, respectively; P≤ .029 for all) but significant reductions in Tegner scores (6 ± 3 vs 4 ± 2; 7 ± 2 vs 5 ± 2; 5 ± 2 vs 3 ± 1; P≤ .003 for all). Younger patients had higher postoperative Tegner scores than older patients (5 ± 2 vs 3 ± 1, respectively; P = .003), but no other differences in PROs were observed based on age. At a mean 15-year follow-up, 3.6% of the cohort underwent revision ligament surgery and 10.9% required arthroplasty. Conclusion: The majority of the cohort reported modest subjective improvement and were satisfied with their surgery. Gradual but expected age-related decreases in Tegner scores were observed, and some patients demonstrated continued symptomatic and functional limitations, but mean PRO scores remained satisfactory. Revision surgery and conversion to arthroplasty were not commonly required.

Reconstruction technique of multiligamentous knee injury in a patient with traumatic transtibial amputation.

Multiligamentary knee injuries associated with transtibial amputation is a pathologie with a low incidence, so their diagnosis and treatment represent a great challenge for the medical team, mainly due to the low rate of scientific publications on the matter. This article intends to present the treatment of a really infrequent pathology, presenting the clinical case of a polytraumatized patient who suffered a left transtibial amputation associated with a multiligament knee injury with dislocation of the proximal tibiofibular joint. After analyzing the multiple therapeutic options, a specific surgical planning is carried out for the specific case of a multiligament knee injury associated with an ipsilateral transtibial amputation, proceeding to the execution of the reconstruction of the injury with good results. For this, several specific surgical gestures are carried out, adapted to the patient's condition, which will facilitate the surgery and are explained in the surgical technique. In conclusion, we must know that in order to obtain satisfactory results in these patients, it is important to carry out an early diagnosis and treatment of the injury, analyzing the proximal tibiofibular stability and providing adequate stability through the execution of a precise surgical technique.

The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury.

OBJECTIVE: To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS: Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS: Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION: Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.

Posterior Cruciate Ligament Repair With Suture Augmentation: A Report of Two Cases With Two-Year Follow-Up.

We present two cases of posterior cruciate ligament (PCL) repair with suture augmentation (SA) in the setting of multiligamentous knee injury (MLKI). Excellent clinical outcomes were obtained at two-year follow-up with both patients returning to sport following injury. Both patients demonstrated improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) that exceeded the minimal clinically important difference (MCID) as reported in the literature for ligamentous knee injuries. One patient developed arthrofibrosis, which was successfully treated with manipulation under anesthesia and arthroscopic lysis of adhesions two months postoperatively. Both patients had full knee range of motion (ROM) by a one-year follow-up. One patient returned to full preinjury level of sport at six months postoperatively while the other patient returned to 50% of preinjury intensity at two-year follow-up. This series of two cases of PCL repair with SA in MLKIs demonstrates that PCL repair with SA is a viable procedure that can result in excellent short-term outcomes and restore knee stability.

Distal biceps femoris avulsions: Associated injuries and neurological sequelae.

BACKGROUND: The aim of this study was to describe associated injuries in cases of distal biceps femoris avulsions (DBFA) as well as the incidence of neurological injury and radiographic abnormalities of the common peroneal nerve (CPN). METHODS: A retrospective chart review was conducted of patients presenting to our office or trauma center with DBFA injuries. Demographic data was obtained as well as mechanism of injury. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. The CPN was evaluated for signs of displacement or neuritis. RESULTS: Sixteen patients were identified (mean age-at-injury 28.6 years, 87.5% male) with DBFA. Three patients (18.8%) sustained their injuries secondary to high energy trauma while 13 (81.3%) had injuries secondary to lower energy trauma. Nine patients (56.3%) initially presented with CPN palsy. All patients presenting with CPN palsy of any kind were found to have a displaced CPN on MRI and no patient with a normal nerve course had a CPN palsy. CONCLUSIONS: This case series demonstrates a strong association between DBFA and CPN palsy as well as multi-ligamentous knee injury (MLKI). These injuries have a higher rate of CPN palsy than that typically reported for MLKI. Furthermore, these findings suggest that CPN displacement on MRI may be a clinically significant indicator of nerve injury. LOE: IV.

