Functional outcomes following Multiligament Knee Reconstrcution

Nagraj Shetty

Volume 5 | Issue 1 | Jan – April 2020 | Page 53-57

Author: Nagraj Shetty [1,2,3]

[1] Department of Orthopaedics, Lilavati Hospital, Mumbai, India.
[2] Department of Orthopaedics, Hinduja Healthcare, Mumbai, India.
[3] Department of Orthopaedics, Nanavati Hospital, Mumbai, India.

Address of Correspondence
Dr. Nagraj Shetty
Consultant Arthroscopy Knee & Shoulder Surgeon
Lilavati hospital, Nanavati hospital, Hinduja Healthcare; Mumbai, India.
E-mail: orthodocshetty@gmail.com

Abstract

Purpose: The purpose of this descriptive review was to study the available literature on final functional outcomes of multiligament knee injury (MLKI) reconstructions. Specific study factors included 1) Surgical vs nonoperative treatment 2) Repair vs reconstruction vs combined procedure 3) early vs late surgery; Single stage vs two stage procedures.
Methods: A PubMed search was performed from 1966 until 2020. and search terminologies included multiligament Knee injury, multiple ligament knee injury, knee dislocation, multiligament knee reconstruction and functional outcomes. Study inclusion criteria were 1) Levels I to IV evidence 2) Multiligament knee injury being defined as disruption of minimum 2 of the 4 major knee ligaments. 3) Assesment of final outcome both based on subjective clinical, functional scores like return to sports, preinjury activity level and stability scores. 4) minimum of 12 month follow up.
Results: Four high level studies compared surgical with nonoperative treatment. There were higher Lysholm scores (85 vs 67) in surgically treated patients (pts) as well as higher IKDC scores (69% vs 64%) and return to sport (41% vs 18%).The four studies comparing repair with reconstruction of damaged ligaments showed similar mean Lysholm (84 vs 84) and excellent IKDC scores. Nevertheless repair of the posterolateral corner (PLC) had a higher failure rate (39% vs 8 %) and lower return to sport activities (25% vs 51%). Similarly repair of the cruciates achieved decreased stability and range of motion. Eight articles were studied comparing early (within 3 weeks ) with delayed surgery. Early treatment resulted in higher mean Lysholm scores (89 vs v82), higher percentage of excellent IKDC scores (57% vs 41%)as well as higher mean ROM (129 degree vs 124 degrees)
Conclusions: This review suggests that the best treatment guidelines for MLKI is still awaited, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. Surgery must be performed within first 3 weeks upto 6 weeks for better results.When feasible ACL reconstruction can be delayed thereby reducing rate of arthrofibrosis
Keywords: descriptive review, functional outcomes, multiligament knee injury, multiple ligament knee injury, knee reconstruction.

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How to Cite this article: Shetty N | Functional outcomes following Multiligament Knee Reconstruction | Asian Journal Arthroscopy | January-April 2020; 5(1): 53-57.

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Posterolateral Corner Reconstruction in the Multiligament Injured Knee: State of the Art

Yuen Wen Loong Paul, Lee Yee Han Dave

Volume 5 | Issue 1 | Jan – April 2020 | Page 27-35

Author: Yuen Wen Loong Paul [1], Lee Yee Han Dave [1]

[1] Department of Orthopaedics, Changi General Hospital,2 Simei Street 3, Singapore 5298892

Address of Correspondence

Dr. Lee Yee Han Dave,
Department of Orthopaedics, Changi General Hospital,2 Simei Street 3, Singapore 5298892
E-mail: dave.lee.y.h@singhealth.com.sg

Abstract

Posterolateral corner injuries were labelled as the “dark side” of the knee due to the paucity of knowledge on the subject. This has been increasingly studied and we now have a better understanding of this injury. Posterolateral corner(PLC) injuries are a significant cause of knee instability and cruciate reconstruction failures. This paper aims to review the literature over the last 10 years; on PLC epidemiology, anatomy, biomechanics, clinical and radiographic assessment, management and outcomes.
Keywords: Posterolateral corner, Knee Repair, Reconstruction.

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78. Moulton SG, Matheny LM, James EW, LaPrade RF. Outcomes following anatomic fibular (lateral) collateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2960-6.
79. Gormeli G, Gormeli CA, Elmah N, Karakaplan M, Ertem K, Ersoy Y. Outcome of the treatment of chronic isolated and combined posterolateral corner knee injuries with 2-6 year follow-up. Arch Orthop Trauma Surg. 2015, 135, pages1363–1368.
80. Franciozi CE, Albertoni LJB, Kubota MS, Abdalla RJ, Luzo MVM, Cohen M, LaPrade RF. A Hamstring-Based Anatomic Posterolateral Knee Reconstruction With Autografts Improves Both Radiographic Instability and Functional Outcomes. Arthroscopy. 2019 Jun;35(6):1676-1685.e3.
81. Yoon KH, Lee SHo, Park SY, Park SE, Tak DH. Comparison of Anatomic Posterolateral Knee Reconstruction Using 2 Different Popliteofibular Ligament Techniques. Am J Sports Med. 2016 Apr;44(4):916-21.

