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Management of the Multi-Ligamentous Injured Knee: an Evidence-Based Review

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Management of the Multi-Ligamentous Injured Knee: an Evidence-Based Review Review Article Page 1 of 7 Management of the multi-ligamentous injured knee: an evidence-based review Linsen T. Samuel1, Jacob Rabin1, Alex Jinnah2, Samuel Rosas2, Linda Chao2, Rashad Sullivan2, Chukwuweike U. Gwam2 1Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA; 2Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA Contributions: (I) Conception and design: LT Samuel, J Rabin, CU Gwam; (II) Administrative support: LT Samuel, J Rabin, CU Gwam; (III) Provision of study materials or patients: LT Samuel, J Rabin, CU Gwam; (IV) Collection and assembly of data: LT Samuel, J Rabin, CU Gwam; (V) Data analysis and interpretation: LT Samuel, J Rabin, CU Gwam; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Chukwuweike U. Gwam, MD. Department of Orthopedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA. Email: [email protected]. Abstract: Multi-ligamentous knee injury (MLKI) can be a devastating injury, resulting in long-term knee instability and loss of function. For patients with MLKI, areas of controversy persist on how to best optimize outcomes. These areas of contention are often centered operative timing and technique with the aims of restoring patient function, knee range of motion, and stability. Currently, a paucity of studies exists that can be used to direct orthopedists on how to manage MLKI patients. This review critically analyzes literature in attempts to equip readers with best options for managing patients with MLKI. Keywords: Multi-ligamentous knee injury (MLKI); knee dislocation; management Received: 15 December 2018; Accepted: 22 February 2019; Published: 21 March 2019. doi: 10.21037/aoj.2019.02.06 View this article at: http://dx.doi.org/10.21037/aoj.2019.02.06 Introduction often based on severity of injury with considerations given to patient expectation (2). Earlier treatment modalities Multi-ligamentous knee injury (MLKI) is a rare but serious hinged on non-operative management with immobilization injury of the knee and is defined as involving at least two of and casting. However, this modality quickly fell out of the four main knee ligaments: the anterior cruciate ligament favor as multiple reports demonstrated poor functional (ACL), posterior cruciate ligament (PCL), posteromedial outcomes (3,4). As such, non-operative indications are corner (PMC) including the medial collateral ligament limited, with most patients requiring and undergoing (MCL), and posterolateral corner (PLC) including the operation. However, areas of contention exist amongst lateral collateral ligament (LCL). Mechanisms of injury sports and trauma orthopedists on how best optimize these often involve acute knee dislocation secondary to high patient groups. Current areas of contention include pre- velocity trauma (i.e., motor vehicle accident) but can operative and operative management, and post-operative also be secondary to low -velocity injury that arise from rehabilitation as to best restore function and articular sporting events (1). Early care management involves critical mobility and strength (4). assessment of soft tissue integrity and patient neurovascular The purpose of this review is to explore these current status as both peroneal nerve and popliteal artery are at risk. areas of contention and help facilitate the decision-making Early knee reduction is important as to best relieve tension process for orthopedists caring for patients with MLKI. stress on neurovascular structures. More specifically, this review will examine current literature Subacute management options for MLKIs vary and are on areas associated with operative management of patients © Annals of Joint. All rights reserved. aoj.amegroups.com Ann Joint 2019;4:21 Page 2 of 7 Annals of Joint, 2019 suffering from MLKI. non-operative management of MLKI. The authors found that patients treated operatively showed significantly higher Lysholm scores, and rate of return to work and sport. Conservative management However no statistically significant differences were found The indications for non-operative management are between IKDC and Tenger scores, and in ROM (2). It few, as most patients will require surgical management should be noted that the methodological quality of studies barring comorbidities that preclude surgery. Current included in this review were poor overall. Only 4 studies indications are patients with low-functional demand, directly compared operative and conservative management, severe polytrauma, significant head injury, and extensive and only 61 patients out of the 916 were treated operatively. soft tissue damage above the knee (5). Nonetheless, More recently Everhart