Anna Kropelnicki, Brett A Fritsch
Volume 5 | Issue 1 | Jan – April 2020 | Page 20-26
Author: Anna Kropelnicki [1], Brett A Fritsch [1]
[1] Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Ave., Chatswood, NSW 2067, Australia.
Address of Correspondence
Dr. Anna Kropelnicki
SORI, Level 1, The Gallery, 445 Victoria Ave, Chatswood, NSW 2067, Australia
Email: anna@krop.co.uk
Abstract
Significant injury to the posterior cruciate ligament (PCL) is an uncommon injury in isolation, but frequently occurs in the context of the multi-ligament injury of the knee. A multi-ligament knee injury (MLKI) is commonly defined as rupture of at least two of the four major ligament complexes with resultant coronal and sagittal plane instability [1], [2]. This review discusses the optimal approach to treating the PCL in the context of these injuries. While there is an overall paucity of high-quality evidence, recommendations can be made regarding the necessity for surgical intervention, and that best results appear to be a result of early (less than six weeks) surgery performed as a single reconstruction of all structures in an anatomical manner, including the PCL. In terms of the PCL, a double-bundle anatomic reconstruction is biomechanically preferential, but of little proven clinical benefit and may not always be possible. There is insufficient evidence in the MKLI to discern outcomes between autograft and allograft. The use of synthetic grafts is controversial, and should be avoided until longer-term data is available. Novel strategies such as internal bracing show some promise, but similarly lack clinical data at this stage. Overall, good outcomes can be obtained following this complex and potentially devastating injury, but further research and co-operation across treatment centres is needed to gain sufficient power to draw solid conclusions about the best way to treat the ruptured PCL in the MLKI.
References
1. N. R. Howells, L. R. Brunton, J. Robinson, A. J. Porteus, J. D. Eldridge, and J. R. Murray, “Acute knee dislocation: An evidence based approach to the management of the multiligament injured knee,” Injury, vol. 42, no. 11, pp. 1198–1204, 2011, doi: 10.1016/j.injury.2010.11.018.
2. A. A. Ali and M. B. Abdelwahab, “Short-term outcome of multi-ligament knee injury among sudanese patients,” Open Access Maced. J. Med. Sci., vol. 7, no. 9, pp. 1486–1493, 2019, doi: 10.3889/oamjms.2019.282.
3. P. R. T. Kuzyk and E. H. Schemitsch, “Should you save or Substitute the Posterior Cruciate Ligament in Total Knee Replacement?,” Evidence-Based Orthop. Best Answers to Clin. Quest., pp. 592–597, 2009, doi: 10.1016/B978-141604444-4.50091-6.
4. J. E. Voos, C. S. Mauro, T. Wente, R. F. Warren, and T. L. Wickiewicz, “Posterior cruciate ligament: Anatomy, biomechanics, and outcomes,” Am. J. Sports Med., vol. 40, no. 1, pp. 222–231, 2012, doi: 10.1177/0363546511416316.
5. G. C. Fanelli, C. J. Edson, K. N. Reinheimer, and R. Garofalo, The multiple ligament injured knee, vol. 58, no. 1. 2007.
6. P. S. et al., “Posterior cruciate ligament: Current concepts review,” Arch. Bone Jt. Surg., vol. 6, no. 1, pp. 8–18, 2018.
7. M. S. Shapiro and E. L. Freedman, “Allograft Reconstruction of the Anterior and Posterior Cruciate Ligaments After Traumatic Knee Dislocation,” Am. J. Sports Med., vol. 23, no. 5, pp. 580–587, 1995, doi: 10.1177/036354659502300511.
8. M. J. Strauss et al., “The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 27, no. 6, pp. 1791–1809, 2019, doi: 10.1007/s00167-019-05426-1.
9. B. A. Levy et al., “Controversies in the treatment of knee dislocations and multiligament reconstruction,” J. Am. Acad. Orthop. Surg., vol. 17, no. 4, pp. 197–206, 2009, doi: 10.5435/00124635-200904000-00001.
10. R. F. LaPrade et al., “Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients,” Am. J. Sports Med., vol. 47, no. 11, pp. 2563–2571, 2019, doi: 10.1177/0363546519864539.
11. M. Richter, U. Bosch, B. Wippermann, A. Hofmann, and C. Krettek, “Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations,” Am. J. Sports Med., vol. 30, no. 5, pp. 718–727, 2002, doi: 10.1177/03635465020300051601.
12. N. A. Trasolini, A. Lindsay, A. Gipsman, and G. F. Rick Hatch, “The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment,” Clin. Sports Med., vol. 38, no. 2, pp. 215–234, 2019, doi: 10.1016/j.csm.2018.11.009.
13. M. G. Hubert and J. P. Stannard, “Surgical treatment of acute and chronic anterior and posterior cruciate ligament and medial-side injuries of the knee,” Sports Med. Arthrosc., vol. 19, no. 2file://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedir, pp. 104–109, 2011, doi: 10.1097/JSA.0b013e3182191874.
14. G. Moatshe, G. J. Dornan, S. Løken, T. C. Ludvigsen, R. F. Laprade, and L. Engebretsen, “Demographics and injuries associated with knee dislocation: A prospective review of 303 patients,” Orthop. J. Sport. Med., vol. 5, no. 5, pp. 1–5, 2017, doi: 10.1177/2325967117706521.
15. B. Freychet et al., “All-inside Posterior Cruciate Ligament Reconstruction: Surgical Technique and Outcome,” Clin. Sports Med., vol. 38, no. 2, pp. 285–295, 2019, doi: 10.1016/j.csm.2018.11.005.
16. N. Marom, J. J. Ruzbarsky, C. Boyle, and R. G. Marx, “Complications in Posterior Cruciate Ligament Injuries and Related Surgery,” Sports Med. Arthrosc., vol. 28, no. 1, pp. 30–33, 2020, doi: 10.1097/JSA.0000000000000247.
17. J. E. Tibone, T. J. Antich, J. Perry, and D. Moynes, “Functional analysis of untreated and reconstructed posterior cruciate ligament injuries,” Am. J. Sports Med., vol. 16, no. 3, pp. 217–223, 1988, doi: 10.1177/036354658801600303.
18. A. Bedi, V. Musahl, and J. B. Cowan, “Management of Posterior Cruciate Ligament Injuries,” J. Am. Acad. Orthop. Surg., vol. 24, no. 5, pp. 277–289, 2016, doi: 10.5435/jaaos-d-14-00326.
19. C. J. Tucker, E. J. Cotter, B. R. Waterman, K. G. Kilcoyne, K. L. Cameron, and B. D. Owens, “Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population,” Orthop. J. Sport. Med., vol. 7, no. 10, pp. 1–7, 2019, doi: 10.1177/2325967119875139.
20. M. J. Skyhar, R. F. Warren, G. J. Ortiz, E. Schwartz, and J. C. Otis, “The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee,” J. Bone Jt. Surg. – Ser. A, vol. 75, no. 5, pp. 694–699, 1993, doi: 10.2106/00004623-199305000-00008.
21. R. B. Kohen and J. K. Sekiya, “Single-Bundle Versus Double-Bundle Posterior Cruciate Ligament Reconstruction,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 12, pp. 1470–1477, 2009, doi: 10.1016/j.arthro.2008.11.006.
22. C. J. Peskun and D. B. Whelan, “Outcomes of operative and nonoperative treatment of multiligament knee injuries: An evidence-based review,” Sports Med. Arthrosc., vol. 19, no. 2, pp. 167–173, 2011, doi: 10.1097/JSA.0b013e3182107d5f.
23. B. A. Levy et al., “Decision Making in the Multiligament-Injured Knee: An Evidence-Based Systematic Review,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 4, pp. 430–438, 2009, doi: 10.1016/j.arthro.2009.01.008.
24. C. D. Harner, M. A. Janaushek, A. Kanamori, M. Yagi, T. M. Vogrin, and S. L. Y. Woo, “Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction,” Am. J. Sports Med., vol. 28, no. 2, pp. 144–151, 2000, doi: 10.1177/03635465000280020201.
25. G. S. DiFelice, M. Lissy, and P. Haynes, “When to arthroscopically repair the torn posterior cruciate ligament,” Clin. Orthop. Relat. Res., vol. 470, no. 3, pp. 861–868, 2012, doi: 10.1007/s11999-011-2034-4.
26. G. Moatshe, J. Chahla, R. F. LaPrade, and L. Engebretsen, “Diagnosis and treatment of multiligament knee injury: state of the art,” J. ISAKOS Jt. Disord. Orthop. Sport. Med., vol. 2, no. 3, pp. 152–161, 2017, doi: 10.1136/jisakos-2016-000072.
27. G. C. Fanelli and C. J. Edson, “Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-Year follow-up,” Arthroscopy, vol. 18, no. 7, pp. 703–714, 2002, doi: 10.1053/jars.2002.35142.
28. A. J. Krych, P. L. Sousa, A. H. King, W. M. Engasser, M. J. Stuart, and B. A. Levy, “Meniscal tears and articular cartilage damage in the dislocated knee,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3019–3025, 2015, doi: 10.1007/s00167-015-3540-9.
29. K. D. Plancher and J. Siliski, “Long-term functional results and complications in patients with knee dislocations.,” J. Knee Surg., vol. 21, no. 4, pp. 261–268, 2008, doi: 10.1055/s-0030-1247829.
30. P. P. Mariani, P. Santoriello, S. Iannone, V. Condello, and E. Adriani, “Comparison of surgical treatments for knee dislocation.,” Am. J. Knee Surg., 1999.
31. D. R. Whiddon, C. T. Zehms, M. D. Miller, J. S. Quinby, S. L. Montgomery, and J. K. Sekiya, “Double compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model,” J. Bone Jt. Surg. – Ser. A, vol. 90, no. 9, pp. 1820–1829, 2008, doi: 10.2106/JBJS.G.01366.
32. K. L. Markolf, S. Park, S. R. Jackson, and D. R. Mcallister, “Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions,” J. Bone Jt. Surg. – Ser. A, vol. 91, no. 1, pp. 107–118, 2009, doi: 10.2106/JBJS.G.01215.
33. P. E. Gelber et al., “Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 31, no. 9, pp. 1764–1771, 2015, doi: 10.1016/j.arthro.2015.03.007.
34. M. Group, “Predictors of clinical outcome following revision anterior cruciate ligament reconstruction,” J. Orthop. Res., no. May 2019, 2020, doi: 10.1002/jor.24562.
35. S. An et al., “Autologous BPTB ACL Reconstruction Results in Lower Failure Rates Than ACL Repair with and without Synthetic Augmentation at 30 Years of Follow-up,” pp. 2074–2081, 2019.
36. C. C. Kaeding et al., “Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction : Predictors of Failure From a MOON Prospective Longitudinal Cohort,” vol. 3, no. 1, pp. 73–81, 2011, doi: 10.1177/1941738110386185.
37. M. B. Mestriner, R. de P. L. Cury, A. dos Santos Netto, V. M. de Oliveira, O. P. A. de Camargo, and J. C. Belloti, “Double-bundle posterior cruciate ligament reconstruction: No differences between two types of autografts in isolated or combined lesions,” Knee, vol. 27, no. 1, pp. 140–150, 2019, doi: 10.1016/j.knee.2019.09.015.
38. J. W. Belk, M. J. Kraeutler, J. M. Purcell, and E. C. McCarty, “Autograft Versus Allograft for Posterior Cruciate Ligament Reconstruction: An Updated Systematic Review and Meta-analysis,” Am. J. Sports Med., vol. 46, no. 7, pp. 1752–1757, 2018, doi: 10.1177/0363546517713164.
