Risk of Postoperative Stiffness Following Multiligamentous Knee Injury Surgery Is Not Affected by Obesity: A Multicenter Study

Greater Detail Is Needed When Reporting Schenck Knee Dislocation V Injuries in the Orthopaedic Literature: A Systematic Review

Purpose

To examine how knee dislocations (KDs) with associated periarticular fractures classified using the Schenck KD V subcategory are reported in the literature.

Methods

PubMed, Cumulative Index to Nursing and Allied Health Literature, and Scopus were queried in January 2024. Studies were included if full-text articles in English were available, the Schenck KD classification system was used, and Schenck KD class V was mentioned. The exclusion criteria were as follows: studies in which the Schenck KD classification system was used but only KD classes I to IV were mentioned; systematic reviews, meta-analyses, review articles, commentaries, surgical technique articles, or animal studies; or studies in which pediatric patients were included. Studies were systematically examined for details regarding the descriptions of KD V injuries, including fracture and ligament tear patterns.

Results

Seventy-four studies met the inclusion criteria. Of these 74 studies, 45 (60.8%) provided no description of either the ligament tear or fracture patterns that were present in KD V injuries. Fifty-two studies (70.3%) provided no description of the ligament tear patterns and 51 studies (68.9%) provided no description of the fracture patterns associated with KD V injuries. Only 16 of 74 studies (21.6%) included descriptions of ligament tear patterns and fractures present in KD V injuries.

Conclusions

Descriptions of Schenck KD class V are poorly represented in the orthopaedic literature.

Level of Evidence

Level IV, systematic review of Level II to IV studies.

External Fixator Application, 2-Stage Procedures, and Postoperative Infection Risk Are Higher in Multiligamentous Knee Injuries After Frank Knee Dislocations

Purpose

To examine outcomes after surgical treatment of multiligamentous knee injuries (MLKIs) in patients with dislocated versus non-dislocated knees.

Methods

Patients who were surgically treated for MLKIs between 2008 and 2021 were included in this study. Patients were divided into 2 groups: those with a frank knee dislocation (KD), diagnosed by radiographs or reduction notes in the emergency department, and those without a frank KD (non-KD). The following patient-reported outcome measures were collected: visual analog scale for pain, International Knee Documentation Committee subjective score, and Lysholm knee scoring scale. Additional procedures such as revision ligamentous reconstruction and complications such as infection and arthrofibrosis were also obtained.

Results

A total of 88 patients (88 knees; 36 KD vs 52 non-KD) were included in the final analysis. This study included 30 female and 58 male patients, and the mean age was 34.3 ± 12.7 years (range, 10-61 years). The mean follow-up period for the patients who did not receive revision surgery was 9.2 years (range, 3.4-15.3 years). There were no differences in age, sex, mechanism of injury, meniscal/chondral injury, or neurovascular status between the groups. Furthermore, there were no differences in visual analog scale, International Knee Documentation Committee, or Lysholm scores. Significantly more patients in the KD group showed higher KD grades (KD III-KD V, 29 [81%] vs 21 [40%]; P < .001), and significantly more KD I injuries were observed in the non-KD group (48.1% vs 11.1%, P < .001). More patients in the KD group underwent staged procedures (69.4% vs 28.8%, P < .001) and had external fixators applied (50% vs 5.8%, P < .001). The overall complication rate was comparable between groups, with no differences in revision surgery or arthrofibrosis; however, the KD group had a higher postoperative infection rate (16.7% vs 1.9%, P = .017).

Conclusions

Patients who experienced frank KDs showed an increased odds of receiving external fixation, showed an increased odds of undergoing a staged procedure, had higher grades of injury, and had a higher risk of postoperative infection compared with those without KDs. At final follow-up, no differences in patient-reported outcomes were noted between the 2 groups.

Level of Evidence

Level III, retrospective cohort study.

Surgeon experience in multi-ligament knee injury reconstruction is associated with decreased complications and surgical time

INTRODUCTION

Operative management of multi-ligament knee injuries (MLKI) is technically challenging, with high complication rates. However, the impact of surgeon experience on surgical outcomes remains underreported. This purpose of this study was to examine how surgeon experience impacts operative time and complication rates. It was hypothesized that increased surgeon experience in MLKI correlates with reduced surgical duration and postoperative complications.

METHODS

A retrospective review of MLKI patients who underwent reconstruction from 2011 to 2024 by fellowship-trained sports medicine surgeons at two high-volume level 1 trauma centers was conducted. Patient demographics, surgical procedure characteristics, complications, and surgeon experience (defined by years in practice postfellowship) were analyzed. Correlations were examined using linear regression for continuous variables and binary logistic regression for binary variables.

