Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment

How do surgically treated multiligamentous knee injuries affect overall complication rate and especially stiffness? A systematic review

BACKGROUND

Multiligamentous knee injuries (MLKIs), defined as injuries involving at least two of the four primary knee ligaments, are rare but severe, with potentially limb- or life-threatening complications. Despite numerous publications, the low incidence and heterogeneity of injury patterns limit high-level evidence for optimal surgical timing, technique, and management of complications. This systematic review aims to consolidate the available evidence on MLKI surgery complications, with a particular focus on arthrofibrosis as the underlying cause of stiffness, infection, and graft failure.

METHODS

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO) (no. CRD42024618025). A comprehensive search of PubMed, EMBASE, and MEDLINE from January 2013 to November 2024 identified studies reporting complications in surgically treated MLKIs with at least a 12-month follow-up. The studies were screened independently by two reviewers. Data on demographics, injury mechanisms, surgical techniques, and complication outcomes were extracted. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

A total of 33 studies with 2863 patients met the inclusion criteria. The mean age was 32.4 years (standard deviation, SD ± 5.37), with males constituting 69.4% of the sample. Arthrofibrosis was the most common complication, requiring surgical management in 8.4% of cases. Graft failure was reported in 5%, while infection, the third most common complication, occurred in 2.86% of cases. Management of lack of range of motion varied, with manipulation under anesthesia and arthroscopic arthrolysis utilized. Surgical timing also influenced outcomes; 54.2% of patients underwent acute surgery (< 21 days), which seems to be associated with increased stiffness rates.

CONCLUSIONS

This systematic review highlights the complexity of managing MLKIs, with a 19.2% overall complication rate. Stiffness demanding reoperation remains a rare but a significant challenge, underscoring the need for standardized treatment protocols. However, the included studies demonstrate heterogeneity and lack high methodological rigor, highlighting the need to account for these limitations.

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.

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.

Do Age and Timing Influence the Outcomes of Single-stage Reconstruction of Multiple Ligament Knee Injuries? 5-10 Years Follow Up

OBJECTIVES

Multiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single-stage reconstruction of MLKIs.

METHODS

The patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF-36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann-Whitney U test or χ2 test.

RESULTS

A total of 102 MLKI patients managed by single-stage multi-ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2-10.7 years). At the last follow-up, no significant difference was found in knee ROM, functional scores, and patient-reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%-80.4% of patients, and grade B in 11.8%-23.5% patients.

CONCLUSION

The single-stage reconstruction of MLKIs can obtain comparative long-term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.

Complex Anterior Cruciate Ligament Revision and Lateral Extra-Articular Tenodesis With Achilles Tendon Allograft: The "Monoloop" Technique

Revision of anterior cruciate ligament reconstruction (ACL-R) presents many challenges that are not encountered in the primary setting and, therefore, requires thorough preoperative planning. Recently, there has been growing evidence showing that combining the anterolateral ligament (ALL) reconstruction with ACL-R revision reduces the risk of postoperative ACL rupture and meniscal tears, and therefore, the ALL reconstruction becomes essential to a complex ACL revision. The technique that we describe is mainly used in the setting of complex ACL revision with extensive tunnel osteolysis associated with rotational instability of the knee. This article presents a technique for a one-stage complex ACL-R revision combined with ALL reconstruction using an Achilles tendon allograft with a bone plug.

Surgical approach on combined chronic patellar tendon and bicruciate knee ligament injury

A combined injury of the patellar tendon and both the anterior and posterior cruciate ligaments is disabling. It directly affects knee kinematics and biomechanics, presenting a considerable surgical challenge. In this complex and uncommon injury, decision-making should take into account the surgeon's experience and consider one- or two-stage surgery, tendon graft, graft fixation, and rehabilitation protocol. This manuscript discusses the surgical approach based on a comprehensive understanding of the patellar tendon and bicruciate biomechanics to guide which structures should be reconstructed first, especially when a two-stage procedure is chosen.

Patient Reported Clinical Outcomes Following PCL Suture Augmentation in Patients with Multiligamentous Knee Injury: A Retrospective Observational Study

Purpose

To compare the patient-reported outcomes between patients with posterior cruciate ligament (PCL) reconstruction or repair alone versus PCL reconstruction or repair with internal bracing (IB) in the context of multi-ligament knee injuries (MLKI).

Methods

All patients who underwent surgical management of MLKI at two institutions between 2006 and 2020 were retrospectively identified and offered participation in the study. Patient reported outcomes were measured via three instruments: Lysholm Knee score, Multiligament Quality of Life (ML-QOL), and the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT). The postoperative outcomes and reoperation rates were compared between the internal bracing and non-internal bracing groups.

Results

Fifty-two patients were analyzed; 34 were included in the IB group (17.6% female; age 33.1 ±1.60 years), and 18 were included in the non-IB group (11.1% female; age 34.1 ±3.72 years). Mean follow-up time of the entire cohort was 1.44 ± 0.22 years (IB: 1.21 ± 0.18; non-IB: 2.1 ±0.65). There were no significant differences between PROMIS CAT [PROMIS Pain (54.4 ±1.78 vs 51.7 ±1.70, p=0.319), Physical Function (44.3 ±2.27 vs 47.9 ±1.52, p=0.294), Mobility (44.0 ±1.71 vs 46.1 ±2.10, p=0.463)], ML-QOL [ML-QOL Physical Impairment (40.7 ±4.21 vs 41.7±5.10, p=0.884), Emotional Impairment (49.2 ±4.88 vs 44.7±5.87, p=0.579), Activity Limitation (43.5 ±4.56 vs 31.5±3.62, p=0.087), Societal Involvement (44.9 ±4.96 vs 37.5 ±5.30, p=0.345)] and Lysholm knee score (61.8 ±4.55 vs 61.0 ±4.95, p=0.916) postoperatively compared to the non-IB group.

Conclusion

In this group of patients, function and patient-reported outcomes between patients treated with PCL reconstruction and repair without internal brace versus those with additional internal brace augmentation were not significantly different. Further research encompassing a larger patient sample is necessary to investigate the efficacy of the internal brace for PCL injury in the context of MLKI injuries.

Arthroscopic Trans-septal Portal of the Knee With Direct Visualization and No Need for Posterolateral Portal Creation

Arthroscopic visualization and access of the posterior knee are limited when using standard anterior and posterior portals. The creation of a trans-septal portal allows for complete access to the posterior compartment as arthroscopic instruments are able to be passed back and forth between the posteromedial and posterolateral compartments. Due to the close proximity of the popliteal artery and its branches, precise portal placement and safe orientation of arthroscopic instruments are critical to avoid iatrogenic injury. The conventional technique of trans-septal portal creation, involving a posterolateral portal, can be difficult in some cases. To overcome these obstacles, a posteromedial technique of trans-septal portal creation is presented. By using the medial parapatellar portal as the viewing portal, our technique allows for direct visualization of the posterior septum on each step of creation of the trans-septal portal, eliminating the need for "blind" maneuvers. What is more, no posterolateral portal is needed, decreasing the risk of potential complications. Using the posterior cruciate ligament fibers as a main landmark for trans-septal portal placement, preservation of the posterior part of the septum is achieved. This ensures optimal safe-margin distance away from the popliteal neurovascular bundle and making the technique safe and reproducible.

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.