et al. 2018 performed a systematic outcomes can be optimized for patients undergoing review of 21 studies (524 patients) to investigate rates conservative management, although this is not expected of return to work and sport after MLKI. Rate of return to mirror results obtained from surgery. Important points to work and sport was practically and statistically more to consider are an expeditious closed reduction after significant in patients treated operatively. In studies where knee dislocation with care taken to avoid the popliteal all patients were treated operatively 59% returned to sport fossa as to not compromise arterial flow. After reduction, and 79% returned to work with minimal restriction, while the knee should be immobilized in 15 to 20 degrees of in studies including a mix of operative and non-operative flexion with a subsequent arteriogram conducted to assess treatment only 46% returned to sport and 65% returned to vascular compromise. It is important to note that the use work with minimal restriction (9). of doppler ultrasound has been controversial due to occult In conclusion, indications for non-operative management intimal thrombosis in the presence of normal pulses (6). are few as most patients who are able to endure surgery and Magnetic resonance imaging can be conducted one week rehabilitation should undergo operative treatment. Early after initial injury to assess for ligamentous damage. reduction, followed by rehabilitation focused on optimizing Rehabilitation should entail range of motion exercises that range of motion and muscle strength yields the best emphasizes extension (7). Isometric exercises should be outcomes. conducted to strengthen quadriceps and hamstring muscles. Still, the literature demonstrates inferior outcomes with Optimal operative management non-operative management when compared to operative management. Dedmond and Almekinders 2001 performed Most orthopaedic surgeons would recommend a meta-analysis encompassing treatment of 206 knee surgical treatment of MLKI in absence of significant dislocations, 132 treated operatively and 74 conservatively. contraindications, and, as discussed, the literature The analysis supported superiority of operative treatment lends some support to this (10). The optimal course of with statistically higher Lysholm scores and ROM relative operative management however is another source of to conservative management. However there was no controversy. There are a variety of surgical techniques statistical difference found in ability to return to sport or and protocols employed to treat MLKI. Broadly they can pre-injury employment (8). A systematic review by Levy be categorized as either suture repair, or reconstruction et al. 2009 which included the meta-analysis of Dedmond using autograft, allograft, or synthetic ligament. and Almekinders in addition to three retrospective cohort Ligamentous repair is usually performed during the analyses comparing operative and conservative management acute injury phase, typically defined as <3 weeks after of MLKI also lends support to the former. It was found that injury, since tissue planes are more easily identified and patients receiving operative treatment did return to work are of sufficient integrity to allow re-approximation (72% vs. 52%) and sport (29% vs. 10%) at higher rates. without retraction and holding of sutures (11). Operative treatment additionally yielded higher Lysholm Reconstruction is performed during either the acute scores (80 vs. 57) and International Knee Documentation phase or the chronic phase, which is usually defined as Committee (IKDC) scores (58 vs. 20). However difference in any time point after the 3-week acute period. Different postoperative ROM between the groups was negligible (1). structures in a given MLKI may be treated with repair or Peskun and Whelan 2011 performed an evidence-based reconstruction, or with different timing, using a staged review of 31 studies (916 patients) evaluating operative or surgical protocol. Surgeons may also elect to treat some © Annals of Joint. All rights reserved. aoj.amegroups.com Ann Joint 2019;4:21 Annals of Joint, 2019 Page 3 of 7 structures conservatively performing neither a repair nor a repair of these structures (5,12,14-24). Comparative studies reconstruction. There are additionally different techniques however suggest that reconstruction may be a superior for ligamentous reconstruction varying, among other approach for lateral structures. In a prospective cohort qualities, in choice of graft, and method of graft fixation. study Stannard et al. found a statistically significantly higher This heterogeneity in operative strategies combined rate of failure for repair compared to reconstruction of with rapid evolution of surgical technique, and rarity and the PLC [37% (13/35)
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