Management and Myths of Ligamentous Injury · LCL/PLC Repair vs Reconstruction •Late: >3-4 weeks;...
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Management of Knee Injuries: An Evidence Based Update Management and Myths of Ligamentous Injury Kenneth G. Swan, Jr., M.D. Clinical Assistant Professor Rutgers Robert Wood Johnson Medical School June 1, 2019
Transcript of Management and Myths of Ligamentous Injury · LCL/PLC Repair vs Reconstruction •Late: >3-4 weeks;...
Management of Knee Injuries: An Evidence
Based Update
Management and
Myths of Ligamentous
Injury
Kenneth G. Swan, Jr., M.D.
Clinical Assistant Professor
Rutgers Robert Wood Johnson Medical School
June 1, 2019
Levels of Evidence
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Knee Ligaments
• MCL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
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Knee Ligaments
• MCL – Posteromedial Corner (PMC)
• LCL
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Knee Ligaments
• MCL – Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, Anterolateral (AL) and Posteromedial (PM)
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, AL and PM
• ACL
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Knee Ligaments
• MCL
– Posteromedial Corner (PMC)
• LCL
– Posterolateral Corner (PLC)
• PCL
– 2 bundles, AL and PM
• ACL
– Anterolateral Ligament (ALL)?
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Medial Collateral Ligament (MCL)
• Superficial MCL
• Posterior oblique ligament
• Deep MCL
• Oblique popliteal ligament
• “PMC”
• [Semimembranosis]
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MCL
• Injury: valgus force, typically contact injury (~75%)
• Medial based pain
• Difficulty with WB
• If isolated injury, no effusion
• Pain/laxity to valgus stress testing (30*)
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MCL
• Injury Severity Grading
– Grade I
• MCL focal tenderness, minimal to no laxity; structures strained but intact
– Grade II
• Diffuse MCL tenderness, + laxity in 30* flexion, with endpoint; tearing of sMCL
– Grade III
• Significant tenderness and swelling, gross laxity, no endpoint at 30*, laxity in full extension, + anteromedial rotatory instability in 90* flexion; tearing of sMCL and PMC
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MCL Injury: Management
• R-I-C-E
• Protected WB prn
• Immobilization? – Animal studies show Increased
collagen mass and Improved biomechanical properties if early ROM utilized over immobilization***
MRI if severe/add’l injuries suspected
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MCL Injury: RTP
• Grade I – <1-2 weeks
• Grade II – 2-4 weeks
• Grade III – ~6 weeks
– Pending additional injuries
– ~75% have add’l injury, most commonly ACL • Kovachevich, KSSTA, 2009
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MCL Reconstruction
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MCL repair vs reconstruction
• Dong, Arthroscopy, 2015 – Level 2 study – Better objective results with reconstruction, similar subjective
scores
• Wijdicks, AJSM, 2013
– Anatomic, biomechanical study – Equivalent results between “anatomic” repair and reconstruction
• Bottom line: No high-level evidence to support
reconstruction over repair. However, many surgeons prefer repair for acute avulsions; reconstruction favored over repair in sub-acute and chronic situation
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Lateral collateral ligament (LCL)
• PLC (posterolateral corner)
– Lateral collateral ligament
– Popliteus tendon
– Popliteal fibular ligament (arcuate ligament)
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LCL/PLC
• Injury: Direct varus force and/or hyperextension injury
• Usually (~75%) in combination with cruciate injury*
• Biceps, fibular head, ITB, peroneal nerve often injured as well
• Popliteal artery
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LCL/PLC Injury
• Exam: lateral swelling and tenderness over LCL
• Laxity to varus stress in 30* flexion, and in extension (Grade III)
• + Dial test
– Prone, 30 degrees flexion, check ER
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Dial Test -- PLC
LCL/PLC Injuries: Management
• Grade I – LCL sprain; non-operative, RICE, early ROM
• Grade II – Similar to Grade I, longer recovery, Rare
• Grade III – High Energy injury
– Typically additional [major] injuries
– Needs surgery to LCL/PLC in addition to other injured structures
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LCL/PLC
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LCL/PLC Repair vs Reconstruction
• Late: >3-4 weeks; Reconstruction
• Early: <3-4 weeks – Avulsions can be repaired
– Several studies show better results with reconstruction vs repair, even in early stages, even with avulsions • 37% failure rate in repair vs 9% in reconstruction group
– Stannard, AJSM, 2005 [Level II study]
– Levy, AJSM, 2010 [Level III study]
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PLC repair?