39. D. C. Wascher, J. R. Becker, J. G. Dexter, and F. T. Blevins, “Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts,” Am. J. Sports Med., vol. 27, no. 2, pp. 189–196, 1999, doi: 10.1177/03635465990270021301.
40. S. U. Scheffler, T. Schmidt, I. Gangéy, M. Dustmann, F. Unterhauser, and A. Weiler, “Fresh-Frozen Free-Tendon Allografts Versus Autografts in Anterior Cruciate Ligament Reconstruction: Delayed Remodeling and Inferior Mechanical Function During Long-term Healing in Sheep,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 24, no. 4, pp. 448–458, 2008, doi: 10.1016/j.arthro.2007.10.011.
41. A. Ventura, C. Terzaghi, C. Legnani, E. Borgo, and W. Albisetti, “Synthetic grafts for anterior cruciate ligament rupture: 19-year outcome study,” Knee, vol. 17, no. 2, pp. 108–113, 2010, doi: 10.1016/j.knee.2009.07.013.
42. L. Y. Chiang et al., “Posterior cruciate ligament reconstruction implemented by the Ligament Advanced Reinforcement System over a minimum follow-up of 10 years,” Knee, vol. 27, no. 1, pp. 165–172, 2019, doi: 10.1016/j.knee.2019.11.004.
43. C. F. van Eck, O. Limpisvasti, and N. S. ElAttrache, “Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review,” Am. J. Sports Med., vol. 46, no. 9, pp. 2291–2298, 2018, doi: 10.1177/0363546517717956.
44. G. C. Fanelli, “Posterior cruciate ligament rehabilitation: how slow should we go?,” Arthroscopy, vol. 24, no. 2, pp. 234–235, 2008, doi: 10.1016/j.arthro.2007.09.009.
45. H. M. and B. L. Li B, Shen P, Wang JS, Wang G, “Therapeutic effects of tibial support braces on posterior cruciate ligament reconstruction with autogenous hamstring tendon graft.,” Eur. J. Phys. Rehab Med., vol. 51, no. 2, pp. 163–70, 2014.
46. R. F. LaPrade, S. D. Smith, K. J. Wilson, and C. A. Wijdicks, “Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3070–3076, 2015, doi: 10.1007/s00167-014-3238-4.
47. F. R. Noyes and S. D. Barber-Westin, “Posterior cruciate ligament revision reconstruction, part 1: Causes of surgical failure in 52 consecutive operations,” Am. J. Sports Med., vol. 33, no. 5, pp. 646–654, 2005, doi: 10.1177/0363546504271210.
48. D. E. Cooper and D. Stewart, “Posterior Cruciate Ligament Reconstruction Using Single-Bundle Patella Tendon Graft with Tibial Inlay Fixation: 2- to 10-Year Follow-up,” Am. J. Sports Med., vol. 32, no. 2, pp. 346–360, 2004, doi: 10.1177/0363546503261511.
| How to Cite this article: Kropelnicki A, Fritsch B A | PCL Reconstruction in Multi-ligament Injured Knees: State of the art | Asian Journal of Arthroscopy | January- April 2020; 5(1): 20-26. |
Consideration sin the Management of Knee Dislocations in the Limited Resource Setting (KD-LRS)
Dustin L. Richter, Michael MFG Held, Maritz Laubscher, Richard B von Bormann, David North, Sachin Tapasvi, Anshu Shekhar, Daniel C. Wascher, Robert C Schenck
Volume 5 | Issue 1 | Jan – Apr 2020 | Page 66-72
Author: Dustin L. Richter [1], Michael MFG Held [2], Maritz Laubscher [2], Richard B von Bormann [2], David North [2], Sachin Tapasvi [3], Anshu Shekhar [3], Daniel C. Wascher [1], Robert C Schenck [1]
[1] Department of Orthopaedics, University of New Mexico, Albuquerque, USA.
[2] Department of Orthopaedics, University of Cape Town, Cape Town, Sauth Africa.
[3] The Orthopaedic Speciality Clinic in Pune, India
Address of Correspondence
Dr. Dustin L. Richter,
University of New Mexico, MSC10 5600, Albuquerque, NM 87131-0001, United States
E-mail: dlrichter@salud.unm.edu
Abstract
Knee dislocations (KD’s) are an increasingly recognized and potentially devastating injury that crosses between sports medicine and trauma. This intersection of orthopaedic specialities involves differing patient populations with individual challenges. While much of the literature on managing knee dislocations comes from academic centers in economically advantaged countries, the majority of knee dislocations worldwide are treated in limited resource settings (LRS). Even in high income countries, such as the United States, there are significant rural and underserved populations whose available treatment can often mimic LRS in developing nations. Additionally, there are patients with these injuries who refuse allograft reconstructions based on personal or religious beliefs. We have recruited authors with extensive experience in the management of KD’s who also have a special interest in managing the KD patient in the limited resource setting (KD-LRS). Additionally, the LRS environment should not be confused with the quality of professional care provided as the LRS has no limits on human capital.
Our topics will include acute evaluation and management of the KD, management with or without delayed ligament reconstruction, staged management, use of external fixation, reliance on autografts for ligament reconstruction, and management of the neglected KD or delayed presentation. Our goal is to provide a road map, in an area which has very limited references or direction, for the clinician practicing where “less, often has to be more” or utilizing what is available to its greatest capacity.
Keywords/phrases: Limited resource setting (LRS), Knee Dislocation, Neglected KD, Treatment Gap, Autograft KD reconstructions.
References
1. Chhabra A, Cha PS, Rihn JA, et al. Surgical management of knee dislocations. Surgical technique. J Bone Joint Surg Am. 2005 Mar;87 Suppl 1(Pt 1):1-21.
2. Scott JW, Lin Y, Ntakiyiruta G, et al. Contextual Challenges to Safe Surgery in a Resource-limited Setting: A Multicenter, Multiprofessional Qualitative Study. Ann Surg. 2018 Mar;267(3):461-7.
3. Scott JW, Lin Y, Ntakiyiruta G, et al. Identification of the Critical Nontechnical Skills for Surgeons Needed for High Performance in a Variable-resource Context (NOTSS-VRC). Ann Surg. 2019 Dec;270(6):1070-8.
4. Linden AF, Sekidde FS, Galukande M, et al. Challenges of surgery in developing countries: a survey of surgical and anesthesia capacity in Uganda’s public hospitals. World J Surg. 2012 May;36(5):1056-65.
5. Malelelo-Ndou H, Ramathuba DU, Netshisaulu KG. Challenges experienced by health care professionals working in resource-poor intensive care settings in the Limpopo province of South Africa. Curationis. 2019 Mar 26;42(1):e1-e8.
6. LaGrone LN, Isquith-Dicker LN, Huaman Egoavil E, et al. Surgeons’ and Trauma Care Physicians’ Perception of the Impact of the Globalization of Medical Education on Quality of Care in Lima, Peru. JAMA Surg. 2017 Mar 1;152(3):251-6.
7. O’Hara NN. Is safe surgery possible when resources are scarce? BMJ Qual Saf. 2015 Jul;24(7):432-4.
8. Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000 Jul;19(3):457-77.
9. Patterson, BM, Agel J, Swiontkowski MF, et al. and the LEAP Study Group. Knee Dislocations With Vascular Injury: Outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63:855-858.
10. Natsuhara KM, Yeranosian MG, Cohen JR, et al. What is the frequency of vascular injury after knee dislocation? Clin Orthop Relat Res. 2014 Sep;472(9):2615-20.
11. Weinberg DS, Scarcella NR, Napora JK, et al. Can vascular injury be appropriately assessed with physical examination after knee dislocation? Clin Orthop Relat Res. 2016 Jun;474(6):1453-8.
12. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261
13. Stannard JP, Sheils TM, Lopez-Ben RR, et al. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004 May;86(5):910-5.
14. Held M, Laubscher M, von Bormann R, et al. High rate of popliteal artery injuries and limb loss in 96 knee dislocations. SA Orthopaedic Journal. 2016 Apr;15(1):72-6.
15. Reddy PK, Posteraro RH; Schenck RC: The Role of MRI in Evaluation of the Cruciate Ligaments in Knee Dislocations. Orthopedics 1996 Feb; 19(2):166-170.
16. Walker DN, Schenck RC. A baker’s dozen of knee dislocations. Am J Knee Surg 1994:117–24.
17. Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop. 1981:212–5.
18. Heister L. A General system of surgery: in three parts: London: Printed for W. Innys…[and 5 others]; 1745.
19. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14(1):33-8.
20. Hegyes MS, Richardson MW, Miller MD. Knee dislocation: complications of nonoperative and operative management. Clin Sports Med. 2000;19(3):519-43.
21. Richter M, Bosch U, Wippermann B, et al. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30(5):718-27.
22. Wong C-H, Tan J-L, Chang H-C, et al. Knee dislocations—a retrospective study comparing operative versus closed immobilization treatment outcomes. Knee Surg Sports Traumatol Arthrosc. 2004;12(6):540-4.
23. Haro MS, Shelbourne KD. Selective Surgical Treatment of Knee Dislocations. In:The Multiple Ligament Injured Knee: Springer; 2019:109-19.
24. Taylor A, Arden G, Rainey H. Traumatic dislocation of the knee: a report of forty-three cases with special reference to conservative treatment. J Bone Joint Surg [Br]. 1972;54(1):96-102.
25. Javidan P, Owen J, Cutuk A, et al. How do spanning external fixators on knee dislocation patients affect the use of MRI and knee stability? J Knee Surg. 2015 Jun;28(3):247-54.
26. Frosch K-H, Preiss A, Heider S, et al. Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1502-9.
27. Bin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy. 2007;23(10):1066-72.
28. King JJ 3rd, Cerynik DL, Blair JA, et al. Surgical outcomes after traumatic open knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2009;17(9):1027-32.
29. Levy BA, Krych AJ, Shah JP, et al. Staged protocol for initial management of the dislocated knee. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1630-7.
30. Wright DG, Covey DC, Born CT, et al. Open dislocation of the knee. J Orthop Trauma. 1995;9(2):135-40.
31. Cook S, Ridley TJ, McCarthy MA, et al. Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrtosc. 2015;23(10):2983-91.
32. Fitzpatrick DC, Sommers MB, Kam BC, et al. Knee stability after articulated external fixation. Am J Sports Med. 2005;33(11):1735-41.
33. Stannard JP, Sheils TM, McGwin G, et al. Use of a hinged external knee fixator after surgery for knee dislocation. Arthroscopy. 2003;19(6):626-31.
34. Leonardi F, Zorzan A, Palermo A, et al. Neglected posterior knee dislocation: An unusual case report. Joints. 2017;5(4):253-255.
35. Said HG, Learmonth DJA. Chronic Irreducible Posterolateral Knee Dislocation: Two-Stage Surgical Approach. Arthrosc – J Arthrosc Relat Surg. 2007;23(5):564.e1-564.e4.
36. Khamaisy S, Haleem AM, Williams RJ, et al. Neglected rotatory knee dislocation: A case report. Knee. 2014;21(5):975-978.
37. Simonian PT, Wickiewicz TL, Hotchkiss RN, et al. Chronic knee dislocation: Reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med. 1998;26(4):591-596.
38. Cheung SC, Allen CR, Gallo RA, et al. Patients’ attitudes and factors in their selection of grafts for anterior cruciate ligament reconstruction. Knee. 2012;19(1):49-54.