Soft Tissue Injury Considerations in the Treatment of Tibial Plateau Fractures.

Tibial plateau fractures represent a highly variable spectrum of injury that requires a multifaceted diagnostic and therapeutic approach in order to adequately treat. Constant vigilance is required to consider all the injured structures and avoid focusing only on the bony aspect of the injury. Management of the soft tissue envelope and repair/reconstruction of critical stabilizing structures of the knee should be at the forefront of the thought process when approaching these complex injuries. This article aims to emphasize the high incidence of injury to associated soft tissue structures and provide general approach considerations to these complex injuries.

National trends, 90-day readmission and subsequent knee surgery following multi-ligament knee reconstruction.

INTRODUCTION/BACKGROUND: Given the uncommon nature of the multi-ligament injured knee, a better understanding of its outcomes may be achieved by contemporary evaluation of a national administrative database. We aim to identify risk factors for 90-day major complications, 90-day readmissions, and subsequent knee surgery after a multi-ligament knee reconstruction. METHODS: The Humana Claims Database was queried for all patients undergoing a multi-ligament knee reconstruction procedure from 2007 to 2016 using International Classification of Diseases (ICD)-9 procedure codes and Current Procedural Terminology (CPT) codes. Outcomes of interest included Center of Medicaid and Medicare Services (CMS)- reportable 90-day complications, 90-day readmission and subsequent ligament reconstruction or total knee arthroplasty. Predictive factors studied included demographics (ie. age, sex, tobacco use) comorbidity burden and operative factors (ie. surgical setting, diagnosis of knee dislocation, concomitant meniscal repair or meniscectomy). RESULTS: 588 multi-ligament knee reconstruction procedures were identified. The 90-day readmission rate 8.3%. The rate of subsequent ligament surgery was 7.1%. On multivariate regression analysis, a diagnosis of knee dislocation was associated with a four times greater likelihood of readmission and a two and a half greater likelihood of subsequent ligament surgery. Concomitant meniscectomy was associated with higher likelihood of subsequent total knee arthroplasty (9.1, 1.4-67.0) and outpatient setting of surgery compared to inpatient hospital setting was associated with reduced likelihood of readmission. CONCLUSION: While uncommon, the patient population undergoing multi-ligament knee surgery is relatively diverse. Understanding common factors predisposing this population to adverse events following surgery may assist in improved outcomes.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment.

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Knee Dislocation (KD) IV Injuries of the Knee: Presentation, Treatment, and Outcomes.

"KDIV ligamentous injuries of the knee are frequently high-energy injuries with significant soft tissue disruption, gross knee instability, and rarely are treated nonoperatively. KDIVs frequently require external fixation, but when presenting in an isolated fashion can be reconstructed in one setting. Five presentations of KDIV injury are described: closed with multitrauma/closed head injury requiring external fixation, irreducible KDIV requiring semi-emergent open reduction and repair, isolated KDIV without arterial injury undergoing 4-ligament reconstruction after regaining motion, KDIV with varus and slight thrust undergoing medial opening osteotomy before ligament reconstruction, and KDIV with failed ligaments requiring revision and posterior tibial tendon transfer."

Epidemiology and outcomes of traumatic knee dislocations: Isolated vs multi-trauma injuries.

