Indian Journal of Orthopaedics最新文献

Introduction: Multi-ligament knee injuries present in various combinations of structures around the knee joint, with or without involvement of neurovascular structures, posing significant challenges to the treating physician and therapists. Accurate diagnosis with appropriate surgical intervention and comprehensive rehabilitation to restore function and stability is, therefore, paramount. This article looks at the recent advancements in technology that are aiding in the management of these injuries.

Method: An extensive search of literature was done in PubMed, SCOPUS, and Google Scholar on this topic and the necessary information was derived from the relevant articles for this review. The progress made in the field of diagnosis, surgical management, rehabilitation and patient education tools were explored.

Discussion: A wide variety of diagnostic tools exists that are providing a more accurate evaluation of multi-ligament knee injuries both pre-operatively and post operatively. Advances in technology and techniques have aided in transforming their surgical management to a more minimally invasive approach. Patient-specific instrumentation, computer navigation and robotic-assisted surgery are in various stages of development offering enhanced precision and accuracy during ligament reconstruction procedures along with developments in digital technology and artificial intelligence.

Conclusion: Advancements in technology have transformed the management of multi-ligament knee injuries, offering new tools and techniques that enhance diagnostic accuracy, surgical precision, and rehabilitation effectiveness. Artificial intelligence and its utility have widened the horizons, while at the same time bringing in the need for regulations necessary to monitor and develop these technologies.

Background: Multiligament knee injuries (MLKIs) are complex and heterogeneous, often associated with concomitant injuries, and necessitates precise treatment strategies.

Preoperative management: Effective preoperative management in MLKIs requires comprehensive evaluation, starting with a detailed patient history to identify the mechanisms of injury and prior treatments. Physical examination assesses for knee stability, while imaging techniques including magnetic resonance imaging (MRI) and radiographs detail ligament, cartilage, and meniscal injuries to identify all injured structures. Vascular evaluations are critical given the high risk of concomitant neurovascular injuries especially in dislocated knees, bicruciate injuries, and lateral-sided injuries.

Avoiding tunnel convergence: Anatomic reconstruction of the torn ligaments has been biomechanically and clinically validated to improve knee stability and function. When performing multiple anatomic reconstructions, the risk of tunnel convergence is high. Therefore, surgical intervention aimed at optimizing outcomes necessitates careful planning to avoid tunnel convergence. This involves strategic tunnel placement, orientation, and techniques, such as adjusting tunnel angulation and using intraoperative imaging. These measures are vital for restoring knee functionality and minimizing future complications. Managing tunnel convergence is vital in treating MLKIs. Avoiding convergence on the medial side of the femur and tibia is more challenging due to the number of tunnels. In an MLKI involving all ligaments, 4 femoral tunnels and 4 tibial tunnels are required on the medial side, compared to 3 on the femur and 1 on the tibia for the lateral side, respectively.

Conclusion: The success of a multiligament knee reconstruction depends on a precise diagnosis, thorough preoperative management, and strategic tunnel placement. A multidisciplinary approach not only enhances surgical outcomes, but also ensures long-term improvement in knee function, effectively addressing the complexities and risks associated with these injuries.

Adjustable Loop Fixation devices (ALD) were introduced to allow tensioning and re-tensioning while increasing flexibility of graft length in the bone tunnel. ALDs have shown comparable clinical and biomechanical results when used for anterior cruciate ligament reconstructions. We routinely use ALDs in multi-ligament knee reconstructions. In double bundle posterior cruciate ligament reconstruction, using an ALD, we can achieve differential tensioning of the anterolateral and posteromedial bundles utilizing two femoral and one tibial tunnel. When performing an anatomic posterolateral corner reconstruction using our modification of the anatomical LaPrade technique, an ALD permits differential tensioning of the fibular collateral ligament and popliteus tendon/popliteofibular ligaments with a single graft. In anatomic superficial medial collateral ligament reconstructions, ALD allows for tensioning from the femoral side, subsequent cycling, followed by re-tensioning to achieve a stable reconstruction. In conclusion, ALDs provide numerous benefits when performing multi-ligament knee reconstructions. ALDs allow for appropriate tensioning and re-tensioning which is helpful in removing creep from the graft to prevent postoperative laxity. Additionally, it permits differential tensioning which helps achieve accurate tensioning of individual bundles to help restore native knee kinematics.

Background: The medial collateral ligament (MCL) is frequently involved in injuries around the knee but is uncommonly treated surgically. There are various techniques to reconstruct the medial side of the knee, which have varying outcomes.

Purpose/hypothesis: The purpose of the present systematic review and meta-analysis is to describe the clinical results of surgical management of acute and chronic isolated grade III MCL injury using various functional scores, such as IKDC, Lysholm, and VAS, and to ascertain complication rates associated with these interventions.

Methods: A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, and two independent authors (L.F and A.M) conducted a comprehensive search across multiple databases (PubMed, Web of Science, and Scopus). They reviewed each article's title and abstract for studies available until April 2024. The search terms used were "((MCL) OR (Medial collateral ligament)) AND (injuries) AND (treatment)". The full texts of the studies were evaluated when eligibility could not be assessed from the title and abstract.