39. Cohen SB, Yucha DT, Ciccotti MC, et al. Factors affecting patient selection of graft type in anterior cruciate ligament reconstruction. Arthroscopy. 2009;25(9):1006-10.
40. Cooper MT, Kaeding C. Comparison of the hospital cost of autograft versus allograft soft-tissue anterior cruciate ligament reconstructions. Arthroscopy. 2010;26(11):1478-82.
41. Stannard JP, Brown SL, Farris RC, et al. The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med. 2005;33(6):881-8.
42. Menzer H, Treme G, Wascher D. Surgical treatment of medial instability of the knee. Sports Med Arthrosc Rev. 2015;23(2):77-84.
43. Treme GP, Salas C, Ortiz G, et al. A Biomechanical Comparison of the Arciero and LaPrade Reconstruction for Posterolateral Corner Knee Injuries. Orthop J Sports Med.2019;7(4):2325967119838251.
44. Fanelli GC, Edson CJ.Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up.Arthroscopy. 2004;20(4):339-45.
45. Tapasvi SR, Shekhar A, Patil SS. Anatomic Posterolateral Corner Reconstruction With Autogenous Peroneus Longus Y Graft Construct. Arthroscopy Techniques. 2019;8(12):e1501-9.
46. Setyawan R, Soekarno NR, Asikin AI, et al. Posterior Cruciate Ligament reconstruction with peroneus longus tendon graft: 2-Years follow-up. Annals of Med and Surg. 2019;43:38-43.
47. Khamaisy S, Haleem AM, Williams RJ, et al. Neglected rotatory knee dislocation: A case report. Knee. 2014;21(5):975-978.
48. Henshaw RM, Shapiro MS, Oppenheim WL. Delayed reduction of traumatic knee dislocation. A case report and literature review. Clin Orthop Relat Res. 1996;330(330):152-156.
49. Chen HC, Chiu FY. Chronic knee dislocation treated with arthroplasty. Inj Extra. 2007;38(8):258-261.
50. Petrie RS, Trousdale RT, Cabanela ME. Total knee arthroplasty for chronic posterior knee dislocation: Report of 2 cases with technical considerations. J Arthroplasty. 2000;15(3):380-386.
(Abstract) (Full Text HTML) (Download PDF)
Multi Ligament Knee Instability: How to swim in choppy waters?
Sachin Tapasvi, Anshu Shekhar
Volume 5 | Issue 1 | Jan – Apr 2020 | Page 1-2
Author: Sachin Tapasvi [1], Anshu Shekhar [1]
[1] Orthopaedic Speciality Clinic, Pune Mahatrahtra.
Address of Correspondence
Dr. Anshu Shekhar,
The Orthopaedic Speciality Clinic, Pune
E-mail: dr.anshushekhar@gmail.com.
Multi Ligament Knee Instability: How to swim in choppy waters?
The spectrum of multi ligament knee injury (MLKI) encompasses injury to every tissue in and around the knee joint- ligaments, menisci, cartilage, bone, nerves and vessels. The management of such an injury involves marshalling every possible resource and skill at the knee surgeon’s disposal. In fact, it is often in the emergency room (ER) and not the operating room (OR) that the most critical decisions need to be taken when dealing with a patient with MLKI. The absence of ‘best practice guidelines’ or ‘standard of care’ means that every institution must have its own standard operating protocols (SOPs) for managing these complex injuries. Muddling the water further, is the absence of high quality evidence, thus making the formulation of such SOPs a difficult task. Hence, decision making is largely guided by Level IV evidence, expert opinions and personal experience. The current issue of Asian Journal of Arthroscopy aims to collate the available literature and opinions of some stalwarts of knee surgery from all parts of the globe, in ten narrative reviews.
The terminology of MLKI is often used interchangeably with knee dislocation (KD). This is not always true because a KD typically involves injury to both cruciates, whereas an MLKI can have a single cruciate and collateral ligament injury. Knee dislocations were once considered rare injuries but this is changing because of increasing incidence of high velocity trauma, the occurrence of ultra-low velocity KDs in morbidly obese patients and the recognition that almost half of KDs present with a reduced knee [1-3]. The initial assessment in the ER is crucial so as to not miss injuries to the nerves and vessels and has been discussed in great detail by the team from University of New Mexico led by Robert Schenck. The Schenck Classification [4] is perhaps the best system to categorize these injuries to formulate a treatment plan. The management of specific injuries of the medial collateral ligament and posterolateral corner has been helmed by Andy Williams and Dave Lee respectively. Both these authors have discussed every aspect of diagnosis and treatment and the reader can learn a lot from their vast experience. Posterior cruciate ligament injury in MLKI has been reviewed by Brett Fritsch with exhaustive details about restoring the central pivot of the knee in this complex scenario. The occurrence of fractures and neurovascular injuries in a knee dislocation pushes the surgeon to an unfamiliar territory and thus requires a team effort involving trauma and vascular surgeons. A comprehensive review of these problems and management guidelines has been elegantly presented by Sundararajan S.R. based on his wide experience at Ganga Hospital.
Some more contentious issues in MLKI like the role of ligament repair has been discussed and guidelines are provided. A peculiar problem faced by surgeons in Asia, Africa and Latin Americas is treating knee dislocations with limited resources. Michael Held from South Africa has coined the terminology ‘limited resource setting’ (LRS) and has steered an excellent paper on this topic, which is of immense value to surgeons from such regions. The role of correcting osseous mal-alignment in all three dimensions in a multi-ligament injured knee is well established now [5]. A comprehensive review on such osteotomies aims to provide the readers with the latest concepts and trends. It is imperative that any surgery for this complex injury pattern would be fraught with risks and complications. Dinshaw Pardiwala has written an excellent and detailed review for salvaging such difficult situations. A current review on the functional outcomes of these complex and serious injuries has been presented by Nagraj Shetty.
The aim of this issue is to provide the reader with information and knowledge which can then be used to guide patient management. We hope that the wealth of knowledge shared by our authors will enrich the readers and guide them in creating their own SOPs for swimming in the choppy waters of MLKI.
Sachin Tapasvi
Anshu Shekhar
(Abstract) (Full Text HTML) (Download PDF)
Assessment and Decision Making in Acute Knee Dislocation
Dustin L. Richter, Heidi Smith, Marisa Su, Gehron P. Treme, Daniel C. Wascher, Robert C. Schenck
Volume 5 | Issue 1 | Jan – April 2020 | Page 3-8
Author: Dustin L. Richter [1], Heidi Smith [1], Marisa Su [1], Gehron P. Treme [1], Daniel C. Wascher [1], Robert C. Schenck [1]
[1] The University of New Mexico Health Sciences Center
Address of Correspondence
Dr. Dustin L. Richter,
The University of New Mexico, MSC10 5600, Albuquerque, NM 87131-0001, United States
E-mail: dlrichter@salud.unm.edu
Abstract
The traumatic knee dislocation (KD) is a complex condition resulting in injury to more than one ligament or ligament complexes about the knee. Most of the time, KDs result in injury to both cruciate ligaments with variable injury to the collateral ligament complexes. However, there are rare presentations of a single cruciate and collateral ligament injury that present with the tibiofemoral joint dislocated. With the use of the term multi-ligamentous knee injuries (MLKI), it is important to understand that not all MLKIs are KDs. Knees can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history, physical exam and imaging, with particular attention to vascular status which has the most emergent treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.
Keywords: Knee dislocation (KD), Multi-ligament knee injury, Assessment, Classification.
References
1. MH, Harvey JP. Traumatic dislocation of the knee joint. A study of eighteen cases. J Bone Joint Surg Am. 1971;53:16-29.
2. Wilson SM, Mehta N, Do HT, Ghomrawi H, Lyman S, Marx RG. Epidemiology of multiligament knee reconstruction. Clin Orthop Relat Res. 2014;472:2603-8.
3. Arom GA, Yeranosian MG, Petriglioano FA, Terrell RD, McAllister DR. The changing demographics of knee dislocation: a retrospective database review. Clin Orthop Relat Res. 2014;472:2609-14.
4. Georgiadis AG, Mohammad FH, Mizerik KT, Nypaver TJ, Shepard AD. Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese. J Vasc Surg. 2013 May;57(5):1196-203.
5. Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma. 1997;11:525-9.
6. O’Malley M, Reardon P, Pareek A, et al. Extensor Mechanism Disruption in Knee Dislocation. J Knee Surg. 2016 May;29(4):293-9.
7. Wroble RR, Lindenfeld TN. The stabilized Lachman test. Clin Orthop Relat Res. 1988 Dec(237):209-12.
8. Damoe; DM, Stone ML, Barnett P, Sachs R. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Joint Surg. 1988 Mar;70(3):386-391.
9. Patterson BM, Agel J, Swiontkowski MF, et al. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007 Oct;63(4):855-8.
10. Parker S, Handa A, Deakin M, Sideso E. Knee dislocation and vascular injury: 4 year experience at a UK major trauma centre and vascular hub. Injury. 2016 Mar;47(3):752-6.
11. Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma. 2013 Apr;27(4):226-31.
12. Natsuhara KM, Yeranosian MG, Cohen JR, et al. What is the frequency of vascular injury after knee dislocation? Clin Orthop Relat Res. 2014 Sep;472(9):2615-20.
13. Sillanpaa PJ, Kannus P, Niemi ST, et al. Incidence of knee dislocation and concomitant vascular injury requiring surgery: a nationwide study. J Trauma Acute Care Surg. 2014 Mar;76(3):715-9.
14. Weinberg DS, Scarcella NR, Napora JK, Vallier HA. Can vascular injury be appropriately assessed with physical examination after knee dislocation? Clin Orthop Relat Res. 2016 Jun;474(6):1453-8.
15. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261
16. Stannard JP, Sheils TM, Lopez-Ben RR, et al. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004 May;86(5):910-5.
17. Reddy CG, Amrami KK, Howe BM, et al. Combined common peroneal and tibial nerve injury after knee dislocation: one injury or two? An MRI-clinical correlation. Neurosurg Focus. 2015 Sep;39(3):E8.
18. Cho D, Saetia K, Lee S, et al. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus. 2011 Nov;31(5):E11.
19. Cush G, Irgit K. Drop foot after knee dislocation: evaluation and treatment. Sports Med Arthrosc Rev. 2011 Jun;19(2):139-46.
20. Krych AJ, Giuseffi SA, Kuzma SA, et al. Is peroneal nerve injury associated with worse function after knee dislocation? Clin Orthop Relat Res. 2014 Sep;472(9):2630-6.
21. Jabara M, Bradley J, Merrick M. Is stability of the proximal tibiofibular joint important in the multiligament-injured knee? Clin Orthop Relat Res. 2014 Sep;472(9):2691-7.
22. Reddy PK, Posteraro RH, Schenck RC, Jr. The role of MRI in evaluation of the cruciate ligaments in knee dislocations. Orthopedics. 1996 Feb;19(2):166-70.
23. Bui KL, Ilaslan H, Parker RD, et al. Knee dislocations: a magnetic resonance imaging study correlated with clinical and operative findings. Skeletal Radiol. 2008 Jul;37(7):653-61.
24. James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res. 2014 Sep;472(9):2644-57.
25. Schenck RC, Jr., Hunter RE, Ostrum RF, et al. Knee dislocations. Instr Course Lect. 1999;48:515-22.
26. Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am. 1963;45:889–904.
27. Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop. 1981:212–5.