BACKGROUND AND PURPOSE: Traumatic dislocation of the knee (TKD) is a rare injury, accounting for approximately 0.02% of orthopaedic injuries. They are a challenging entity for orthopaedic surgeons to manage, and can have devastating consequences. The aim of this study was to describe the epidemiology of traumatic knee dislocations (TKD'S) and contrast the incidence of neurovascular injury between isolated and multi-trauma dislocations as well as key patient reported outcomes achieved between these groups. MATERIAL AND METHODS: Patients who had a traumatic disruption of the tibiofemoral articulation between March 1 2007 and February 31, 2015 were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data was cross-checked with medical records and radiological reports to confirm true multi-ligamentous dislocation. VOTOR collects information pertaining to orthopaedic injuries, treatment, complications and outcomes from four adult hospitals in Victoria, Australia, including the major trauma centers. Patient-reported outcomes are collected by VOTOR at 12 months post-injury including the EQ-5D-3L (EQ-5D) and Glasgow Extended Outcome Scores (GOS-E) and return to work status. Patient reported functional and quality of life outcomes at 12 months after injury were analysed. RESULTS: A cohort of 88 patients were identified that fit the inclusion criteria for the study, and at 12 months post-injury there was data available for 80 patients (90.9%). There were 38 (42.9%) patients who experienced an isolated traumatic knee dislocation and 52 (57.1%) who experienced a traumatic knee dislocation in association with another injury. Of the 88 patients identified as eligible for the study, two had bilateral knee dislocations, hence there were 90 multi-ligamentous knee injuries. Those who were injured at a higher velocity were more likely to have additional injuries. Dislocations that occurred at a lower velocity were shown to have better overall outcomes, as did dislocations that occurred in isolation. CONCLUSIONS: Traumatic knee dislocations that occur in isolation typically result in better outcomes than those that occur with associated injuries. TKD's are a rare but severe injury that requires further research in order for functional outcomes to be optimized.

A novel technique for combined medial collateral ligament and posterior oblique ligament reconstruction: technical note.

PURPOSE: In the last year, we have performed a new technique for combined medial collateral ligament (MCL) and posterior oblique ligament (POL) reconstruction in chronic setting of anterior cruciate ligament and MCL complex deficiency. Autogenous semitendinosus tendon with the tibial attachment preserved has been used for the medial/posteromedial compartment reconstruction. We describe the operative technique. METHODS: Between January and December 2014, 12 consecutive patients with multiligamentous injuries underwent concomitant MCL/POL using a novel technique. The usefulness of the novel technique is the semitendinosus sling on the semimembranosus tendon and the POL fixation with the knee in full extension. RESULTS: An ideal anteroposterior and rotational stability avoiding the medial compartment over constraint was achieved, in the immediate after surgery, due to the sequence of the bundle fixations and to the semitendinosus sling below the semimembranosus tendon. CONCLUSIONS: This technique is easily reproducible and useful and restores the medial stability immediately after surgery.

Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: a systematic review.

BACKGROUND: Combined injuries to the posterolateral corner and cruciate ligaments are uncommon. The heterogeneity of injury patterns in many studies complicates the assessment of outcomes. OBJECTIVE: To assess the prognosis and functional outcomes after surgery for combined injuries to the posterolateral corner and to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). MATERIAL AND METHODS: We systematically reviewed the literature for articles reporting outcomes 1 year or more after surgery for combined injuries to the posterolateral corner and ACL (n=4) or PCL (n=9). Patients with bicruciate injuries were not studied. RESULTS: Overall, 65% of patients were IKDC A or B after surgery. The mean Lysholm score improved from 67 to 90. Mean time to surgery was 4.43 months in the group with ACL tears and 18.4 months in the group with PCL tears, and mean follow-up was 34.4 and 40.7 months in these two groups, respectively. In the groups with ACL and PCL tears, the proportions of patients classified as IKDC A or B at last follow-up were 81.6% and 81.0%, respectively, whereas 88% and 99% of patients, respectively, were IKDC grade C or D before surgery. The mean Lysholm score improved from 77 to 92 in the group with ACL tears and from 65 to 89 in the group with PCL tears. Improvements in laxity ranged from 28% to 79% in the group with PCL tears. DISCUSSION: Most of the articles selected for our review provided level III or IV evidence. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. Full reconstruction seems the best strategy in patients with combined ACL/posterolateral corner injuries. Outcomes were also good but more variable in the group with PCL/posterolateral corner injuries. The time to surgery, which reflected the time to diagnosis, was shorter in patients with ACL than with PCL tears in addition to the posterolateral corner injury. LEVEL OF EVIDENCE: Level III (systematic literature review).

Knee Dislocations: Lessons Learned From 20-Year Follow-up.

BACKGROUND: Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking. PURPOSE: To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee. STUDY DESIGN: Review and case reports. METHODS: Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form-36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability. RESULTS: The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject's IKDC score to "C." CONCLUSION: Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.