RESULTS

There were 191 MLKI patients meeting inclusion criteria, with a 25.7% overall complication rate. Arthrofibrosis (16.2%) was most common, followed by recurrent instability (3.7%), infection (3.7%), revision surgery (2.7%), and hardware removal (1.0%). Controlling for age, sex, BMI, and number of ligaments reconstructed, we found a significant negative correlation between surgeon experience and both surgical duration (ß =  - 0.28, p < .001) and complication risk (OR 0.92, p = 0.024).

CONCLUSION

This study demonstrates that increased surgeon experience in operative management of MLKI is associated with decreased complication rates and shorter procedure duration. Additional risk factors for complications included the number of ligaments injured and concomitant knee dislocation.

Variability in the Spectrum of Reporting on the Schenck KD I Classification in the Orthopaedic Literature: A Systematic Review and Meta-analysis

Background

There has been a marked increase in the number of Schenck knee dislocation (KD) I injuries reported in the multiligament knee (MLK) injury (MLKI) and KD literature.

Purpose

To examine the heterogeneity of the Schenck KD I classification in the MLKI and KD literature.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic literature search of PubMed, CINAHL, Scopus, Web of Science, EMBASE, and Cochrane Library was conducted for all studies that investigated KDs and/or MLKIs, utilized the Schenck or an MLKI classification system, and included patients with KD I or MLK 1 injuries. Pooled analysis determined the total number of KD I or MLK 1 injuries and the specific ligamentous tear patterns. Binary meta-analyses of the studies that reported neurovascular injury within each Schenck KD class compared the pooled odds ratio (OR) of vascular and neurological injury in unicruciate (KD I) and bicruciate (KD II-IV) injuries.

Results

Included were 50 studies in which 3460 KD I injuries were reported out of 7872 KDs and MLKIs (43.9%). Of the 2912 patients reported to have had a Schenck KD I injury, 26 patients (0.9%) had a clinically and/or radiographically confirmed tibiofemoral KD. The overall prevalence of Schenck KD I injury with documented tibiofemoral KD was 26 of 7872 (0.3%). A total of 22 studies (n = 1702 patients) reported the specific ligamentous tear patterns; the most common patterns were posterior cruciate ligament (PCL)/lateral collateral ligament (LCL) (n = 526; 30.9%), anterior cruciate ligament (ACL)/LCL (n = 488; 28.7%), ACL/medial collateral ligament (MCL) (n = 408; 24.0%), and PCL/MCL (n = 198; 11.6%). Meta-analyses demonstrated that when compared with bicruciate KD or MLKI, unicruciate KD or MLKI was significantly less likely to have concomitant vascular injury (OR, 0.28; 95% CI, 0.15-0.51; P < .0001) and concomitant neurologic injury (OR, 0.49; 95% CI, 0.37-0.65; P < .00001).

Conclusion

The number of true, clinically and/or radiographically confirmed unicruciate KDs was extremely rare, representing <1% of all reported Schenck KD I injuries. A misappropriation of these injury patterns as true KDs may be taking place, affecting outcome studies and potentially biasing published clinical results. An MLKI classification system must document whether a confirmed KD has occurred.

Effect of Timing of Surgery on the Outcomes and Complications in Multi-ligament Knee Injuries: An Overview of Systematic Reviews and A Meta-analysis

Background and Aims

Multi-ligament knee injuries (MLKI) are serious and challenging to manage. This study aimed to elucidate the impact of surgical timing on both early and long-term outcomes following an MLKI.

Methods

A comprehensive search strategy was employed across PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were identified using a combination of relevant keywords encompassing "multi-ligament knee injury," "knee dislocation," "reconstruction," "repair," "surgery," and "timing," and their synonyms, along with appropriate Boolean operators. Selection of articles (systematic reviews and meta-analyses) adhered to predefined inclusion and exclusion criteria. Furthermore, a meta-analysis was conducted utilizing data extracted from primary studies.