28. Huang FS, Simonian PT, Chansky HA. Irreducible posterolateral dislocation of the knee. Arthrosc. 2000;16:323–7.
29. Shelbourne KD, Klootwyk TE. Low-velocity knee dislocation with sports injuries. Treatment principles. Clin Sports Med. 2000 Jul;19(3):443-56.
30. Shelbourne KD, Porter DA, Clingman JA, et al. Low-velocity knee dislocation. Orthop Rev. 1991 Nov;20(11):995-1004.
31. Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000 Jul;19(3):457-77.
32. Dosher WB, Maxwell GT, Warth RJ, et al. Multiple Ligament Knee Injuries: Current State and Proposed Classification. Clin Sports Med. 2019 Apr;38(2):183-92.
33. Azar FM, Brandt JC, Miller RH, 3rd, et al. Ultra-low-velocity knee dislocations. Am J Sports Med. 2011 Oct;39(10):2170-4.
34. Stannard JP, Wilson TC, Sheils TM, et al. Heterotopic ossification associated with knee dislocation. Arthrosc. 2002 Oct;18(8):835-9.
35. Mills WJ, Tejwani N. Heterotopic ossification after knee dislocation: the predictive value of the injury severity score. J Orthop Trauma. 2003 May;17(5):338-45.
36. McCoy GF, Hannon DG, Barr RJ, Templeton J. Vascular injury associated with low-velocity dislocations of the knee. J Bone Joint Surg Br. 1987 Mar;69(2):285-7.
37. Pardiwala DN, Rao NN, Anand K, Raut A. Knee Dislocations in Sports Injuries. Indian J Orthop. 2017 Sep-Oct;51(5):552-62.
38. Werner BC, Gwathmey FW Jr, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med. 2014 Feb;42(2):358-63.
39. Walker DN, Schenck RC. A baker’s dozen of knee dislocations. Am J Knee Surg 1994:117–24.
40. Bratt HD, Newman AP. Complete dislocation of the knee without disruption of both cruciate ligaments. J Trauma. 1993 Mar;34(3):383-9.
41. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742-6.
42. Everhart JS, Du A, Chalasani R, et al. Return to Work or Sport After Multiligament Knee Injury: A Systematic Review of 21 Studies and 524 Patients. Arthrosc. 2018 May;34(5):1708-16.
43. Merritt AL, Wahl CJ. Rationale and treatment of multiple-ligament injured knees: the seattle perspective. Oper Tech Sports Med. 2011;19:51-72.
44. Moatshe G, Dornan GJ, Løken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and injuries associated with knee dislocation: a prospective review of 303 patients. Orthop J Sports Med. 2017 May 22;5(5):2325967117706521.
45. Cook S, Ridley TJ, McCarthy MA, et al. Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrtosc. 2015Oct;23(10):2983-91.
46. Bakshi NK, Khan M, Lee S, et al. Return to play after multiligament knee injuries in National Football League athletes. Sports Health. 2018; 10(6):495-99.
(Abstract) (Full Text HTML) (Download PDF)
Role of osteotomy in multiligament knee instability
Anshu Shekhar, Anoop Pilar, Sachin Tapasvi
Volume 5 | Issue 1 | Jan – April 2020 | Page 43-52
Author: Anshu Shekhar [1], Anoop Pilar [1], Sachin Tapasvi [1]
[1] The Orthopaedic Speciality Clinic, Pune
Address of Correspondence
Dr. Anshu Shekhar,
The Orthopaedic Speciality Clinic, Pune
E-mail: dr.anshushekhar@gmail.com
Abstract
Alignment of the lower limb (coronal, sagittal and axial) has a significant effect on knee stability in a multiligament injured knee. This malalignment can be due to a pre-existing condition like tibia vara, an abnormal tibial slope, a malunited intra articular fracture with ligament injury, or can develop later in a neglected case of instability. Restoration of limb alignment is one of important factors to restore the stability in these patients. The importance of performing an osteotomy in a ligament-deficient knee is to further prevent the articular cartilage wear, to protect the graft(s) from abnormally high stress, to restore stability and to restore geometry. Thus, an osteotomy has a more profound bearing in restoring knee laxity and reducing graft stress after any soft tissue reconstruction. An osteotomy can be performed either alone or with simultaneous ligament reconstruction, or as a staged procedure. This review analyses the importance of lower limb alignment, its impact on knee ligamentous stability, decision making and planning for an osteotomy and briefly discuss technical aspects of performing an osteotomy.
Keywords: Knee dislocation, Ligament injury, Osteotomy, Instability, Malalignment.
References
1. Paley D, Pfeil J. Prinzipien der kniegelenknahenDeformitätenkorrektur [Principles of deformity correction around the knee]. Orthopade. 2000;29(1):18–38. doi:10.1007/s001320050004
2. Bellemans J, Colyn W, Vandenneucker H, Victor J. The ChitranjanRanawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. ClinOrthopRelat Res. 2012;470(1):45–53. doi:10.1007/s11999-011-1936-5
3. Song MH, Yoo SH, Kang SW, Kim YJ, Park GT, Pyeun YS. Coronal alignment of the lower limb and the incidence of constitutional varus knee in korean females [published correction appears in Knee SurgRelat Res. 2015 Sep;27(3):197]. Knee SurgRelat Res. 2015;27(1):49–55. doi:10.5792/ksrr.2015.27.1.49
4. Thaller PH, Fürmetz J, Chen F, Degen N, Manz KM, Wolf F. Bowlegs and Intensive Football Training in Children and Adolescents [published correction appears in DtschArztebl Int. 2018 Aug;115(33-34):548]. DtschArztebl Int. 2018;115(24):401–408. doi:10.3238/arztebl.2018.0401
5. Galla M., Lobenhoffer P. Physiological axes of the lower limb. In: Lobenhoffer P., van Heerwaarden R, Staubli AE, Jakob RP (Eds). Osteotomies around the Knee. Thieme, Stuttgart.
6. Amis AA. Biomechanics of high tibial osteotomy. Knee Surg Sports TraumatolArthrosc. 2013;21(1):197–205. doi:10.1007/s00167-012-2122-3.
7. Teichtahl AJ, Davies-Tuck ML, Wluka AE, et al. Change in knee angle influences the rate of medial tibial cartilage volume loss in knee osteoarthritis. OsteoarthrCartil 2009;17:8-11.
8. Noyes FR, Simon R: The role of high tibial osteotomy in the anterior cruciate ligament-deficient knee with varus alignment, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Principles and Practice. Philadelphia, WB Saunders, 1994, pp 1401–1443
9. Tischer T, Paul J, Pape D, et al. The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med. 2017;5(3):2325967117697287. doi:10.1177/2325967117697287
10. Abdelrahman T., Getgood A. Role of osteotomy in multiligament knee injuries. Ann Joints 2019;4:8. Doi: 10.21037/aoj.2018.12.07.
11. Giffin JR, Stabile KJ, Zantop T, et al. Importance of tibial slope for stability of the posterior cruciate ligament deficient knee. Am J Sports Med 2007;35:1443-9.
12. Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg [Am] 1975;57-A:961–967.
13. Marriott K, Birmingham TB, Kean CO, Hui C, Jenkyn TR, Giffin JR. Five-year changes in gait biomechanics after concomitant high tibial osteotomy and ACL reconstruction in patients with medial knee osteoarthritis. Am J Sports Med. 2015;43(9):2277–2285. doi:10.1177/0363546515591995
14. Marriott K, Birmingham TB, Pinto R, et al. Gait biomechanics after combined HTO-ACL reconstruction versus HTO alone: A matched cohort study. J Orthop Res. 2019;37(1):124–130. doi:10.1002/jor.24157
15. Chehab EF, Favre J, Erhart-Hledik JC, et al. 2014. Baseline knee adduction and flexion moments during walking are both associated with 5 year cartilage changes in patients with medial knee osteoarthritis. Osteoarthritis Cartilage 22:1833–1839
16. Schneider A, Gaillard R, Gunst S, et al. Combined ACL reconstruction and opening wedge high tibial osteotomy at 10-year follow-up: excellent laxity control but uncertain return to high level sport. Knee Surg Sports TraumatolArthrosc. 2020;28(3):960–968. doi:10.1007/s00167-019-05592-2
17. Malahias MA, Shahpari O, Kaseta MK. The clinical Outcome of One-stage High Tibial Osteotomy and Anterior Cruciate Ligament Reconstruction. A Current Concept Systematic and Comprehensive Review. Arch Bone Jt Surg. 2018;6(3):161–168.
18. Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, part 1: causes of surgical failure in 52 consecutive operations. Am J Sports Med. 2005;33(5):646–654. doi:10.1177/0363546504271210
19. Mehl J, Otto A, Kia C, et al. Osseous valgus alignment and posteromedial ligament complex deficiency lead to increased ACL graft forces [published online ahead of print, 2019 Nov 2]. Knee Surg Sports TraumatolArthrosc. 2019;10.1007/s00167-019-05770-2. doi:10.1007/s00167-019-05770-2
20. Salmon LJ, Heath E, Akrawi H, Roe JP, Linklater J, Pinczewski LA. 20-Year Outcomes of Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: The Catastrophic Effect of Age and Posterior Tibial Slope. Am J Sports Med. 2018;46(3):531–543. doi:10.1177/0363546517741497
21. Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture. Knee Surg Sports TraumatolArthrosc. 2015;23(10):2846–2852. doi:10.1007/s00167-015-3758-6
22. Sonnery-Cottet B, Mogos S, Thaunat M, et al. Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;42(8):1873–1880. doi:10.1177/0363546514534938
23. Yamaguchi KT, Cheung EC, Markolf KL, et al. Effects of Anterior Closing Wedge Tibial Osteotomy on Anterior Cruciate Ligament Force and Knee Kinematics [published correction appears in Am J Sports Med. 2018 Feb;46(2):NP2]. Am J Sports Med. 2018;46(2):370–377. doi:10.1177/0363546517736767
24. Bernhardson AS, Aman ZS, Dornan GJ, et al. Tibial Slope and Its Effect on Force in Anterior Cruciate Ligament Grafts: Anterior Cruciate Ligament Force Increases Linearly as Posterior Tibial Slope Increases. Am J Sports Med. 2019;47(2):296–302. doi:10.1177/0363546518820302
25. Imhoff FB, Mehl J, Comer BJ, et al. Slope-reducing tibial osteotomy decreases ACL-graft forces and anterior tibial translation under axial load. Knee Surg Sports TraumatolArthrosc. 2019;27(10):3381–3389. doi:10.1007/s00167-019-05360-2
26. Bernhardson AS, DePhillipo NN, Daney BT, Kennedy MI, Aman ZS, LaPrade RF. Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury. Am J Sports Med. 2019;47(2):312–317. doi:10.1177/0363546518819176
27. Bernhardson AS, DePhillipo NN, Aman ZS, Kennedy MI, Dornan GJ, LaPrade RF. Decreased Posterior Tibial Slope Does Not Affect Postoperative Posterior Knee Laxity After Double-Bundle Posterior Cruciate Ligament Reconstruction. Am J Sports Med. 2019;47(2):318–323. doi:10.1177/0363546518819786
28. Herman B, Litchfield R, Getgood A. Role of Osteotomy in Posterolateral Instability of the Knee. J Knee Surg. 2015;28(6):441–449. doi:10.1055/s-0035-1558856
29. Laprade RF, Engebretsen L, Johansen S, Wentorf FA, Kurtenbach C. The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability: a biomechanical study. Am J Sports Med. 2008;36(5):956–960. doi:10.1177/0363546507312380
30. Helito CP, Sobrado MF, Giglio PN, et al. Posterolateral reconstruction combined with one-stage tibial valgus osteotomy: Technical considerations and functional results. Knee. 2019;26(2):500–507. doi:10.1016/j.knee.2018.12.001
31. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118–1126. doi:10.1177/0363546514525929
32. Miniaci A, Ballmer FT, Ballmer PM, Jakob RP. Proximal tibial osteotomy. A new fixation device. ClinOrthopRelat Res. 1989;(246):250–259.
33. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. ClinOrthopRelat Res. 1992;(274):248–264.
34. Coventry MB. Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am. 1985;67(7):1136–1140.
35. Standard SC, Herzenberg JE, Conway JD, Siddiqui NA, McClure PK. The Art of Limb Alignment. 8th Ed. Baltimore: Rubin Institute of Advanced Orthopaedics, Sinai Hospital of Baltimore, 2019.
36. Vaishya R, Bijukchhe AR, Agarwal AK, Vijay V. A critical appraisal of medial open wedge high tibial osteotomy for knee osteoarthritis. Journal of Clinical Orthopaedics and Trauma. 2018 Oct-Dec;9(4):300-306. DOI: 10.1016/j.jcot.2018.02.004.
37. Sherman SL, Thompson SF, Clohisy JCF. Distal Femoral Varus Osteotomy for the Management of Valgus Deformity of the Knee. J Am AcadOrthop Surg. 2018;26(9):313–324. doi:10.5435/JAAOS-D-16-00179
38. Nha KW, Shin YS, Kwon HM, Sim JA, Na YG. Navigated versus Conventional Technique in High Tibial Osteotomy: A Meta-Analysis Focusing on Weight Bearing Effect. Knee SurgRelat Res. 2019;31(2):81–102. doi:10.5792/ksrr.17.090
39. Donnez M, Ollivier M, Munier M, et al. Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J OrthopSurg Res. 2018;13(1):171. Published 2018 Jul 9. doi:10.1186/s13018-018-0872-4
40. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28(3):282–296. doi:10.1177/03635465000280030201
41. Badhe NP, Forster IW. High tibial osteotomy in knee instability: the rationale of treatment and early results. Knee Surg Sports TraumatolArthrosc. 2002;10(1):38–43. doi:10.1007/s001670100244
42. Naudie DD, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32(1):60–70. doi:10.1177/0363546503258907
43. Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med. 2007;35(11):1844–1850. doi:10.1177/0363546507304717.
(Abstract) (Full Text HTML) (Download PDF)
Primary repair in acute multiligamant knee injury
Anshu Shekhar, Siddharth Reddy, Sachin Tapasvi
Volume 5 | Issue 1 | Jan – April 2020 | Page 14-19
Author: Anshu Shekhar [1], Siddharth Reddy [1], Sachin Tapasvi [1]
[1] The Orthopaedic Speciality Clinic, Pune
Address of Correspondence
Dr. Anshu Shekhar,
The Orthopaedic Speciality Clinic, Pune
E-mail: dr.anshushekhar@gmail.com
Abstract
Acute multilagment knee injuries (MLKI) are those in which more than two ligaments are injured and which present within a period of three weeks. Treatment of life threatening conditions, neurovascular injuries, peri-articular fractures and irreducible dislocations take precedence over ligaments in setting of an acute MLKI associated with or without knee dislocations. There is no consensus or well defined guidelines regarding management of these complex injuries. For medial sided injuries, early repair for avulsions with good tissue quality and reconstruction for mid substance tears or poor tissue quality is a reasonable approach. Early repairs of posterolateral corner structures have had good functional outcomes but failure rates of such repairs are higher compared to a reconstruction. Better stability and better knee range of motion have been reported in knees with cruciate reconstructions than repairs in an acute setting. Primary suture repair in indicated low demand patients has shown promising outcomes. However, the risks of arthrofibrosis and revision surgery must be explained to the patients undergoing and arthrotomy for cruciate repairs. Use of synthetic augmentation seems reasonable although there is no strong science to support this presumption. A comparative study between homogenous injury groups would perhaps shed more light on the relevance of repair or reconstruction in acute surgery for MLKI.
Keywords: Knee dislocation, Multiligament knee injury, Acute, Ligament repair, Ligament reconstruction.
References
1. Moatshe G, Chahla J, LaPrade RF, et al Diagnosis and treatment of multiligament knee injury: state of the art Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2017;2:152-161.
2. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am 2004;86-A:262–73.
3. Mariani PP, Santoriello P, Iannone S, et al. Comparison of surgical treatments for knee dislocation. Am J Knee Surg 1999;12:214–21.
4. Geeslin AG, LaPrade RF. Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: a prospective case series and surgical technique. J Bone Joint Surg Am 2011;93:1672–83.
5. Liow RY, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br. 2003;85(6):845–851.
6. Tardy N, Boisrenoult P, Teissier P, Steltzlen C, Beaufils P, Pujol N. Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):524–531. doi:10.1007/s00167-016-4067-4
7. Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010 May;92(5):1266-80. doi: 10.2106/JBJS.I.01229.
8. Cinque ME, Chahla J, Kruckeberg BM, DePhillipo NN, Moatshe G, LaPrade RF. Posteromedial Corner Knee Injuries: Diagnosis, Management, and Outcomes: A Critical Analysis Review. JBJS Rev. 2017 Nov;5(11):e4. doi: 10.2106/JBJS.RVW.17.00004.
9. Chahal J, Al-Taki M, Pearce D, Leibenberg A, Whelan DB. Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1098–1104. doi:10.1007/s00167-009-1011-x
10. Andrews K, Lu A, McKean L, Ebraheim N. Review: Medial collateral ligament injuries. Journal of Orthopaedics. 2017;14(4):550-554.
11. Werner BC, Hadeed MM, Gwathmey FW Jr, Gaskin CM, Hart JM, Miller MD. Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes?. Clin Orthop Relat Res. 2014;472(9):2658–2666. doi:10.1007/s11999-014-3483-3
12. Dold AP, Swensen S, Strauss E, Alaia M. The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies. J Am Acad Orthop Surg. 2017;25(11):752–761. doi:10.5435/JAAOS-D-16-00020
13. Kovachevich R, Shah JP, Arens AM, Stuart MJ, Dahm DL, Levy BA. Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc. 2009;17(7):823–829. doi:10.1007/s00167-009-0810-4
14. Stannard JP, Black BS, Azbell C, Volgas DA. Posteromedial corner injury in knee dislocations. J Knee Surg. 2012;25(5):429–434. doi:10.1055/s-0032-1322605
15. Mehl JT, Kia C, Murphy M, et al. Posteromedial Ligament Repair of the Knee With Suture Tape Augmentation: A Biomechanical Study. Am J Sports Med. 2019;47(12):2952–2959. doi:10.1177/0363546519868961
16. van der List JP, DiFelice GS. Primary Repair of the Medial Collateral Ligament With Internal Bracing. Arthrosc Tech. 2017;6(4):e933–e937. Published 2017 Jul 3. doi:10.1016/j.eats.2017.03.003
17. Vicenti G, Solarino G, Carrozzo M, et al. Major concern in the multiligament-injured knee treatment: A systematic review. Injury. 2019;50 Suppl 2:S89–S94. doi:10.1016/j.injury.2019.01.052
18. Shelbourne KD, Haro MS, Gray T. Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side. Am J Sports Med. 2007;35(7):1105–1116. doi:10.1177/0363546507299444
19. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 2010;38:804–9, doi:http:// dx.doi.org/10.1177/0363546509352459.
20. Stannard JP. The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med 2005;33:881–8, doi:http://dx.doi.org/ 10.1177/0363546504271208.
21. McCarthy M, Ridley TJ, Bollier M, Cook S, Wolf B, Amendola A. Posterolateral Knee Reconstruction Versus Repair. Iowa Orthop J. 2015;35:20–25.
22. Westermann RW, Marx RG, Spindler KP, et al. No Difference Between Posterolateral Corner Repair and Reconstruction With Concurrent ACL Surgery: Results From a Prospective Multicenter Cohort. Orthop J Sports Med. 2019;7(7):2325967119861062. Published 2019 Jul 30. doi:10.1177/2325967119861062
23. Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30(5):718–727. doi:10.1177/03635465020300051601
24. Mariani PP, Santoriello P, Iannone S, Condello V, Adriani E. Comparison of surgical treatments for knee dislocation. Am J Knee Surg. 1999;12(4):214–221.
25. Tapasvi SR, Shekhar A, Patil SS. Primary Anterior Cruciate Ligament Repair With Augmentation. Arthrosc Tech. 2018;7(2):e139–e145. Published 2018 Jan 22. doi:10.1016/j.eats.2017.08.063
26. Frosch KH, Preiss A, Heider S, et al. Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1502–1509. doi:10.1007/s00167-012-2154-8
27. Martinek V, Steinbacher G, Friederich NF, Müller WE. Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?. Am J Knee Surg. 2000;13(2):74–82.
28. Tapasvi SR, Shekhar A, Patil SS. Primary Anterior Cruciate Ligament Repair With Augmentation. Arthrosc Tech. 2018;7(2):e139–e145. Published 2018 Jan 22. doi:10.1016/j.eats.2017.08.063
29. Owens BD, Neault M, Benson E, Busconi BD. Primary repair of knee dislocations: results in 25 patients (28 knees) at a mean follow-up of four years. J Orthop Trauma. 2007;21(2):92–96. doi:10.1097/BOT.0b013e3180321318
30. Hua X, Tao H, Fang W, Tang J. Single-stage in situ suture repair of multiple-ligament knee injury: a retrospective study of 17 patients (18 knees). BMC Musculoskelet Disord. 2016;17:41. Published 2016 Jan 22. doi:10.1186/s12891-016-0894-1
31. Heitmann M, Akoto R, Krause M, et al. Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2710–2718. doi:10.1007/s00167-018-5317-4
32. Ranger P, Senay A, Gratton GR, Lacelle M, Delisle J. LARS synthetic ligaments for the acute management of 111 acute knee dislocations: effective surgical treatment for most ligaments. Knee Surg Sports Traumatol Arthrosc. 2018;26(12):3673–3681. doi:10.1007/s00167-018-4940-4
33. Kohl S, Stock A, Ahmad SS, et al. Dynamic intraligamentary stabilization and primary repair: a new concept for the treatment of knee dislocation. Injury. 2015;46(4):724–728. doi:10.1016/j.injury.2014.10.012.
(Abstract) (Full Text HTML) (Download PDF)
Complications of Multiple Ligament Knee Injury Surgery : Prevention and Salvage
Dinshaw N. Pardiwala, Kushalappa Subbiah, Nandan Rao, Vicky Jain
Volume 5 | Issue 1 | Jan – April 2020 | Page 58-65
Author: Dinshaw N. Pardiwala [1], Kushalappa Subbiah [1], Nandan Rao [1], Vicky Jain [1]
[1] Department of Orthopaedics, okilaben Dhirubhai Ambani Hospital, Mumbai, India.
Address of Correspondence
Dr. Dinshaw Pardiwala,
Kokilaben Dhirubhai Ambani Hospital
Four Bungalows, Andheri (W), Mumbai 400053, India.
