Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3451-1
KNEE
Surgical treatment of multiligament knee injuries Shane Cook · T. J. Ridley · Mark A. McCarthy · Yubo Gao · Brian R. Wolf · Annunziato Amendola · Matthew J. Bollier
Received: 12 June 2014 / Accepted: 17 November 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose To analyse one institution’s experience with multiligament knee injuries. Methods Over 10 years, 133 multiligament knee injuries including 130 patients were included in the study. Inclusion criteria included: (1) injury to two or more knee ligaments (2) multiligament knee repair/reconstructive surgery. Results The average age at time of injury was 26 years old, and 76 % were male. Fifty-one (38 %) multiligament knee injuries had >2 ligaments injured. Peroneal injuries occurred in 26 patients (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism of injury was noted in 39 %. Twenty-five per cent of patients had an additional orthopaedic injury and, 11.5 % suffered additional non-orthopaedic injuries. Definitive surgical intervention was performed acutely (2 ligament injury or had surgery acutely were at an increased risk of knee stiffness requiring manipulation under anaesthesia (MUA) (p = 0.016 and p = 0.047, respectively). Knees with >2 ligaments injured were associated with higher post-operative complications (p = 0.007). Knee dislocation IV knees were at increased risk to undergo revision surgery (p = 0.041). Obese patients were more likely to have a post-operative infection (p = 0.038). Repair, reconstruction or type of graft used had no impact on need for revision surgery. Conclusions Multiligament knee injured patients undergoing surgical intervention are a highly complex patient population. This study outlines the patient population, treatment, and complications of one academic institution over 10 years. Overall complications were higher in patients with >2 ligaments injured. Knee stiffness requiring MUA was more common in patients who had >2 ligaments ruptured and those treated acutely. Knees with all four ligaments injured were more likely to undergo revision surgery. Level of evidence Retrospective case series, Level IV. Keywords Knee dislocation · Multiligament knee injury · Complications · Treatment
Introduction Multiligament knee injuries involve a disruption to two or more of the major ligaments of the knee: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial sided injury including the medial collateral ligament (MCL), and posterolateral corner (PLC) [34, 36, 43].
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Multiligament knee injuries are a relatively rare injury accounting for 0.02–0.2 % of all orthopaedic injuries [10, 16, 32, 37, 38]. Significant morbidity and functional impairment can result from multiligament knee injuries. This is especially true if not managed appropriately on initial presentation and a vascular injury is missed. Many of these injuries do not present as a frank knee dislocation (KD) and most spontaneously reduce prior to evaluation [40, 41]. Outcomes are difficult to assess because of the low incidence, assortment of injury patterns, and multiple reconstruction and repair options [17]. Multiligament knee injuries can be classified in several different ways: low energy vs high energy, number of ligaments involved, or direction of the dislocation. In 1994, Schenck described a classification system based on the pattern of multiligamentous injury of KD [34]. The rate of life-threatening injuries to the head, chest, and abdomen has been reported as high as 27 % in patients with high-velocity knee dislocations [44]. Nerve and vascular injuries are also common not only in the high-velocity injuries but also in the ultra-low-velocity injuries seen in the obese population [44, 45]. Both neurologic and vascular injures are an important factor in the workup of a multiligamentous injury and can have devastating complications if not recognized and treated appropriately. Treatment of multiligament knee injuries remains controversial. In the 1930s, prolonged immobilization was recommended to create a stiff, stable knee [13]. In 1955, O’Donoghue et al. [27] proposed that early repair would allow for range of motion and decreased rates of stiffness. Over the last 20 years, multiple studies have shown improved outcomes, decreased stiffness, and better function with surgical intervention [8, 30, 46]. Debate still exists on timing of surgery, repair and/or reconstruction, autograft and/or allograft, single stage vs two stage and post-operative immobilization among other variables. Surgical complication rates are high and include knee stiffness, wound-healing issues, infection, deep-vein thrombosis/pulmonary embolism (DVT/PE), recurrent instability, and symptomatic hardware [1, 5, 11, 26, 35]. The purpose of this paper is to examine a single Level 1 trauma centre’s experience with multiligament knee injuries over a 10-year period. This study aimed to define demographic data, incidence of varying injury patterns, concomitant injuries, and complications associated with surgical intervention. To our knowledge, this is the first study to evaluate all comers of only surgically treated multiligament knee injuries at one institution over a substantial period of time. This information can help surgeons in their evaluation of these complex patients and assists in predicting complications with surgical intervention.
