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Knee Surgery, Sports Traumatology, Arthroscopy

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24-07-2023 | External Fixator | KNEE

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

Authors: Emre Anil Özbek, Sahil Dadoo, Camila Grandberg, Armin Runer, Ting Cong, Jonathan D. Hughes, James J. Irrgang, Volker Musahl

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 10/2023

Abstract

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.

Ahmed AA, Saeed AM (2013) All-in-one management of chronic traumatic multiligament knee injury: 2–5-year follow-up. Egyptian Orthop J 48(2):117–121

Angelini FJ, Helito CP, Bonadio MB, da Mota E, Albuquerque RF, Pecora JR, Camanho GL (2015) Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator. Orthop Traumatol Surg Res 101(1):77–81PubMedCrossRef

Arom GA, Yeranosian MG, Petrigliano FA, Terrell RD, McAllister DR (2014) The changing demographics of knee dislocation: a retrospective database review. Clin Orthop Relat Res 472(9):2609–2614PubMedCrossRef

Axibal DP, Yeatts NC, Hysong AA, Hong IS, Trofa DP, Moorman CT 3rd, Piasecki DP, Fleischli JE, Saltzman BM (2022) Intraoperative and early (90-day) postoperative complications and associated variables with multiligamentous knee reconstruction: 15-year experience from a single academic institution. Arthroscopy 38(2):427–438PubMedCrossRef

Bi AS, Mojica ES, Markus DH, Blaeser AM, Kahan J, Moran J, Jazrawi LM, Medvecky MJ, Alaia MJ (2022) Risk of postoperative stiffness following multiligamentous knee injury surgery is not affected by obesity: a multicenter study. Arthroscopy 38(12):3175–3181PubMedCrossRef

Billières J, Labruyère C, Steltzlen C, Gonzalez A, Boisrenoult P, Beaufils P, Pujol N (2020) Multiligament knee injuries treated by one-stage reconstruction using allograft: postoperative laxity assessment using stress radiography and clinical outcomes. Orthop Traumatol Surg Res 106(5):937–944PubMedCrossRef

Born TR, Engasser WM, King AH, Krych AJ, Dahm DL, Levy BA, Stuart MJ (2014) Low frequency of symptomatic venous thromboembolism after multiligamentous knee reconstruction with thromboprophylaxis. Clin Orthop Relat Res 472(9):2705–2711PubMedPubMedCentralCrossRef

Chahla J, Dean CS, Matheny LM, Mitchell JJ, Cinque ME, LaPrade RF (2017) Outcomes of inside-out meniscal repair in the setting of multiligament reconstruction in the knee. Am J Sports Med 45(9):2098–2104PubMedCrossRef

Cook S, Ridley TJ, McCarthy MA, Gao Y, Wolf BR, Amendola A, Bollier MJ (2015) Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc 23(10):2983–2991PubMedCrossRef

10.

Freychet B, Kennedy NI, Sanders TL, Levy NM, Leland DP, Krych AJ, Stuart MJ, Levy BA (2020) No difference between single and staged posterolateral corner surgical procedures in the multiligament injured/dislocated knee. Knee Surg Sports Traumatol Arthrosc 28(7):2170–2176PubMedCrossRef

11.

Godin JA, Cinque ME, Pogorzelski J, Moatshe G, Chahla J, LaPrade RF (2017) Multiligament knee injuries in older adolescents: a 2-year minimum follow-up study. Orthop J Sports Med 5(9):2325967117727717PubMedPubMedCentralCrossRef

12.

Goyal A, Kumar S, Mishra P, Mehta N, Joshi D, Sinha S (2020) Long term outcome of early single stage surgery in multi-ligamentous injuries of knee. J Clin Orthop Trauma 11(Suppl 4):S650–S656PubMedPubMedCentralCrossRef

13.

Hanley J, Westermann R, Cook S, Glass N, Amendola N, Wolf BR, Bollier M (2017) Factors associated with knee stiffness following surgical management of multiligament knee injuries. J Knee Surg 30(6):549–554PubMedCrossRef

14.

Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ (2004) Surgical management of knee dislocations. J Bone Joint Surg Am 86(2):262–273PubMedCrossRef

15.

Heitmann M, Akoto R, Krause M, Hepp P, Schöpp C, Gensior TJ, Bartl C, Lill H, Frosch KH (2019) Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surg Sports Traumatol Arthrosc 27(8):2710–2718PubMedCrossRef

16.