How to Cite this article: Paul YWL, Dave LYH | Posterolateral Corner Reconstruction in the Multiligament Injured Knee: State of the Art | Asian Journal of Arthroscopy | January-April 2020; 5(1):27-35.

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Management of Multiligament knee injuries (mlki’s) with concomitant fractures and neurovascular injuries- A descriptive review

S R Sundararajan, Terrance D’souza, Ramakanth Rajagopal, S Rajasekaran

Volume 5 | Issue 1 | Jan – April 2020 | Page 9-13

Author: S R Sundararajan [1], Terrance D’souza [2], Ramakanth Rajagopal [2], S Rajasekaran [2]

[1] Department of Arthroscopy and sports medicine. Ganga hospital, Coimbatore, India.
[2] Department of Orthopaedics, Ganga hospital, Coimbatore, India.

Address of Correspondence
Dr. S. R Sundararajan,
Department of Arthroscopy and sports medicine. Ganga hospital, Coimbatore, India.
E-mail: sundarbone70@hotmail.com

Abstract

MLKI’S are on the rise due to increasing number of Road traffic accidents (RTA). MLKI’s are often challenging injuries to treat especially when they are associated with periarticular fractures and/or neurovascular deficits. These additional knee injuries can affect the surgical timing of ligament injuries and also can affect the outcome. The existing literature lacks clear-cut guidelines regarding approach and management of MLKI’s with these associated injuries. This descriptive review is an attempt to highlight key concepts from the existing literature, along with our experience in treating MLKI’s with these associated injuries and formulate protocols that could help clinicians in their day to day practice.
Keywords: MLKI, KDV, Periarticular fractures, Neurovascular injuries, Vascular assessment, CPN palsy, Staged reconstruction.

References

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20. Sanders TL, Johnson NR, Levy NM, Cole PA, Krych AJ, Stuart M, et al. Effect of vascular injury on functional outcome in knees with multi-ligament injury: A matched-cohort analysis. J Bone Jt Surg – Am Vol. 2017;99(18):1565–71.
21. Peskun CJ, Chahal J, Steinfeld ZY, Whelan DB. Risk factors for peroneal nerve injury and recovery in knee dislocation. Clin Orthop Relat Res. 2012;470(3):774–8.
22. Nobel W. Peroneal palsy due to hematoma in the common peroneal nerve sheath after distal torsional fractures and inversion ankle sprains. J Bone Joint Surg Am [Internet]. 1966 Dec [cited 2020 Feb 15];48(8):1484–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4289139
23. Prince MR, King AH, Shin AY, Bishop AT, Stuart MJ, Levy BA. Peroneal Nerve Injuries: Repair, Grafting, and Nerve Transfers. Oper Tech Sports Med. 2015;23(4):357–61.
24. Gruber H, Peer S, Meirer R, Bodner G. Peroneal nerve palsy associated with knee luxation: Evaluation by sonography – Initial experiences. Am J Roentgenol. 2005;185(5):1119–25.

How to Cite this article: Sundararajan S R, D’souza T, Rajagopal R, Rajasekaran S| Management of Multiligament knee injuries(mlki’s) with concomitant fractures and neurovascular injuries- A descriptive review | Asian Journal of Arthroscopy | January-April 2020; 5(1): 9-13.

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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

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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.
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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.
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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.
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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.
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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.
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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.
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How to Cite this article: Richter DL, Held M, Laubscher M, Benno R, North D, Tapasvi S, Shekhar A, Wascher DC, Schenck RC | Considerations in the Management of Knee Dislocations in the Limited Resource Setting (KD-LRS) | Asian Journal of Arthroscopy | January- April 2020; 5(1):66-72.

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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

How to Cite this article: Tapasvi S, Shekhar A. Multi Ligament Knee Instability: How to swim in choppy waters?. Asian Journal of Arthroscopy Jan – Apr 2020;5(1):1-2.

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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.
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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.
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How to Cite this article: Richter DL, Smith H, Su M, Gehron P, Wascher DC, Robert C Schenck RC. Assessment and Decision Making in Acute Knee Dislocation. Asian Journal Arthroscopy. Jan- Apr 2020;5(1):3-8.

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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.

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How to Cite this article: Shekhar A, Pilar A, Tapasvi S. Role of osteotomy in multiligament knee instability. Asian Journal Arthroscopy. Jan- Apr 2020;5(1):43-52.

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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.

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How to Cite this article: Shekhar A, Reddy S, Tapasvi S | Primary repair in acute multiligament knee injury | Asian Journal of Arthroscopy | January- April 2020; 5(1): 14-19.

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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

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How to Cite this article: Pardiwala DN, Subbiah K, Rao N, Jain V | Complications of Multiple Ligament Knee Injury Surgery : Prevention and Salvage | Asian Journal of Arthroscopy | January-April 2020; 5(1): 58-65.

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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.

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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.

(Abstract)    (Full Text HTML)      (Download PDF)