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Knee Surg Sports Traumatol Arthrosc
Materials and methods After obtaining institutional review board approval (HawkIRB approval ID # 201201782, University of Iowa Hospitals and Clinics), a chart review was performed to identify patients who underwent surgical treatment for multiligamentous injuries from June 2003 to May 2013 at the University of Iowa hospital and clinics performed by one of three sports medicine orthopaedic surgeons at our institution. All charts were reviewed at a minimum of 1 year from their surgery. Inclusion criteria included the following: (1) injury to two or more knee ligaments and (2) multiligament knee repair/reconstructive surgery performed by one of three sports medicine orthopaedic surgeons on multiligament knee injury call at our institution. A chart review was performed to collect demographic data, type and degree of injury, concomitant injuries, surgical technique, and complications in addition to other variables. A wide variety of CPT codes were pulled from the electronic medical record (EMR) to ensure no multiligament surgeries were missed. After a thorough chart review, 133 multiligament knee injuries including 130 patients who met the inclusion criteria were included in the study. Demographic data, mechanism of injury, high versus low energy, number of ligaments injured, neurovascular injury, treatment, complications, and need for repeat surgery were recorded. We reviewed each patient’s chart for any other major orthopaedic injuries (i.e. not meniscal tears, cartilage injuries) at the time of the multiligament injury, as well as any non-orthopaedic injuries. Orthopaedic injuries included any fractures, dislocation of another/other joint(s), tendon ruptures, compartment syndrome, and/or arthrotomies not including the injured knee. Non-orthopaedic injuries included traumatic brain injuries, facial fractures, pneumothoraces, pulmonary contusions, and splenic lacerations. Complications included the need for revision surgery, operative hardware/suture removal, post-operative wound issues or signs of infection in the operative extremity, knee stiffness requiring MUA and/or arthroscopic lysis of adhesions, DVT, and PE. Each chart reviewed at least a year after their definitive surgery. Statistical analysis Statistical analysis was performed by a statistician using Chi-squared test on all complications, and their association with sex, age, timing of surgery, concomitant orthopaedic and non-orthopaedic injuries, number of ligaments injured, high or low energy mechanism, neurovascular injury, obese vs non-obese, knee dislocation classification and method of treatment (allograft, autograft, repair or combination) with
Knee Surg Sports Traumatol Arthrosc
significance set at p 2 ligaments) and the remaining 82 were a cruciate and a medial or lateral sided injury. Peroneal injuries occurred in 26 multiligament knee injuries (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism (motor vehicle collision, pedestrian vs car, all-terrain vehicle (ATV) accident or falls >5 feet) of injury was noted in 39 % of knee injuries with the majority remainder of low energy (falls
KNEE
Surgical treatment of multiligament knee injuries Shane Cook · T. J. Ridley · Mark A. McCarthy · Yubo Gao · Brian R. Wolf · Annunziato Amendola · Matthew J. Bollier
Received: 12 June 2014 / Accepted: 17 November 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose To analyse one institution’s experience with multiligament knee injuries. Methods Over 10 years, 133 multiligament knee injuries including 130 patients were included in the study. Inclusion criteria included: (1) injury to two or more knee ligaments (2) multiligament knee repair/reconstructive surgery. Results The average age at time of injury was 26 years old, and 76 % were male. Fifty-one (38 %) multiligament knee injuries had >2 ligaments injured. Peroneal injuries occurred in 26 patients (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism of injury was noted in 39 %. Twenty-five per cent of patients had an additional orthopaedic injury and, 11.5 % suffered additional non-orthopaedic injuries. Definitive surgical intervention was performed acutely (2 ligament injury or had surgery acutely were at an increased risk of knee stiffness requiring manipulation under anaesthesia (MUA) (p = 0.016 and p = 0.047, respectively). Knees with >2 ligaments injured were associated with higher post-operative complications (p = 0.007). Knee dislocation IV knees were at increased risk to undergo revision surgery (p = 0.041). Obese patients were more likely to have a post-operative infection (p = 0.038). Repair, reconstruction or type of graft used had no impact on need for revision surgery. Conclusions Multiligament knee injured patients undergoing surgical intervention are a highly complex patient population. This study outlines the patient population, treatment, and complications of one academic institution over 10 years. Overall complications were higher in patients with >2 ligaments injured. Knee stiffness requiring MUA was more common in patients who had >2 ligaments ruptured and those treated acutely. Knees with all four ligaments injured were more likely to undergo revision surgery. Level of evidence Retrospective case series, Level IV. Keywords Knee dislocation · Multiligament knee injury · Complications · Treatment
Introduction Multiligament knee injuries involve a disruption to two or more of the major ligaments of the knee: anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial sided injury including the medial collateral ligament (MCL), and posterolateral corner (PLC) [34, 36, 43].