E-mail: pardiwala@outlook.com
Abstract
Multiple ligament injuries of the knee are a complex group of injuries with diverse presentations, varying treatment options, and the potential for an array of significant complications. These include iatrogenic neurovascular injuries, fluid extravasation with compartment syndrome, intraoperative technical complications related to tunnel placement and graft tensioning, tourniquet complications, wound problems and infection, venous thromboembolic events, arthrofibrosis with loss of motion, residual knee instability, heterotopic ossification, and missed postoperative knee dislocations. Prevention of these complications is based on a comprehensive knowledge of knee ligament anatomy and biomechanics, understanding the unique and complex nature of these uncommon injuries, detailed preoperative clinico-radiological evaluation, astute surgical planning, careful operative execution, close postoperative monitoring, and a proper rehabilitation program. Early recognition of complications with appropriate and immediate management is critical for satisfactory functional outcomes.
Keywords: Multiple ligament knee injury, Knee dislocation, Complications, Prevention, Salvage, Surgical reconstruction
References
1. Pardiwala DN, Soni S, Raut A. Knee dislocations : classification and treatment algorithm. In: Marghereritini F et al, editors. Complex knee ligament injuries. Springer; 2019. p 3-18.
2. Natividad TT, Wascher CD. Complications associated with the treatment of the multiple ligament injured knee. In: Fanelli GC, editor. The multiple ligament injured knee: a practical guide to management. New York: Springer; 2013. p. 443–50.
3. McDonough EB Jr, Wojtys EM. Multi-ligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156–9.
4. Kaufman SL, Martin LG. Arterial injuries associated with complete dislocation of the knee. Radiology 1992;184:153–5.
5. Pardiwala DN, Rao NN, Anand K, Raut A. Knee dislocations in sports injuries. Indian J Orthop. 2017;51(5):552-562.
6. Matava MJ, Sethi NS, Totty WG. Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796–804.
7. Tay AK, MacDonald PB. Complications associated with treatment of multiple ligament injured (dislocated) knee. Sports Med Arthrosc 2011;19(2):153–61.
8. Woodmass JM, Romatowski NPJ, Esposito JG, Mohtadi NGH, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2992–3002.
9. Krych AJ, Giuseffi SA, Kuzma SA, Stuart MJ, Levy BA. Is peroneal nerve injury associated with worse function after knee dislocation? Clin Orthop. 2014 Sep;472(9):2630–6.
10. Luo H, Yu JK, Ao YF, et al. Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction. Chin Med J (Engl) 2007;120:1127–30.
11. Poehling GG, Pollock FE Jr, Korman LA Reflex sympathetic dystrophy of the knee after sensory nerve injury. Arthroscopy 4:31-35, 1988.
12. Figueroa D, Calvo R, Vaisman A, et al. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study. Knee 2008;15:360–3.
13. Zazanis GA, Kummell BM: Preservation of infrapatellar branch of saphenous nerve J Surg 140:186, 1980 9:135-140, 1995.
14. Bomberg BC, Hurley PE, Clark CA, et al. Complications associated with the use of an infusion pump during knee arthroscopy. Arthroscopy 1992;8:224–8
15. Ekman EF, Poehling GG. An experimental assessment of the risk of compartment syndrome during knee arthroscopy. Arthroscopy 1996;12:193–9
16. Amendola A, Faber K, Willits K, et al. Compartment pressure monitoring during anterior cruciate ligament reconstruction. Arthroscopy 1999;15:607–12.
17. Konan S, Haddad FS. Femoral fracture following knee ligament reconstruction surgery due to an unpredictable complication of bioabsorbable screw fixation: a case report and review of literature. J Orthop Traumatol 2010;11:51–5.
18. Athanasian EA, Wickiewicz TL, Warren RF. Osteonecrosis of the femoral medial condyle after arthroscopic reconstruction of a cruciate ligament: Report of two cases. J Bone Joint Surg. 1995; 77A:1418-1422.
19. Moatshe G, Brady AW, Slette EL, et al. Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med 2017;45(3):563–9.
20. Moatshe G, Slette EL, Engebretsen L, et al. Intertunnel relationships in the tibia during reconstruction of multiple knee ligaments: how to avoid tunnel convergence. Am J Sports Med 2016;44(11):2864–9.
21. Hegyes MS, Richardson MW, Miller MD. Knee dislocation: Complications of operative and non operative management. Clin Sports Med. 2000;19:519-543.
22. Moore MR, Garfin SR, Hargens AR Wide tourniquets eliminate blood flow at low infiltration pressures. J Hand Surg 12:1006-1011, 1987.
23. Almekinders LC, Logan TC: Results following treatment of traumatic knee dislocations of the knee joint. Orthop Clin North Am 284:203-207, 1992.
24. Graf B, Uhr F: Complications of intra-articular anterior cruciate reconstruction. Clin Sports Med 7935-842, 1988.
25. Hughston J: Complications of anterior cruciate ligament surgery. Orthop Clin North Am 16:237-245, 1985.
26. Engebretsen L, Risberg MA, Robertson B, et al. Outcome after knee dislocations: a 2-9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc 2009;17:1013–26.
27. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86: 910–915.
28. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am 2004;86-A:262–73.
29. Harner CD, Irrgang JJ, Paul J, et al. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med 1992;20:499–506.
30. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292–9.
31. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991;19:332–6.
32. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of motion following anterior cruciate ligament reconstruction. A case-control study. Am J Sports Med 1991; 19:620–5.
33. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy 1996;12: 521–30.
34. Fu FH, Irrgang JJ, Sawhney R, et al: Loss of knee motion following anterior cruciate ligament reconstruction. Am J Sports Med 18:557-562, 1990.
35. Shapiro MS, Freedman EL Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation. Am J Sports Med 23:580-587, 1995
36. Thomas P, Rud B, Jensen U: Stability and motion after traumatic dislocation of the knee. Acta Orthop Scand 55:278-283, 1984
37. Stannard JP, Wilson TC, Sheils TM, et al. Heterotopic ossification associated with knee dislocation. Arthroscopy 2002;18:835–9.
38. Patton WC, Tew WM. Periarticular heterotopic ossification after multiple knee ligament reconstructions. A report of three cases. Am J Sports Med 2000;28(3): 398–401.
39. Whelan DB, Dold AP, Trajkovski T, Chahal J. Risk factors for the development of heterotopic ossification after knee dislocation. Clin Orthop Relat Res. 2014 Sep;472(9):2698-704.
40. Simonian PT, Wickiewicz TL, Hotchkiss RN, et al. Chronic knee dislocation: reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med. 1998;26:591–596.
(Abstract) (Full Text HTML) (Download PDF)
PCL Reconstruction in Multi-ligament Injured Knees: state of the art
Anna Kropelnicki, Brett A Fritsch
Volume 5 | Issue 1 | Jan – April 2020 | Page 20-26
Author: Anna Kropelnicki [1], Brett A Fritsch [1]
[1] Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Ave., Chatswood, NSW 2067, Australia.
Address of Correspondence
Dr. Anna Kropelnicki
SORI, Level 1, The Gallery, 445 Victoria Ave, Chatswood, NSW 2067, Australia
Email: anna@krop.co.uk
Abstract
Significant injury to the posterior cruciate ligament (PCL) is an uncommon injury in isolation, but frequently occurs in the context of the multi-ligament injury of the knee. A multi-ligament knee injury (MLKI) is commonly defined as rupture of at least two of the four major ligament complexes with resultant coronal and sagittal plane instability [1], [2]. This review discusses the optimal approach to treating the PCL in the context of these injuries. While there is an overall paucity of high-quality evidence, recommendations can be made regarding the necessity for surgical intervention, and that best results appear to be a result of early (less than six weeks) surgery performed as a single reconstruction of all structures in an anatomical manner, including the PCL. In terms of the PCL, a double-bundle anatomic reconstruction is biomechanically preferential, but of little proven clinical benefit and may not always be possible. There is insufficient evidence in the MKLI to discern outcomes between autograft and allograft. The use of synthetic grafts is controversial, and should be avoided until longer-term data is available. Novel strategies such as internal bracing show some promise, but similarly lack clinical data at this stage. Overall, good outcomes can be obtained following this complex and potentially devastating injury, but further research and co-operation across treatment centres is needed to gain sufficient power to draw solid conclusions about the best way to treat the ruptured PCL in the MLKI.
References
1. N. R. Howells, L. R. Brunton, J. Robinson, A. J. Porteus, J. D. Eldridge, and J. R. Murray, “Acute knee dislocation: An evidence based approach to the management of the multiligament injured knee,” Injury, vol. 42, no. 11, pp. 1198–1204, 2011, doi: 10.1016/j.injury.2010.11.018.
2. A. A. Ali and M. B. Abdelwahab, “Short-term outcome of multi-ligament knee injury among sudanese patients,” Open Access Maced. J. Med. Sci., vol. 7, no. 9, pp. 1486–1493, 2019, doi: 10.3889/oamjms.2019.282.
3. P. R. T. Kuzyk and E. H. Schemitsch, “Should you save or Substitute the Posterior Cruciate Ligament in Total Knee Replacement?,” Evidence-Based Orthop. Best Answers to Clin. Quest., pp. 592–597, 2009, doi: 10.1016/B978-141604444-4.50091-6.
4. J. E. Voos, C. S. Mauro, T. Wente, R. F. Warren, and T. L. Wickiewicz, “Posterior cruciate ligament: Anatomy, biomechanics, and outcomes,” Am. J. Sports Med., vol. 40, no. 1, pp. 222–231, 2012, doi: 10.1177/0363546511416316.
5. G. C. Fanelli, C. J. Edson, K. N. Reinheimer, and R. Garofalo, The multiple ligament injured knee, vol. 58, no. 1. 2007.
6. P. S. et al., “Posterior cruciate ligament: Current concepts review,” Arch. Bone Jt. Surg., vol. 6, no. 1, pp. 8–18, 2018.
7. M. S. Shapiro and E. L. Freedman, “Allograft Reconstruction of the Anterior and Posterior Cruciate Ligaments After Traumatic Knee Dislocation,” Am. J. Sports Med., vol. 23, no. 5, pp. 580–587, 1995, doi: 10.1177/036354659502300511.
8. M. J. Strauss et al., “The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 27, no. 6, pp. 1791–1809, 2019, doi: 10.1007/s00167-019-05426-1.
9. B. A. Levy et al., “Controversies in the treatment of knee dislocations and multiligament reconstruction,” J. Am. Acad. Orthop. Surg., vol. 17, no. 4, pp. 197–206, 2009, doi: 10.5435/00124635-200904000-00001.
10. R. F. LaPrade et al., “Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients,” Am. J. Sports Med., vol. 47, no. 11, pp. 2563–2571, 2019, doi: 10.1177/0363546519864539.
11. M. Richter, U. Bosch, B. Wippermann, A. Hofmann, and C. Krettek, “Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations,” Am. J. Sports Med., vol. 30, no. 5, pp. 718–727, 2002, doi: 10.1177/03635465020300051601.
12. N. A. Trasolini, A. Lindsay, A. Gipsman, and G. F. Rick Hatch, “The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment,” Clin. Sports Med., vol. 38, no. 2, pp. 215–234, 2019, doi: 10.1016/j.csm.2018.11.009.
13. M. G. Hubert and J. P. Stannard, “Surgical treatment of acute and chronic anterior and posterior cruciate ligament and medial-side injuries of the knee,” Sports Med. Arthrosc., vol. 19, no. 2file://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedir, pp. 104–109, 2011, doi: 10.1097/JSA.0b013e3182191874.
14. G. Moatshe, G. J. Dornan, S. Løken, T. C. Ludvigsen, R. F. Laprade, and L. Engebretsen, “Demographics and injuries associated with knee dislocation: A prospective review of 303 patients,” Orthop. J. Sport. Med., vol. 5, no. 5, pp. 1–5, 2017, doi: 10.1177/2325967117706521.