Hoit G, Rubacha M, Chahal J, Khan R, Ravi B, Whelan DB (2021) Is there a disadvantage to early physical therapy after multiligament surgery for knee dislocation? A pilot randomized clinical trial. Clin Orthop Relat Res 479(8):1725–1736PubMedPubMedCentralCrossRef

17.

Hughes JD, Lynch AD, Smith CN, Musahl V, Irrgang JJ (2022) External fixation increases complications following surgical treatment of multiple ligament knee injuries. Knee Surg Sports Traumatol Arthrosc 30(1):161–166PubMedCrossRef

18.

Kahan JB, Li D, Schneble CA, Huang P, Bullock J, Porrino J, Medvecky MJ (2020) The pathoanatomy of posterolateral corner ligamentous disruption in multiligament knee injuries is predictive of peroneal nerve injury. Am J Sports Med 48(14):3541–3548PubMedCrossRef

19.

Kohl S, Stock A, Ahmad SS, Zumstein M, Keel M, Exadaktylos A, Kohlhof H, Eggli S, Evangelopoulos DS (2015) Dynamic intraligamentary stabilization and primary repair: a new concept for the treatment of knee dislocation. Injury 46(4):724–728PubMedCrossRef

20.

LaPrade RF, Chahla J, DePhillipo NN, Cram T, Kennedy MI, Cinque M, Dornan GJ, O’Brien LT, Engebretsen L, Moatshe G (2019) Single-stage multiple-ligament knee reconstructions for sports-related injuries: outcomes in 194 patients. Am J Sports Med 47(11):2563–2571PubMedCrossRef

21.

Lau BC, Varsheya K, Morriss N, Wickman J, Kirkendall D, Abrams G (2022) Single-stage surgical treatment of multi-ligament knee injuries results in lower cost and fewer complications and unplanned reoperations compared with staged treatment. Arthrosc Sports Med Rehabil 4(5):e1659–e1666PubMedPubMedCentralCrossRef

22.

Lee JH, Cook JL, Wilson N, Rucinski K, Stannard JP (2022) Outcomes after multiligament knee injury reconstruction using novel graft constructs and techniques. J Knee Surg 35(5):502–510PubMedCrossRef

23.

Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ (2010) Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 38(4):804–809PubMedCrossRef

24.

Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG (2009) Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy 25(4):430–438PubMedCrossRef

25.

Lian J, Patel NK, Nickoli M, Vaswani R, Irrgang JJ, Lesniak BP, Musahl V (2020) Obesity is associated with significant morbidity after multiligament knee surgery. J Knee Surg 33(6):525–530PubMedCrossRef

26.

Lo YP, Hsu KY, Chen LH, Wang CJ, Yeh WL, Chan YS, Chen WJ (2009) Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligament using hamstring and quadriceps tendon autografts. J Trauma 66(3):780–788PubMed

27.

Lynch AD, Chmielewski T, Bailey L, Stuart M, Cooper J, Coady C, Sgroi T, Owens J, Schenck R, Whelan D, Musahl V, Irrgang J (2017) STaR Trial Investigators. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr Rev Musculoskelet Med 10(3):328–345PubMedPubMedCentralCrossRef

28.

Marder RS, Poonawala H, Pincay JI, Nguyen F, Cleary PF, Persaud CS, Naziri Q, Zikria BA (2021) Acute versus delayed surgical intervention in multiligament knee injuries: a systematic review. Orthop J Sports Med 9(10):23259671211027856PubMedPubMedCentralCrossRef

29.

Mariani PP, Margheritini F, Camillieri G (2001) One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction. Arthroscopy 17(7):700–707PubMedCrossRef

30.

Mook WR, Miller MD, Diduch DR, Hertel J, Boachie-Adjei Y, Hart JM (2009) Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg Am 91(12):2946–2957PubMedCrossRef

31.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71CrossRefPubMedPubMedCentral

32.

Patel NK, Lian J, Nickoli M, Vaswani R, Irrgang JJ, Lesniak BP, Musahl V (2021) Risk factors associated with complications after operative treatment of multiligament knee injury. Orthop J Sports Med 9(3):2325967121994203PubMedPubMedCentralCrossRef

33.

Qin C, Baker H, Qin MM, Athiviraham A (2021) Utilization and costs of postoperative physical therapy after multiligament knee surgery: a retrospective cross-sectional study. Curr Orthop Pract 32(2):134–138CrossRef

34.