Results

Early surgery for MLKI demonstrated a significant advantage over delayed surgery, reflected by significantly higher Lysholm scores (Mean Difference [MD] 3.51; 95% Confidence Interval [CI] 1.79, 5.22), IKDC objective scores (Mantel-Haenszel Odds Ratio [MH-OR] 2.95; 95% CI 1.30, 6.69), Tegner activity scores (MD 0.38; 95% CI 0.08, 0.69), and Mayer's ratings (MH-OR 5.47; 95% CI 1.27, 23.56). In addition, we found a significantly reduced risk of secondary chondral lesions (MH-OR 0.33; 95% CI 0.23, 0.48), lower instrumented anterior tibial translation in the early surgery group (MD -0.92; 95% CI -1.83, -0.01), but no significant difference was observed in the secondary meniscal tears, between the two groups. However, the early surgery group also exhibited a significantly increased risk of knee stiffness (MH-OR 2.47; 95% CI 1.22, 5.01) and a greater likelihood of requiring manipulation under anaesthesia (MH-OR 3.91; 95% CI 1.10, 13.87).

Conclusion

Early surgery for MLKI improves function, and stability, and reduces further articular cartilage damage, but increases the risk of stiffness.

Level of Evidence

IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01224-1.

Obesity-associated outcomes after ACL reconstruction: a propensity-score-matched analysis of the US Nationwide Inpatient Sample 2005-2018

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common among physically active individuals, and obesity may increase the risk of such injuries due to factors like biomechanical stress on the knee. We aimed to determine if obesity affects postoperative outcomes after ACL reconstruction.

METHODS

Data from adults aged 20 years and older with ACL injuries who underwent inpatient reconstruction from 2005 to 2018 were extracted from the United States (US) Nationwide Inpatient Sample (NIS) database. Patients were divided into two groups based on the presence of co-existing obesity, defined as a body mass index (BMI) ≥ 30 kg/m2. Propensity-score matching (PSM) was employed to balance between-group differences. Associations between obesity and concomitant meniscus injury, length of stay (LOS), post-procedural complications, and non-routine discharge were examined using univariate and multivariable logistic and linear regressions.

RESULTS

After PSM, data from 1323 patients (representing 6396 individuals in the US) were analyzed. Of these, 441 (33%) were classified as obese, while 882 (67%) were not obese. After adjustment, obesity was significantly associated with a longer LOS (adjusted beta (aBeta) = 0.32, 95% confidence interval (CI) 0.31-0.321) and an increased likelihood of non-routine discharge (adjusted OR (aOR) = 2.18, 95% CI 1.47-3.22). There were no significant associations between obesity and concomitant meniscus injury (aOR = 1.04, 95% CI 0.81-1.32) or post-procedural complications (aOR = 0.97, 95% CI 0.74-1.27).

CONCLUSIONS

In patients undergoing ACL reconstruction in the US, obesity is independently associated with a longer LOS and a higher risk of non-routine discharge. Nevertheless, obesity does not appear to be associated with concomitant meniscus injury or post-procedural complications.

Frailty is a predictor of immediate postoperative complications following surgical management of knee dislocations

PURPOSE

To assess the utility of frailty in predicting outcomes following surgical intervention for KDs.

METHODS

The NIS database was queried for non-congenital knee dislocations from 2015 to 2019 that underwent ligament repair or surgical reduction. Patients were assigned frailty scores using the mFI-11, and outcomes were compared. Multivariate regression and ROC curve analysis were used to assess the independent association of obesity, frailty, VI, and age with adverse outcomes.

RESULTS

A total of 3797 patients who underwent surgical management were included. Frailty was associated with extended LOS (OR 1.353, 95% CI 1.212-1.510, p < 0.001), adverse discharge (OR 1.716, 95% CI 1.515-1.946, p < 0.001), and complications (OR 1.449, 95% CI 1.352-1.553, p < 0.001). Severely frailty was associated with extended LOS (OR 1.838, 95% CI 1.611-2.097, p < 0.001), adverse discharge (OR 2.756, 95% CI 2.394-3.171, p < 0.001), and complications (OR 1.603, 95% CI 1.453-1.768, p < 0.001). Additionally, VI was a risk factor for extended LOS (OR 7.647 (6.442-9.076) p < 0.001), complications (OR 2.065 (1.810-2.341) p < 0.001), and adverse discharge (OR 1.825 (1.606-2.075), p < 0.001). Obesity was a risk factor for extended LOS (OR 1.599 (1.470-1.739), p < 0.001) and complications (OR 1.235 (1.108-1.377), p < 0.001). AUC analysis showed that frailty was the most accurate predictor of all outcomes when compared to VI, obesity, and age.

CONCLUSIONS

Frailty is superior to age and obesity, and comparable to VI, at predicting adverse outcomes following surgical management of KDs. These findings suggest that frailty assessment might play a role in risk stratification and preoperative planning for KD patients that require surgical intervention.