15. B. Freychet et al., “All-inside Posterior Cruciate Ligament Reconstruction: Surgical Technique and Outcome,” Clin. Sports Med., vol. 38, no. 2, pp. 285–295, 2019, doi: 10.1016/j.csm.2018.11.005.
16. N. Marom, J. J. Ruzbarsky, C. Boyle, and R. G. Marx, “Complications in Posterior Cruciate Ligament Injuries and Related Surgery,” Sports Med. Arthrosc., vol. 28, no. 1, pp. 30–33, 2020, doi: 10.1097/JSA.0000000000000247.
17. J. E. Tibone, T. J. Antich, J. Perry, and D. Moynes, “Functional analysis of untreated and reconstructed posterior cruciate ligament injuries,” Am. J. Sports Med., vol. 16, no. 3, pp. 217–223, 1988, doi: 10.1177/036354658801600303.
18. A. Bedi, V. Musahl, and J. B. Cowan, “Management of Posterior Cruciate Ligament Injuries,” J. Am. Acad. Orthop. Surg., vol. 24, no. 5, pp. 277–289, 2016, doi: 10.5435/jaaos-d-14-00326.
19. C. J. Tucker, E. J. Cotter, B. R. Waterman, K. G. Kilcoyne, K. L. Cameron, and B. D. Owens, “Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population,” Orthop. J. Sport. Med., vol. 7, no. 10, pp. 1–7, 2019, doi: 10.1177/2325967119875139.
20. M. J. Skyhar, R. F. Warren, G. J. Ortiz, E. Schwartz, and J. C. Otis, “The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee,” J. Bone Jt. Surg. – Ser. A, vol. 75, no. 5, pp. 694–699, 1993, doi: 10.2106/00004623-199305000-00008.
21. R. B. Kohen and J. K. Sekiya, “Single-Bundle Versus Double-Bundle Posterior Cruciate Ligament Reconstruction,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 12, pp. 1470–1477, 2009, doi: 10.1016/j.arthro.2008.11.006.
22. C. J. Peskun and D. B. Whelan, “Outcomes of operative and nonoperative treatment of multiligament knee injuries: An evidence-based review,” Sports Med. Arthrosc., vol. 19, no. 2, pp. 167–173, 2011, doi: 10.1097/JSA.0b013e3182107d5f.
23. B. A. Levy et al., “Decision Making in the Multiligament-Injured Knee: An Evidence-Based Systematic Review,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 4, pp. 430–438, 2009, doi: 10.1016/j.arthro.2009.01.008.
24. C. D. Harner, M. A. Janaushek, A. Kanamori, M. Yagi, T. M. Vogrin, and S. L. Y. Woo, “Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction,” Am. J. Sports Med., vol. 28, no. 2, pp. 144–151, 2000, doi: 10.1177/03635465000280020201.
25. G. S. DiFelice, M. Lissy, and P. Haynes, “When to arthroscopically repair the torn posterior cruciate ligament,” Clin. Orthop. Relat. Res., vol. 470, no. 3, pp. 861–868, 2012, doi: 10.1007/s11999-011-2034-4.
26. G. Moatshe, J. Chahla, R. F. LaPrade, and L. Engebretsen, “Diagnosis and treatment of multiligament knee injury: state of the art,” J. ISAKOS Jt. Disord. Orthop. Sport. Med., vol. 2, no. 3, pp. 152–161, 2017, doi: 10.1136/jisakos-2016-000072.
27. G. C. Fanelli and C. J. Edson, “Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-Year follow-up,” Arthroscopy, vol. 18, no. 7, pp. 703–714, 2002, doi: 10.1053/jars.2002.35142.
28. A. J. Krych, P. L. Sousa, A. H. King, W. M. Engasser, M. J. Stuart, and B. A. Levy, “Meniscal tears and articular cartilage damage in the dislocated knee,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3019–3025, 2015, doi: 10.1007/s00167-015-3540-9.
29. K. D. Plancher and J. Siliski, “Long-term functional results and complications in patients with knee dislocations.,” J. Knee Surg., vol. 21, no. 4, pp. 261–268, 2008, doi: 10.1055/s-0030-1247829.
30. P. P. Mariani, P. Santoriello, S. Iannone, V. Condello, and E. Adriani, “Comparison of surgical treatments for knee dislocation.,” Am. J. Knee Surg., 1999.
31. D. R. Whiddon, C. T. Zehms, M. D. Miller, J. S. Quinby, S. L. Montgomery, and J. K. Sekiya, “Double compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model,” J. Bone Jt. Surg. – Ser. A, vol. 90, no. 9, pp. 1820–1829, 2008, doi: 10.2106/JBJS.G.01366.
32. K. L. Markolf, S. Park, S. R. Jackson, and D. R. Mcallister, “Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions,” J. Bone Jt. Surg. – Ser. A, vol. 91, no. 1, pp. 107–118, 2009, doi: 10.2106/JBJS.G.01215.
33. P. E. Gelber et al., “Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 31, no. 9, pp. 1764–1771, 2015, doi: 10.1016/j.arthro.2015.03.007.
34. M. Group, “Predictors of clinical outcome following revision anterior cruciate ligament reconstruction,” J. Orthop. Res., no. May 2019, 2020, doi: 10.1002/jor.24562.
35. S. An et al., “Autologous BPTB ACL Reconstruction Results in Lower Failure Rates Than ACL Repair with and without Synthetic Augmentation at 30 Years of Follow-up,” pp. 2074–2081, 2019.
36. C. C. Kaeding et al., “Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction : Predictors of Failure From a MOON Prospective Longitudinal Cohort,” vol. 3, no. 1, pp. 73–81, 2011, doi: 10.1177/1941738110386185.
37. M. B. Mestriner, R. de P. L. Cury, A. dos Santos Netto, V. M. de Oliveira, O. P. A. de Camargo, and J. C. Belloti, “Double-bundle posterior cruciate ligament reconstruction: No differences between two types of autografts in isolated or combined lesions,” Knee, vol. 27, no. 1, pp. 140–150, 2019, doi: 10.1016/j.knee.2019.09.015.
38. J. W. Belk, M. J. Kraeutler, J. M. Purcell, and E. C. McCarty, “Autograft Versus Allograft for Posterior Cruciate Ligament Reconstruction: An Updated Systematic Review and Meta-analysis,” Am. J. Sports Med., vol. 46, no. 7, pp. 1752–1757, 2018, doi: 10.1177/0363546517713164.
39. D. C. Wascher, J. R. Becker, J. G. Dexter, and F. T. Blevins, “Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts,” Am. J. Sports Med., vol. 27, no. 2, pp. 189–196, 1999, doi: 10.1177/03635465990270021301.
40. S. U. Scheffler, T. Schmidt, I. Gangéy, M. Dustmann, F. Unterhauser, and A. Weiler, “Fresh-Frozen Free-Tendon Allografts Versus Autografts in Anterior Cruciate Ligament Reconstruction: Delayed Remodeling and Inferior Mechanical Function During Long-term Healing in Sheep,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 24, no. 4, pp. 448–458, 2008, doi: 10.1016/j.arthro.2007.10.011.
41. A. Ventura, C. Terzaghi, C. Legnani, E. Borgo, and W. Albisetti, “Synthetic grafts for anterior cruciate ligament rupture: 19-year outcome study,” Knee, vol. 17, no. 2, pp. 108–113, 2010, doi: 10.1016/j.knee.2009.07.013.
42. L. Y. Chiang et al., “Posterior cruciate ligament reconstruction implemented by the Ligament Advanced Reinforcement System over a minimum follow-up of 10 years,” Knee, vol. 27, no. 1, pp. 165–172, 2019, doi: 10.1016/j.knee.2019.11.004.
43. C. F. van Eck, O. Limpisvasti, and N. S. ElAttrache, “Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review,” Am. J. Sports Med., vol. 46, no. 9, pp. 2291–2298, 2018, doi: 10.1177/0363546517717956.
44. G. C. Fanelli, “Posterior cruciate ligament rehabilitation: how slow should we go?,” Arthroscopy, vol. 24, no. 2, pp. 234–235, 2008, doi: 10.1016/j.arthro.2007.09.009.
45. H. M. and B. L. Li B, Shen P, Wang JS, Wang G, “Therapeutic effects of tibial support braces on posterior cruciate ligament reconstruction with autogenous hamstring tendon graft.,” Eur. J. Phys. Rehab Med., vol. 51, no. 2, pp. 163–70, 2014.
46. R. F. LaPrade, S. D. Smith, K. J. Wilson, and C. A. Wijdicks, “Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3070–3076, 2015, doi: 10.1007/s00167-014-3238-4.
47. F. R. Noyes and S. D. Barber-Westin, “Posterior cruciate ligament revision reconstruction, part 1: Causes of surgical failure in 52 consecutive operations,” Am. J. Sports Med., vol. 33, no. 5, pp. 646–654, 2005, doi: 10.1177/0363546504271210.
48. D. E. Cooper and D. Stewart, “Posterior Cruciate Ligament Reconstruction Using Single-Bundle Patella Tendon Graft with Tibial Inlay Fixation: 2- to 10-Year Follow-up,” Am. J. Sports Med., vol. 32, no. 2, pp. 346–360, 2004, doi: 10.1177/0363546503261511.
(Abstract) (Full Text HTML) (Download PDF)
Management of the Medial Collateral Ligament in the Combined Ligament Injured Knee
Kyle Borque, Mary Jones, Andy Williams
Volume 5 | Issue 1 | Jan – April 2020 | Page 36-42
Author: Kyle Borque [1], Mary Jones [2], Andy Williams [2]
[1] Houston Methodist Hospital, Houston, TX, USA
[2] Fortius Clinic, London, UK
Address of Correspondence
Dr. Kyle Borque,
Houston Methodist Hospital, Houston, TX, USA.
E-mail: kaborque@gmail.com
Abstract
While isolated medial collateral ligament (MCL) injuries can frequently be treated non-operatively, in the setting of a multiple ligament injured knee, operative intervention is frequently required. The MCL’s biomechanical roles (primary restraint to valgus, secondary restraint to internal and external tibial rotation) must be taken into account when addressing the injured MCL. The authors prefer a combination of repair and reconstruction, with the goal of preserving proprioceptive feedback while also restoring mechanical support. The ideal surgical technique depends on the acuity and location of the injury. The goal of this paper is to provide a framework for approaching both operative and nonoperative treatment of MCL injuries in the setting of multiple ligament knee injuries.
Keywords: Medial collateral ligament (MCL), Knee dislocation, Multiple ligament knee injury, MCL repair, MCL reconstruction.
References
1. Alaia E, Rosenberg Z, Alaia M. Stener-Like Lesions of the Superficial Medial Collateral Ligament of the Knee: MRI Features. Am J Roentgenol. 2019;213(6):W272-W276.
2. Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate ligament: A long-term follow-up study. Am J Sports Med. 1992;20(1):7-12. doi:10.1177/036354659202000103.
3. Azar F. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sport Med Arthrosc Rev. 2006;2:84-90.
4. Bagwell MS, Wilk KE, Colberg RE, Dugas JR. the Use of Serial Platelet Rich Plasma Injections With Early Rehabilitation To Expedite Grade Iii Medial Collateral Ligament Injury in a Professional Athlete: a Case Report. Int J Sports Phys Ther. 2018;13(3):520-525. doi:10.26603/ijspt20180520.
