Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution

Axibal, Derek P.; Yeatts, Nicholas C.; Hysong, Alexander A.; Hong, Ian S.; Trofa, David P.; Moorman, Claude T.; Piasecki, Dana P.; Fleischli, James E.; Saltzman, Bryan M.

doi:10.1016/j.arthro.2021.05.027

Cited by 12 publications

(17 citation statements)

References 23 publications

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“…The ideal timing for surgery has yet to be conclusively determined [25][26][27] . Early surgery has been associated with an increased risk of loss of motion 28,29 . Furthermore, postoperative rehabilitation for MLKIs, which typically involves a period of non-weight-bearing and delayed initiation of range-of-motion exercises 30,31 , may also contribute to loss of motion.…”

Section: Discussionmentioning

confidence: 99%

Presentation and Surgical Management of Multiple Ligament Knee Injuries

Poploski

Lynch

Burns

et al. 2023

Journal of Bone and Joint Surgery

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Background:Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system.Methods:This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively.Results:A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range [IQR], 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved menisci (55.6%), nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication.Conclusions:A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionmentioning

confidence: 99%

Presentation and Surgical Management of Multiple Ligament Knee Injuries

Poploski

Lynch

Burns

et al. 2023

Journal of Bone and Joint Surgery

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“…Similar disagreement is also observed for neurovascular injury accompanying MLKI in two recent studies in the literature [5,17]. In a cohort study involving 296 patients, it was reported that time to surgery was not associated with postoperative stifness, whereas in two other studies involving fewer patients, acute and chronic surgeries are reported to be associated with postoperative stifness [4,14,32].…”

Section: Introductionmentioning

confidence: 61%

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi‐ligament knee injury surgery: a systematic review and meta‐analysis

Özbek

Dadoo

Grandberg

et al. 2023

Knee surg. sports traumatol. arthrosc.

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Purpose To perform a systematic review and meta‐analysis to investigate the rate of stiffness after multi‐ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness. Methods This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non‐Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries. Results Thirty‐six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level‐II, fourteen Level‐III, and twenty Level‐IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07–0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26–0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11–4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.). Conclusion Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured. Level of evidence Level IV.

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“…The reconstruction of these ligaments often involves the creation of several tunnels in a small area of the distal femur. Due to the limited bone mass, a critical step in these procedures is to avoid short tunnels or convergences among them because this can compromise the integrity of the graft [13,14] and may result in damage to fixation devices, poor graft fixation, or intra-operative and post-operative femoral fractures [15][16][17][18]. Some authors have proposed performing these anatomical reconstructions following a specific recommendation on the direction of the bone tunnels to avoid all of these potential complications [19][20][21].…”

Section: Introductionmentioning

confidence: 99%

Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries

Fernández-Poch

Fillat-Gomà

Martínez-Carreres

et al. 2023

International Orthopaedics (SICOT)

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Purpose Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions. Methods Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations. Results The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels. Conclusion The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.

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Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution

Cited by 12 publications

References 23 publications

Presentation and Surgical Management of Multiple Ligament Knee Injuries

Presentation and Surgical Management of Multiple Ligament Knee Injuries

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi‐ligament knee injury surgery: a systematic review and meta‐analysis

Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries

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