Richter D, Wascher DC, Schenck RC Jr (2014) A novel posteromedial approach for tibial inlay PCL reconstruction in KDIIIM injuries: avoiding prone patient positioning. Clin Orthop Relat Res 472(9):2680–2690PubMedPubMedCentralCrossRef

35.

Ridley TJ, Cook S, Bollier M, McCarthy M, Gao Y, Wolf B, Amendola A (2014) Effect of body mass index on patients with multiligamentous knee injuries. Arthroscopy 30(11):1447–1452PubMedCrossRef

36.

Rosteius T, Jettkant B, Rausch V, Lotzien S, Königshausen M, Schildhauer TA, Seybold D, Geßmann J (2021) Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes. Knee Surg Sports Traumatol Arthrosc 29(12):4188–4197PubMedPubMedCentralCrossRef

37.

Saini P, Trikha V (2016) Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure. Injury 47(10):2315–2319PubMedCrossRef

38.

Sanders TL, Johnson NR, Levy NM, Cole PA Jr, Krych AJ, Stuart M, Levy BA (2017) Effect of vascular injury on functional outcome in knees with multi-ligament injury: a matched-cohort analysis. J Bone Joint Surg Am 99(18):1565–1571PubMedCrossRef

39.

Schenck RC Jr (1994) The dislocated knee. Instr Course Lect 43:127–136PubMed

40.

Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73(9):712–716PubMedCrossRef

41.

Strobel MJ, Schulz MS, Petersen WJ, Eichhorn HJ (2006) Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy 22(2):182–192PubMedCrossRef

42.

Sundararajan SR, Sambandam B, Rajagopalakrishnan R, Rajasekaran S (2018) Comparison of KD3-M and KD3-L multiligamentous knee injuries and analysis of predictive factors that influence the outcomes of single-stage reconstruction in KD3 injuries. Orthop J Sports Med 6(9):2325967118794367PubMedPubMedCentralCrossRef

43.

Werner BC, Gwathmey FW Jr, Higgins ST, Hart JM, Miller MD (2014) Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med 42(2):358–363PubMedCrossRef

44.

Whelan DB, Dold AP, Trajkovski T, Chahal J (2014) Risk factors for the development of heterotopic ossification after knee dislocation. Clin Orthop Relat Res 472(9):2698–2704PubMedPubMedCentralCrossRef

45.

Wong CH, Tan JL, Chang HC, Khin LW, Low CO (2004) Knee dislocations-a retrospective study comparing operative versus closed immobilization treatment outcomes. Knee Surg Sports Traumatol Arthrosc 12(6):540–544PubMedCrossRef

46.

Woodmass JM, Johnson NR, Mohan R, Krych AJ, Levy BA, Stuart MJ (2018) Poly-traumatic multi-ligament knee injuries: is the knee the limiting factor? Knee Surg Sports Traumatol Arthrosc 26(9):2865–2871PubMedCrossRef

47.

Woodmass JM, Sanders TL, Johnson NR, Wu IT, Krych AJ, Stuart MJ, Levy BA (2018) Posterolateral corner reconstruction using the anatomical two-tailed graft technique: clinical outcomes in the multiligament injured knee. J Knee Surg 31(10):1031–1036PubMedCrossRef

48.

Worley JR, Brimmo O, Nuelle CW, Cook JL, Stannard JP (2019) Incidence of concurrent peroneal nerve injury in multiligament knee injuries and outcomes after knee reconstruction. J Knee Surg 32(6):560–564PubMedCrossRef

49.

Zhang H, Sun Y, Han X, Wang Y, Wang L, Alquhali A, Bai X (2014) Simultaneous reconstruction of the anterior cruciate ligament and medial collateral ligament in patients with chronic ACL-MCL lesions: a minimum 2-year follow-up study. Am J Sports Med 42(7):1675–1681PubMedCrossRef

50.

Zhang J, Song GY, Feng H (2020) Development of heterotopic ossification after multiple ligament reconstruction of the knee joint: incidence and explanatory factor analysis. Knee 27(3):642–648PubMedCrossRef

Title: Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis
Authors: Emre Anil Özbek
Sahil Dadoo
Camila Grandberg
Armin Runer
Ting Cong
Jonathan D. Hughes
James J. Irrgang
Volker Musahl
Publication date: 24-07-2023
Publisher: Springer Berlin Heidelberg
Keywords: External Fixator
Knee Dislocation
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 10/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07514-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

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