Anatomic reconstruction of the posteromedial corner of the knee: The Versailles technique

INTRODUCTION

Multiligament knee injury with posteromedial laxity is serious and usually requires surgery. Reconstruction is preferable to repair. The main aim of the present study was to report clinical results and laximetry for an original posteromedial corner (PMC) allograft reconstruction technique known as The Versailles Technique. The secondary aim was to determine prognostic factors for surgery. The study hypothesis was that anatomic PMC reconstruction by tendon allograft provides satisfactory medium-term clinical and laximetric results.

METHODS

A retrospective study assessed postoperative clinical and laximetric results after PMC allograft reconstruction at a minimum 12 months' follow-up. Laxity was assessed on comparative bilateral stress X-rays, and functional results on the International Knee Documentation Committee (IKDC) score, the Lysholm score and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Twenty-six patients were included between 2013 and 2019. Mean follow-up was 27.4±9 months. Mean subjective IKDC score was 69.21±17.36, mean Lysholm score 77.78±14.98 and mean KOOS 66.44±18.52.

OBJECTIVE

IKDC results were 77% grade A, 22% grade B, and 0% grade C or D. Mean medial differential laxity in forced varus was 0.83±1.26mm. Mean subjective IKDC scores were poorer in Schenck KD-III than KD-I (p=0.03). Functional results were comparable with acute and with chronic laxity. Age correlated inversely with median KOOS (p=0.009). There was no correlation between postoperative radiologic laxity in forced varus and functional results.

DISCUSSION

Versailles anatomic PMC allograft reconstruction for acute or chronic posteromedial knee laxity showed medium-term efficacy in restoring good objective and subjective stability.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Increased Body Mass Index is Associated with Worse Mid- To Long-Term Patient Outcomes after Surgical Repair of Multiligamentous Knee Injuries

We evaluated the relationship between elevated body mass index (BMI) and mid- to long-term outcomes after surgical treatment of multiligamentous knee injury (MLKI). Records identified patients treated surgically for MLKI at a single institution. Inclusion criteria: minimum 2 years since surgery, complete demographics, surgical data, sustained injuries to two or more ligaments in one or both knees, and available for follow-up. Patients were contacted to complete patient-reported outcomes assessments and were classified according to mechanism of injury. Multivariate logistic regression analysis was used to predict the impact of BMI on outcome scores. A total of 77 patients (72.7% male) were included with a mean age at the time of injury of 29.4 ± 11.0 years and a mean BMI of 30.5 ± 9.4 kg/m2. The mean length of follow-up was 7.4 years. For each 10 kg/m2 increase in BMI, there is a 0.9-point decrease in Tegner activity scale (p = 0.001), a 5-point decrease in Knee Injury and Osteoarthritis Outcome Score (KOOS)-pain (p = 0.007), a 5-point decrease in KOOS-ADL (p = 0.003), a 10-point decrease in KOOS-QOL (p = 0.002), and an 11-point decrease in KOOS-Sport (p = 0.002). There were no significant correlations with BMI and Pain Catastrophizing Scale or Patient Health Questionnaire scores. Increasing BMI has a negative linear relationship with mid- to long-term clinical outcomes including pain, ability to perform activities of daily living, quality of life, and ability to perform more demanding physical activity after MLKI. BMI does not appear to have a significant relationship with knee swelling and mechanical symptoms or patients' mental health.

Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up

BACKGROUND

Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old.

METHODS

This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores.

RESULTS

Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012).

CONCLUSIONS

Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports.

LEVEL OF EVIDENCE

IV, Case series.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness.

METHODS

This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries.

RESULTS

Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.).

CONCLUSION

Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured.

LEVEL OF EVIDENCE

Level IV.

Editorial Commentary: External Fixation and/or Vascular Injury Is Associated With Postoperative Arthrofibrosis After Multiple-Ligament Knee Injury Reconstruction

Patients with a body mass index over 30 do not have a significant increase in postoperative arthrofibrosis after multiple-ligament knee injury (MLKI) reconstruction compared with patients with a body mass index under 30. However, although this may be associated with the severity of injury, recent research has shown that patients who undergo external fixation at index surgery and/or who have vascular injury are at increased risk of requiring manipulation under anesthesia. This finding is clinically significant in that it is reassuring that stiffness requiring manipulation is no more likely to develop in obese patients than in non-obese patients after MLKI reconstruction. I have often believed that controlled arthrofibrosis can be somewhat beneficial in the management of MLKI and have advised patients over the years that a required manipulation in this case is not really a complication but more of a continuation of care. Stiffness after an MLKI surgical procedure is preferable to recurrent instability.