Management of the multi-ligamentous injured knee: an evidence-based review

Samuel, Linsen T.; Rabin, Jacob; Jinnah, Alex; Rosas, Samuel; Chao, Linda; Sullivan, Rashad; Gwam, Chukwuweike U.

doi:10.21037/aoj.2019.02.06

Cited by 5 publications

(11 citation statements)

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“…The heterogeneity of knee injuries and lack of high-level evidence on the matter necessitates individualised consideration when choosing an approach [48]. Mariani et al demonstrated that reconstruction yielded better stability, range of motion, functional outcome scores and return to pre-injury activities [49].…”

Section: Repair Versus Reconstructionmentioning

confidence: 99%

“…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].…”

Section: Timingmentioning

confidence: 99%

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

Scheepers

Khanduja

Held

2021

SICOT-J

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Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

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Section: Repair Versus Reconstructionmentioning

confidence: 99%

Section: Timingmentioning

confidence: 99%

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

Scheepers

Khanduja

Held

2021

SICOT-J

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“…Indications for nonoperative are few and this treatment plan is recommended for patients who are unable to undergo a surgical procedure, those with severe trauma, periarticular knee, soft tissue damage, or those with low activity demands. 41 To optimize outcomes in patients who undergo nonoperative care of knee dislocation, an urgent reduction of the knee should be performed with rehabilitation focusing on knee range of motion and quadriceps muscle strength. 41…”

Section: Nonoperative Managementmentioning

confidence: 99%

“…41 To optimize outcomes in patients who undergo nonoperative care of knee dislocation, an urgent reduction of the knee should be performed with rehabilitation focusing on knee range of motion and quadriceps muscle strength. 41…”

Section: Nonoperative Managementmentioning

confidence: 99%

Posterior Cruciate Ligament Reconstruction in the Multiple Ligament Injured Knee

Kew

Miller

2020

J Knee Surg

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Multiligamentous knee injuries are challenging to treat and diagnose. Posterior cruciate ligament (PCL) injuries are commonly found in the constellation of injuries included in a multiligamentous knee injury and are caused by a posteriorly directed force on the proximal tibia with relation to the femoral condyles. A thorough history and physical examination should be performed to evaluate for associated neurovascular injuries and associated ligamentous, chondral, or bony injuries. Nonsurgical management is reserved for patients who are critically ill or have very low activity demands. Surgical reconstruction is recommended for most patients with multiligamentous knee injuries. The PCL reconstruction can be undertaken with several different graft options and reconstruction techniques, including the transtibial, arthroscopic tibial inlay, and open tibial inlay approach. The literature has a paucity of data regarding outcomes among the various reconstructive options, so the optimal surgical technique has not been established.

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“…The popliteal artery is injured in 1.6% [ 2 ] to 40% [ 3 ] of cases and vascular assessment forms a crucial, yet controversial part of the initial assessment. Ligament reconstruction can be performed acutely (<3 weeks), delayed (>3 weeks), or it can be staged [ 4 ]. Conservative treatment with bracing is reserved for certain compromised patients and if access to surgical care is restricted [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

The management of acute knee dislocations: A global survey of orthopaedic surgeons’ strategies

Venter

Dey

Khanduja

et al. 2021

SICOT-J

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Purpose: Great variety and controversies surround the management strategies of acute multiligament knee injuries (aMKLIs) and no established guidelines exist for resource-limited practices. The aim of this study was to compare the management approach of acute knee dislocations (AKDs) by orthopedic surgeons from nations with different economic status. Methods: This descriptive cross-sectional scenario-based survey compares different management strategies for aMLKIs of surgeons in developed economic nations (DEN) and emerging markets and developing nations (EMDN). The main areas of focus were operative versus non-operative management, timing and staging of surgery, graft choice and vascular assessment strategies. The members of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT) were approached to participate and information was collected regarding their demographics, experience, hospital setting and management strategies of aMLKIs. These were analyzed after categorizing participants into DEN and EMDN based on the gross domestic product (GDP) per capita. Results: One-hundred and thirty-eight orthopedic surgeons from 47 countries participated in this study, 67 from DEN and 71 (51.4%) from EMDN. DEN surgeons had more years of experience and were older (p < 0.05). Surgeons from EMDN mostly worked in public sector hospitals, were general orthopedic surgeons and treated patients from a low-income background. They preferred conservative management and delayed reconstruction with autograft (p < 0.05) if surgery was necessary. Surgeons from DEN favored early, single stage arthroscopic ligament reconstruction. Selective Computerized Tomography Angiography (CTA) was the most preferred choice of arterial examination for both groups. Significantly more EMDN surgeons preferred clinical examination (p < 0.05) and duplex doppler scanning (p < 0.05) compared to DEN surgeons. More surgeons from EMDN did not have access to a physiotherapist for their patients. Conclusions: Treatment of aMLKIs vary significantly based on the economic status of the country. Surgeons from DEN prefer early, single stage arthroscopic ligament reconstruction, while conservative management is favored in EMDN. Ligament surgery in EMDN is often delayed and staged. EMDN respondents utilize duplex doppler scanning and clinical examination more readily in their vascular assessment of aMLKIs. These findings highlight very distinct approaches to MLKIs in low-resource settings which are often neglected when guidelines are generated.

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Management of the multi-ligamentous injured knee: an evidence-based review

Cited by 5 publications

References 0 publications

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

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

Posterior Cruciate Ligament Reconstruction in the Multiple Ligament Injured Knee

The management of acute knee dislocations: A global survey of orthopaedic surgeons’ strategies

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