5. Battaglia MJ, Lenhoff MW, Ehteshami JR, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: A biomechanical evaluation in a cadaveric model. Am J Sports Med. 2009;37(2):305-311. doi:10.1177/0363546508324969.
6. Coltart W. Pellegrini-Stieda lesion. Proc R Soc Med. 1938;31(03):180-181.
7. Eirale C, Mauri E, Hamilton B. Use of platelet rich plasma in an isolated complete medial collateral ligament lesion in a professional football (soccer) player: A case report. Asian J Sports Med. 2013;4(2):158-162. doi:10.5812/asjsm.34517.
8. Engebretsen L, Lind M. Anteromedial rotatory laxity. Knee Surg Sport Traumatol Arthrosc. 2015;23(10):2797-2804.
9. Fanelli GC, Edson C. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy. 2002;18(7):703-714.
10. Fetto J, Marshall J. Medial collateral ligament injuries of the knee: a rationale for treatment. Clin Orthop Relat Res. 1978;132:206-218.
11. Geeslin A, LaPrade RF. Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: a prospective case series and surgical technique. J Bone Jt Surg Am. 2011;93(18):1672-1683.
12. Harner C, Buoncristiani A, Tjoumakaris F. Master Techniques in Orthopaedic Surgery: Reconstructive Knee Surgery. Third ed. Lippincott, Williams & Wilkins Inc; 2008.
13. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20(5):499-506. doi:10.1177/036354659202000503.
14. Holden DL, Eggert AW, Butler JE. The nonoperative treatment of Grade I and 11 medial collateral ligament injuries to the knee. Am J Sports Med. 1983;11(5):340-344. doi:10.1177/036354658301100511.
15. Hughston J. The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up. J Bone Jt Surg Am. 1994;76(9):1328-1344.
16. Kennedy J, Fowler P. Medial and anterior instability of the knee. An anatomical and clinical study using stress machines. J Bone Jt Surg Am. 1971;53(7):1257-1270.
17. LaPrade RF, Bernhardson AS, Griffith CJ, MacAlena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial knee ligament injuries: An in vitro biomechanical study. Am J Sports Med. 2010;38(2):330-338. doi:10.1177/0363546509349347.
18. LaPrade RF, Engebresten A, Ly T, Johansen S, Wentorf F, Engebretsen L. The anatomy of the medial part of the knee. J Bone Jt Surg Am. 2007;89(9):2000-2010.
19. LaPrade RF, Terry GC. Injuries to the Posterolateral Aspect of the Knee. Am J Sports Med. 1997;25(4):433-438. doi:10.1177/036354659702500403.
20. Laprade RF, Wijdicks CA. Development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012;470(3):806-814. doi:10.1007/s11999-011-2061-1.
21. Levy BA, Fanelli GC, Whelan DB, et al. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17(4):197-206. doi:10.5435/00124635-200904000-00001.
22. Lian J, Patel N, Nickoli M, et al. Obesity Is Associated with Significant Morbidity after Multiligament Knee Surgery. J Knee Surg. 2019;10:1055/s-0039-1681027.
23. Lundberg M, Messner K. Long-term prognosis of isolated partial medial collateral ligament ruptures: A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. Am J Sports Med. 1996;24(2):160-163. doi:10.1177/036354659602400207.
24. Mancini EJ, Kohen R, Esquivel AO, Cracchiolo AM, Lemos SE. Comparison of ACL Strain in the MCL-Deficient and MCL-Reconstructed Knee during Simulated Landing in a Cadaveric Model. Am J Sports Med. 2017;45(5):1090-1094. doi:10.1177/0363546516685312.
25. Maor D, Jones M, Lee J, Dunn A, Williams A, Calder J. Prolotherapy as a treatment choice for lateral ankle ligament injuries in elite athletes: A case series. Act Orthop Belgica. 2020;Accepted f.
26. Marchant MH, Tibor LM, Sekiya JK, Hardaker WT, Garrett WE, Taylor DC. Management of medial-sided knee injuries, part 1: Medial collateral ligament. Am J Sports Med. 2011;39(5):1102-1113. doi:10.1177/0363546510385999.
27. Reider B, Sathy MR, Talkington J, Blyznak N, Kollias S. Treatment of Isolated Medial Collateral Ligament Injuries in Athletes with Early Functional Rehabilitation: A Five-year Follow-up Study. Am J Sports Med. 1994;22(4):470-477. doi:10.1177/036354659402200406.
28. Robinson JR, Sanchez-Ballester J, Bull AMJ, Thomas R de WM, Amis AA. The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Jt Surg – Ser B. 2004;86(5):674-681. doi:10.1302/0301-620X.86B5.14853.
29. Shirakura K, Terauchi M, Katayama M, Watanabe H, Yamaji T, Takagishi K. The management of medial ligament team in patients with combined anterior cruciate and medial ligament lesions. Int Orthop. 2000;24(2):108-111. doi:10.1007/s002640000119.
30. Standard Nomenclature of Athletic Injuries. In: American Medical Association, Subcomittee on Classifcation of Sports Injuries. ; 1966.
31. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surgery, Sport Traumatol Arthrosc. 2019;27(8):2450-2459. doi:10.1007/s00167-018-5237-3.
32. Yoshioka T, Kanamori A, Washio T, et al. The effects of plasma rich in growth factors (PRGF-Endoret) on healing of medial collateral ligament of the knee. Knee Surgery, Sport Traumatol Arthrosc. 2013;21:1763-1769.
33. Zhu J, Dong J, Marshall B, Linde M, Smolinski P, Fu F. Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surg Sport Traumatol Arthrosc. 2018;26:550-557.
(Abstract) (Full Text HTML) (Download PDF)
OrthoBiologics: The New Frontier in Knee Osteoarthrosis
Sachin Tapasvi, Anshu Shekhar
Volume 4 | Issue 3 | Sep – Dec 2019 | Page 1-2
Author: Sachin Tapasvi [1], Anshu Shekhar [1]
[1] Orthopaedic Speciality Clinic, Pune Mahatrahtra.
Address of Correspondence
Dr Sachin Tapasvi
AJA Editorial Office, A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [w], Maharashtra, India.
Email: asian.arthroscopy@gmail.com
OrthoBiologics: The New Frontier in Knee Osteoarthrosis
The body has an enormous potential to heal by itself. This potential needs to be explored and exploited, rather than bridled in jargon and mundane complexities of traditional science. It is perhaps this realization that has led to remarkable strides in the magic of “orthobiologics” in the last decade. Orthobiologics are biologically derived materials that intend to induce healing and regeneration of tissues[1]. These have in fact, emerged as a sub-speciality of therapeutic interventional modalities to cure or control an entire gamut of orthopaedic problems, ranging from traumatic to degenerative in etiology. This special edition of the Asian Journal of Arthroscopy visits the biological options available to manage osteoarthrosis of the knee and the currently employed non-surgical tools in nine review articles.
In their review of orthobiologics for treatment for knee osteoarthrosis, Crane et al noted that the bewildering array of treatments and combinations available could actually be a deterrent to patients and providers. Thought the safety of all these methods is not doubted at present, they stressed the need to develop algorithms for the appropriate use of orthobiologics[2]. Even for applications in sports medicine, this therapeutic modalities has shown promising results and the future developments looks exciting[3]. Although intra-articular hyaluronic acid (IAHA) supplementation can be considered an orthobiologic, skeptics would disagree as it does not wield any disease modifying effects in knee OA. Nonetheless, due to proven safety and efficacy record, it is imperative that any newer therapy would first be compared with IAHA[4]. The first orthobiologic to be used in clinical applications is platelet rich plasma (PRP) and it has evolved into its several forms today. Both leucocyte-rich and leucocyte-poor PRP has been safe and effective in early knee OA and has been shown to be superior to intra-articular hyaluronic acid injections in a meta-analysis [4]. Combination therapy of intra-articular PRP with hyaluronic acid and intra-osseous injections of PRP are the emerging trends but need further investigation[5][6].
Besides PRP, the “newer” methods like autologous conditioned serum, bone marrow aspirate concentrate and adipose derived stromal cell therapy have seen significant real world application and are discussed in detail in this issue. Bone marrow aspirate concentrate (BMAC) has been around for a while and has generally been found to be a safe procedure which relieves pain in selected cases[7]. However, the mechanism of pain relief remains to be proven and even its superiority over placebo normal saline injections could not be demonstrated in a randomized controlled trial at 12 months[8]. The largest study to date assessing adipose derived stromal vascular therapy in knee OA showed improvements in patient reported outcomes as well as chondral thickening on MRI scans [9]. The new development in this arena is the use of microfragmented adipose tissue, where the stem cells are not subjected to manipulation or expansion. This has shown encouraging early results and can potentially be used for all stages of knee OA [10]. Interleukin 1 receptor antagonists like autologous conditioned serum and autologous protein solution have also shown positive results in preliminary studies but the experience is limited. The use of Alpha 2 macroglobulin; Stem cell based approaches like embryonic stem cells and induced pluripotent stem cells and Gene therapy have been investigated in animal models and are likely to provide disease-modifying options in the future [11-13].
The frontier is wide open and the possibilities are immense. The most important lacuna to be covered is providing good quality data. This will make universal opinions become more aligned and strengthen the science behind orthobiologics, making it more widely acceptable and applicable. These therapies are easily available, inexpensive and present a tangible non-arthroplasty option although long-term effectiveness needs to be proven [14]. The ultimate benefactor shall be the patient as we all still search for the holy grail of managing osteoarthrosis of the knee.
(Abstract) (Full Text HTML) (Download PDF)
Symptomatic proximal deep venous thrombosis extending to the inferior vena cava after arthroscopic meniscectomy: A case report
Masaki Nagashima, Toshiro Otani, Kota Kojima, Yukio Obitsu , Yasunori Suda, Ken Ishii
Volume 4 | Issue 2 | May – Aug 2019 |
Author: Masaki Nagashima [1,2], Toshiro Otani [3], Kota Kojima [1], Yukio Obitsu [4], Yasunori Suda [2], Ken Ishii [1,2]
[1] Department of Orthopaedic Surgery, International University of Health and Welfare, Mita Hospital, Tokyo, Japan.
[2] Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan.
[3] Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan.
[4] Department of Vascular Surgery, International University of Health and Welfare, Mita Hospital, Tokyo, Japan.
Address of Correspondence
Dr. Masaki Nagashima,
Department of Orthopaedic Surgery, International University of Health and Welfare, Mita Hospital, 1-4-3, Mita, Minato-ku, Tokyo, 108-8329, Japan.
E-mail: masakin@iuhw.ac.jp
Abstract
Introduction: Symptomatic deep venous thrombosis (DVT) is a relatively rare complication following arthroscopic meniscectomy, however, it has the potential to develop into pulmonary embolism that can be life-threatening. Although DVT has been reported to develop on the affected side, iliac vein compression is a known cause of left-sided DVT, particularly in female patients.
Case Presentation: A 54-year old woman complaining of painful locking of her left knee underwent arthroscopic meniscectomy at our hospital. She had no obvious risk factors for DVT other than the age. Thirteen days after the surgery, she complained of left leg swelling and pain. Contrast enhanced computed tomography revealed a DVT that had extended to the inferior vena cava with iliac vein compression.
Conclusion: The iliac vein compression was a possible cause of the DVT. We believe all patients undergoing left knee arthroscopic surgery should have a careful observation for DVT and be considered for pharmacological DVT prophylaxis.
Keywords: Deep venous thrombosis, Iliac vein compression, Arthroscopic meniscectomy
(Abstract) (Full Text HTML) (Download PDF)