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Multiligament knee injuries are a relatively rare injury accounting for 0.02–0.2 % of all orthopaedic injuries [10, 16, 32, 37, 38]. Significant morbidity and functional impairment can result from multiligament knee injuries. This is especially true if not managed appropriately on initial presentation and a vascular injury is missed. Many of these injuries do not present as a frank knee dislocation (KD) and most spontaneously reduce prior to evaluation [40, 41]. Outcomes are difficult to assess because of the low incidence, assortment of injury patterns, and multiple reconstruction and repair options [17]. Multiligament knee injuries can be classified in several different ways: low energy vs high energy, number of ligaments involved, or direction of the dislocation. In 1994, Schenck described a classification system based on the pattern of multiligamentous injury of KD [34]. The rate of life-threatening injuries to the head, chest, and abdomen has been reported as high as 27 % in patients with high-velocity knee dislocations [44]. Nerve and vascular injuries are also common not only in the high-velocity injuries but also in the ultra-low-velocity injuries seen in the obese population [44, 45]. Both neurologic and vascular injures are an important factor in the workup of a multiligamentous injury and can have devastating complications if not recognized and treated appropriately. Treatment of multiligament knee injuries remains controversial. In the 1930s, prolonged immobilization was recommended to create a stiff, stable knee [13]. In 1955, O’Donoghue et al. [27] proposed that early repair would allow for range of motion and decreased rates of stiffness. Over the last 20 years, multiple studies have shown improved outcomes, decreased stiffness, and better function with surgical intervention [8, 30, 46]. Debate still exists on timing of surgery, repair and/or reconstruction, autograft and/or allograft, single stage vs two stage and post-operative immobilization among other variables. Surgical complication rates are high and include knee stiffness, wound-healing issues, infection, deep-vein thrombosis/pulmonary embolism (DVT/PE), recurrent instability, and symptomatic hardware [1, 5, 11, 26, 35]. The purpose of this paper is to examine a single Level 1 trauma centre’s experience with multiligament knee injuries over a 10-year period. This study aimed to define demographic data, incidence of varying injury patterns, concomitant injuries, and complications associated with surgical intervention. To our knowledge, this is the first study to evaluate all comers of only surgically treated multiligament knee injuries at one institution over a substantial period of time. This information can help surgeons in their evaluation of these complex patients and assists in predicting complications with surgical intervention.
13
Knee Surg Sports Traumatol Arthrosc
Materials and methods After obtaining institutional review board approval (HawkIRB approval ID # 201201782, University of Iowa Hospitals and Clinics), a chart review was performed to identify patients who underwent surgical treatment for multiligamentous injuries from June 2003 to May 2013 at the University of Iowa hospital and clinics performed by one of three sports medicine orthopaedic surgeons at our institution. All charts were reviewed at a minimum of 1 year from their surgery. Inclusion criteria included the following: (1) injury to two or more knee ligaments and (2) multiligament knee repair/reconstructive surgery performed by one of three sports medicine orthopaedic surgeons on multiligament knee injury call at our institution. A chart review was performed to collect demographic data, type and degree of injury, concomitant injuries, surgical technique, and complications in addition to other variables. A wide variety of CPT codes were pulled from the electronic medical record (EMR) to ensure no multiligament surgeries were missed. After a thorough chart review, 133 multiligament knee injuries including 130 patients who met the inclusion criteria were included in the study. Demographic data, mechanism of injury, high versus low energy, number of ligaments injured, neurovascular injury, treatment, complications, and need for repeat surgery were recorded. We reviewed each patient’s chart for any other major orthopaedic injuries (i.e. not meniscal tears, cartilage injuries) at the time of the multiligament injury, as well as any non-orthopaedic injuries. Orthopaedic injuries included any fractures, dislocation of another/other joint(s), tendon ruptures, compartment syndrome, and/or arthrotomies not including the injured knee. Non-orthopaedic injuries included traumatic brain injuries, facial fractures, pneumothoraces, pulmonary contusions, and splenic lacerations. Complications included the need for revision surgery, operative hardware/suture removal, post-operative wound issues or signs of infection in the operative extremity, knee stiffness requiring MUA and/or arthroscopic lysis of adhesions, DVT, and PE. Each chart reviewed at least a year after their definitive surgery. Statistical analysis Statistical analysis was performed by a statistician using Chi-squared test on all complications, and their association with sex, age, timing of surgery, concomitant orthopaedic and non-orthopaedic injuries, number of ligaments injured, high or low energy mechanism, neurovascular injury, obese vs non-obese, knee dislocation classification and method of treatment (allograft, autograft, repair or combination) with
Knee Surg Sports Traumatol Arthrosc
significance set at p 2 ligaments) and the remaining 82 were a cruciate and a medial or lateral sided injury. Peroneal injuries occurred in 26 multiligament knee injuries (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism (motor vehicle collision, pedestrian vs car, all-terrain vehicle (ATV) accident or falls >5 feet) of injury was noted in 39 % of knee injuries with the majority remainder of low energy (falls