Results: The pooled proportion (percentage) of complications from the three studies reporting data on surgery for the MCL acute stage was 15.3% with 95% CI [6.1% to 24.6%]. No complications were reported in studies reporting surgery in the chronic stage. Marked resolution of pain was observed with the mean VAS Score for pain at the final follow-up after surgery for MCL injury in the acute stage was 0.4 with 95% CI [-0.04 to 0.84]. The mean IKDC score at the final follow-up in the three studies reporting data on surgery for the MCL in the acute stage was 79.39 with 95% CI [67.96 to 90.82], and in the chronic stage, was 85 with 95% CI [83.02 to 86.98]. The mean Lysholm Score at the final follow-up after surgery for MCL injury in the chronic stage was 83.04 with 95% CI [75.24 to 94.84], and in the acute stage was 95 with 95% CI [91.76 to 98.24].

Conclusion: This systematic review found that functional outcomes regarding IKDC and LYSHOLM scores were comparable for surgeries performed in acute and chronic MCL tears. There was a marginally increased risk of complication in surgeries performed for acute MCL tears. Compared to the acute phase, a marked resolution of pain was observed at the final follow-up after surgery for MCL injury.

Study design: Systematic review; level of evidence, 4..

Background: Multiple ligament knee injuries (MLKI) are a complex group of injuries ideally treated in the acute phase, though delayed presentation is common. Chronic MLKI varies in presentation, requiring individualized management strategies. This review aims to differentiate chronic MLKI types and propose an algorithm that facilitates a tailored treatment plan.

Methods: Chronic MLKI is classified into three types based on knee joint status and limb alignment. Type 1 involves ligament deficiency in a reduced knee with normal alignment, treated with soft-tissue ligament reconstruction. Type 2 includes ligament deficiency with malalignment, where deformity correction precedes ligament surgery. Type 3 entails chronic unreduced knee dislocations, necessitating open reduction and extensive release prior to reconstruction.

Results: Treatment depends on classification, emphasizing realignment for Type 2 and reduction for Type 3 before soft-tissue procedures. Individualized approaches are critical due to the complexity and variability of chronic MLKI.

Conclusion: A treatment algorithm is essential to manage chronic MLKI. Joint reduction, limb realignment, and ligament reconstruction are important to ensure optimal functional outcomes.

Understanding the etiology of nonunion is crucial to its effective management. Nonunion arises from a complex interplay of biological and mechanical factors. High-velocity injuries, which are becoming more prevalent, often involve extensive soft-tissue damage and stripping compromises the vascularity of bone fragments. The lack of adequate blood supply hampers the healing process and contributes to persistence of nonunion. Such injuries often result in high levels of contamination and persistent infections, making fractures particularly difficult to manage and leading to nonunion. Despite recent advances in medical techniques and interventions, managing the problem of nonunion still remains a formidable challenge. Much effort has gone into the understanding of the problem. With this review, we have made an attempt to correlate some of the known factors and looked at the future including the possible role of genetics in predicting the problem and modifying the outcome of nonunion.

Background

The quadrant method is widely used to determine the femoral footprint center (FFC) on radiographs or computed tomography (CT) and can also describe the tibial footprint center (TFC). However, its application on three-dimensional (3D) magnetic resonance imaging (MRI) has been limited. This study aims to describe the ACL footprint center position on 3D MRI of healthy knees using the quadrant method.

Methods

Proton density (PD) sequence 3D MRI was conducted on 45 intact knees, aged 18 to 45 years. The centers of the ACL footprints were determined, and 2D simulated radiographic images were generated from the 3D MRI data. The quadrant method was then applied to calculate the positions of the footprint centers.

Results

The FFC was located at 31.6% in the deep–shallow (DS) direction and 31.3% in the high–low (HL) direction. The TFC was positioned at 45.1% in the mediolateral (ML) direction and 39.9% in the anteroposterior (AP) direction.

Conclusions

The ACL footprint centers identified in this study were positioned similarly to previous studies, with the exception of the TFC in the ML direction, which was found to be more medial. This approach has the potential to enhance preoperative planning and intra-operative navigation in ACL reconstruction surgeries.

Background

Hip surgery is often necessary for children with severe neuromuscular disabilities to avoid chronic pain resulting from hip migration. This study correlated the Surgical Vulnerability Score (SVS), a novel measure of physiological reserve, with reconstructive hip surgery outcomes to improve shared surgical decision-making.

Materials and methods

Sixty-eight cases performed by a single surgeon were retrospectively evaluated. Cases were graded according to physiological vulnerability using the SVS, which was then correlated with two outcomes: length of hospital stay (LOS) and severity of postoperative complications. The Gross Motor Function Classification System (GMFCS) level was used as a baseline comparison. Sub-analysis compared results for patients who underwent only a femoral varus derotation osteotomy (VDRO) (n = 48) with those who underwent a combined VDRO and Dega Pelvic Osteotomy (Dega PO) (n = 20).

Results

Results showed that a higher SVS was associated with increased LOS (p = 0.001) and severity of postoperative complications (p = 0.0008). A greater GMFCS level was not associated with either LOS (p = 0.246) or the severity of postoperative complications (p = 0.282). For patients who underwent only a VDRO, an increase in SVS had no association with LOS (p = 0.483) or severity of complications (p = 0.981). However, for patients who underwent both a VDRO and Dega PO, a higher SVS was associated with increased LOS (p = 0.0002) and severity of complications (p = 0.0001).

Conclusions

The SVS can aid surgical decision-making and prepare the child’s family for surgery. Early intervention and fixation using only a VDRO may lead to better outcomes, underscoring the importance of hip surveillance programs in the early identification of migrating hips.