Multiligamentous Knee Injuries


138 Multiligamentous Knee Injuries


James P. Stannard MD and Hee Young Lee MD


University of Missouri Department of Orthopaedic Surgery, Columbia, MO, USA


Clinical scenario



  • A 32‐year‐old male construction worker is involved in a motor vehicle collision on the way home from work. He sustains a right femur fracture and is noted to have mild swelling around the right knee as well.
  • After intramedullary nailing of the femur the next day, it is noted that the patient has gross knee instability in all directions.
  • He has a normal vascular exam with 2+ pulses bilaterally for both the dorsalis pedis and posterior tibial arteries.

Top three questions



  1. In patients undergoing surgical treatment for knee dislocation, does collateral ligament reconstruction result in better clinical outcome compared to repair?
  2. In patients diagnosed with knee dislocation, does acute reconstruction within three weeks after the injury result in improved results compared to delayed reconstruction?
  3. In patients undergoing knee surgery, does restricted blood flow therapy yield better clinical outcomes, muscle strength, and size compared to conventional rehabilitation?

Question 1: In patients undergoing surgical treatment for knee dislocation, does collateral ligament reconstruction result in better clinical outcome compared to repair?


Rationale


Traditional instruction has been that medial and lateral corners should be repaired if good quality tissue is present and the repair is accomplished within three weeks. However, the current opinion is that the failure rate is lower for both the posteromedial corners (PMCs) and posterolateral corners (PLCs) with reconstruction of the ligaments when compared with repair. Thus, it is important to understand if, and by how much, reconstruction improves clinical outcomes.


Clinical comment


Dislocation of the knee refers to a multiligamentous knee injury that frequently includes a bi‐cruciate injury.1 Commonly, knee dislocation results in disruption of at least three of the four major ligaments of the knee and leads to significant functional instability. Vascular and neurologic damage, as well as associated fractures, can complicate the treatment of the multiligament‐injured knee.2


Early versus delayed surgery, repair versus reconstruction, and autograft versus allograft tissue for reconstruction remain topics of debate. High‐quality research efforts to investigate these controversies are hampered by the heterogeneous nature of the injuries themselves, the relatively infrequent occurrence of knee dislocations, and the many treatment strategies available.3


Available literature and quality of the evidence


Posteromedial corner (PMC)


Stannard et al. reported a significant difference between the failure rate of PMC repairs and PMC reconstructions treated within four weeks of the injury. This study compared the outcomes in knee dislocation patients whose injury included a torn PMC. A total of 71 knee dislocation patients with 73 PMC tears qualified for the study and were followed for a mean of 43 months. A total of 25 patients had a repair, with five failures (20%), compared with 48 patients who had a reconstruction (with auto‐ or allograft) with only two failures (4%). Reconstruction of the PMC using a technique that re‐establishes the critical triangle of the medial collateral ligament, the posterior oblique ligament, and the semitendinosus yielded better stability than repair in patients with a knee dislocation that included PMC instability.4


Posterolateral corner (PLC)


In direct comparisons of repair versus reconstruction, there are two publications regarding high‐grade lateral/posterolateral injuries. Stannard et al. reported a significant difference in favor of reconstruction when evaluating stability and return to sport.5 They did not detect a statistically significant difference in Lysholm, International Knee Documentation Committee (IKDC) scores, or return to work rates between the two groups of 57 knees. Levy et al. initially repaired lateral injuries before reconstruction. The 40% (4 of 10) failure rate in the repair group was reduced to a 6% (1 of 18) failure rate in the reconstruction group.6 Due to the higher failure rate of repair compared to reconstruction (40% vs 6% in one cohort and 37% vs 9% in another cohort), repair is not currently recommended.2,6 However, avulsed ligaments, particularly off the fibular head (lateral collateral ligament, LCL; popliteofibular ligament PFL, and the biceps tendon) should be repaired. Additionally, it is recommended that capsular tissue and the lateral meniscocapsular ligaments should be reattached to the bone.7



  • Level II: 31,4,5
  • Level III: 32,3,6
  • Level V: 1.7

Findings


Level II evidence indicated a significant difference in objective stability with reconstruction but did not indicate a significant difference in Lysholm, IKDC scores, or return to work rates.


Resolution of clinical scenario



  • Reconstruction of the PMC and PLC is recommended to avoid treatment failure.

Question 2: In patients diagnosed with knee dislocation, does acute reconstruction within three weeks after the injury result in improved results compared to delayed reconstruction?


Rationale

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Multiligamentous Knee Injuries

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