Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques

Abstract

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques

“…Taken together, it is likely that these potential advantages are related to robust graft constructs including synthetic internal brace augmentation for favorable immediate and sustained biomechanical function; all-soft-tissue grafts implanted into bone sockets using adjustable loop cortical suspensory fixation devices allowing for four-zone graft-bone integration and functional graft healing and remodeling, as well as repeated graft tensioning to diminish construct creep and achieve desired knee stability, and surgical reconstruction of all major ligaments in MLKIs while preserving bone stock and minimizing socket/tunnel-graft overlap and impingement. 33 These components appear to be able to optimize graft strength, graft integration, knee stability, and functional graft healing to restore joint function and mitigate common complications and failures as realized in the present study.…”

“…Based on the instability and progression to PTOA, the patient opted for TKA at 17 months after the initial MLKI reconstruction. Interestingly, all of the persistent instability cases occurred in patients with high BMI (33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45), which was associated with a significantly higher complication rate and trended toward a significantly lower success Outcomes after Multiligament Injury Reconstruction Lee et al 507…”

“…Finally, stability is rechecked and confirmed. 33 In all cases, injured ligaments were reconstructed. Allografts were used in all cases of PCL, PLC, and PMC reconstruction.…”

“…5 24 25 26 27 28 29 30 Importantly, these constructs and techniques allow for surgical reconstruction of all major ligaments in MLKIs while preserving bone stock and minimizing socket/tunnel-graft overlap and impingement. 31 32 33…”

“…5,[24][25][26][27][28][29][30] Importantly, these constructs and techniques allow for surgical reconstruction of all major ligaments in MLKIs while preserving bone stock and minimizing socket/tunnel-graft overlap and impingement. [31][32][33] Based on preclinical evidence for safety and efficacy in conjunction with clinical evidence for successful singleligament reconstructions, the authors instituted a shift in practice to employ these novel graft constructs and techniques for reconstructions for MLKI and track outcomes in a prospective registry. As such, the purpose of the present study was to assess and report clinical outcomes for the initial cohort of consecutive multiligament reconstruction surgeries performed at the authors' institution using novel graft constructs and techniques.…”