Controversies in acute multiligamentary knee injuries (MLKI)

Abstract

Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. Level of Evidence: V-Expert Opinion.

Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

“…However, two difficulties in our patient cohort were also noticed: (1) residual laxity, especially regarding the ACL and collateral ligaments; and (2) postoperative stiffness due to arthrofibrosis requiring arthroscopic arthrolysis during the follow-up period. In that regard, whether ligament reconstruction or repair provides greater stability, reduces arthrofibrosis and consequently improves the outcomes remains a matter of debate [ 7 , 14 , 32 , 48 ]. Regarding the residual laxity of the ACL, Heitmann et al mentioned a hybrid technique involving ACL reconstruction and bracing of the other ruptured ligaments as a promising option [ 16 ].…”

“…Despite these limitations, anatomical repair and ligament bracing can be evaluated as a promising option for the treatment of KD based on the results of our study. This approach offers orthopedic surgeons a working treatment concept in daily clinical practice, with acceptable short- term objective outcomes, low complication rates and the advantages of early, definitive repair and preservation of the native ligaments, since the treatment of KD is still debated in the literature [ 32 ]. Moreover, in the day-by day work, the results of our study help inform patients, who suffered from KD, about first clinical results and benefits of ligament bracing.…”

“…Furthermore, both open and arthroscopic treatment strategies in the early and late stages have been described as practicable [ 12 , 20 , 46 ]. However, due to the inhomogeneity of the patient characteristics, small case numbers and different associated injuries, no standards of treatment currently exist [ 32 ]. Therefore, Heitmann et al presented the first results of a multicenter study of anatomical repair and ligament bracing as a new treatment option for acute KD [ 16 ].…”

Current concepts in the assessment and management of multiligament injuries of the knee

“…Thus delayed reconstruction is an attractive option in LRS as structures may heal independently and negate unnecessary interventions, and where proper rehabilitation is not readily available. Though controversial, overall recent trends in literature seem to favour early surgery with improved or similar outcomes compared to delayed surgery [2,42,44,48,[58][59][60].…”

“…Conflicting data exist about the ideal timing of surgery for MLKIs. Additionally, there is ambiguity about the time frame defining “early” and “delayed” surgery [ 42 , 48 , 58 ]. Early surgery has typically been described as an intervention within 3 weeks of the injury, when soft-tissue integrity is intact, and tissue planes are still definable [ 48 ], whereas late surgery refers to intervention after 4–6 weeks [ 58 ].…”