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LCL/PLC Reconstruction
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Posterior Cruciate Ligament (PCL)
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PCL Injury
• Mechanism:
– direct blow to proximal tibia (helmet, dashboard)
– Hyperextension
– Hyperflexion
• Can go undiagnosed for years
• Often not as dramatic or symptomatic as an ACL tear
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PCL: exam
• ISOLATED PCL INJURY
– FROM; ABLE TO SLR – MAY HAVE PAIN WITH HYPEREXTENSION – LOOK FOR POSTERIOR SAG IN THE FLEXED
KNEE – + POSTERIOR DRAWER
– DON’T GET FOOLED BY “FALSE LACHMANS”
OR “FALSE ANTERIOR DRAWER”
– SHOULD NOT HAVE VARUS/VALGUS INSTABLITY
– CHECK ROTATION WITH DRAWER TESTING
(ALWAYS!) AND WITH SUPINE AND PRONE DIAL TEST
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PCL Grading
• PCL Instability Grade
– I: <5mm, still anterior to femoral condyles
– II: 5-10mm, even with femoral condyles
– III: >10 mm, posterior to femoral condyles
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PCL Injury
• Grade I – Minimal posterior translation on posterior drawer – PT
• Grade II
– Moderate posterior translation on posterior drawer – PT, expectant management, RTP in 3-4 weeks
• Grade III
– Significant posterior translation on posterior drawer – HIGH INCIDENCE OF ADDITIONAL INJURY; RARE TO HAVE
ISOLATED GRADE III PCL
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PCL Reconstruction
• Autograft vs Allograft
• Technically more demanding and dangerous than ACLR
• More often in combination with multi-ligamentous repair
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PCL Controversies
• Operative vs Non-Operative for isolated Grade III injuries
• Single bundle vs Double Bundle
• Transtibial (arthroscopic) vs Open Inlay technique
CONSISTENT LEVEL I/II DATA IS LACKING
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Anterior Cruciate Ligament (ACL)
• Relatively common injury
• 70% Non-Contact
• More common in females (~3-6x more common)
• Meniscal injuries common (~50%)
– Acute: lateral meniscus
– Chronic: medial meniscus
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ACL bundles (AM, PL)
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ACL Risk Factors
• Female Gender
• Family Hx
• Notch Width
• Posterior tibial slope
• ACL size
• Ligamentous laxity
• PRIOR ACL INJURY
• High BMI
• Jump landing mechanics
• Hormonal
• Playing Surface
Smith, SportsHealth, 2012
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ACL Risk Factors
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ACL Re-Injury
• Not uncommon to have repeat ipsilateral or contralateral ACL injury
• Rates vary from 5-30% • Allograft much higher (~4x) risk of re-injury • Highest risk is in Young, Active, Female, cutting/pivoting sport
athletes
• Shelbourne, AJSM 2009 (LEVEL II) • Paterno, AJSM 2014 (LEVEL II) • Wiggins, AJSM 2014 (LEVEL II) • Andernod, AJSM 2015 (LEVEL II)
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ACL Myths/Controversies
• “Double bundle ACLR is better than single bundle”
• “The Anterolateral Ligament is the reason why my ACL keeps failing”
• “ACL Suture Ligament Augmentation is the wave of the future”
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ACLR: Double Bundle vs Single Bundle
• Mayr, Arthroscopy, 2018 – Prospective, RCT – Level I – 53 patients; 5 year f/u – Findings:
• No difference in Subjective or Objective scores • No difference in Osteoarthritis at 5 years
• Most similar studies agree--- a few show more
objective stability with DB, but no difference in subjective scores
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Anterolateral Ligament
• ALL: Capsular expansion that runs from the lateral epicondyle to lateral tibial plateau
• Early descriptions including by Segond, 1879
• May play a role in rotatory instability, pivot shift
• ALL reconstruction in combination with ACLR now advocated by some
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• ALL Articles:
– 2000-2012: Zero
– 2012-2016: One
– 2016: 45 Articles
All Level IV or V
No RCT, No prospective
Moroz, Clin Sports Med 2018
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NY Times 2013
ALL “Expert Group” Consensus Paper, J Orthopaedic Traumatology, 2017
• Anatomic:
– The ALL is a distinct ligament – ALL in males 2x as thick as females!
• Biomechanical: – ALL is a Secondary stabilizer to internal tibial rotation and pivot shift
• Clinical: – ACL+ALL may have increased pivot shift, but confounding factors (meniscus,
increased tibial slope) not accounted for in studies
• Conclusions: ALL reconstruction or tenodesis during ACLR have NOT been shown to improve clinical outcomes or decrease ACL re-tear rates [but may be considered in some highly unstable, ligamentously lax re-tears]
• LEVEL V Opinion Paper
• “Expert Group”: 13 international surgeons, *8 paid consultants
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ACL repair with “Suture Augmentation”
• aka “Internal Bracing” or “Bridge Enhanced ACL” • Early results: 53% re-injury rate at 5yrs f/u
• Feagin, CORR, 1996
• More recently: – van Eck, AJSM, 2017; Systematic Review of poor quality studies – Suture or scaffold used to repair ACL; biologics added
– Data scant, but:
• Braided suture > Monofilament • Early > Late repair • Skeletally immature > Mature • Proximal avulsions > Mid-substance
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ACL REPAIR
• Perrone, J Orthop Res 2017 – “Bridge-enhanced” ACL repair (BEAR) with collagen scaffold
and whole blood
– Porcine model, shows equivalent biomechanical results vs autograft!
– Human trial has now begun!!
• Gagliardi, AJSM 2019 – Level III retrospective study, comparing ACL suture ligament
augmentation (SLA) [of proximal avulsions] vs QTB autograft
– Adolescents
– 49% FAILURE RATE FOR SLA vs 4.7% for QTB
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Multiligamentous Knee Injury
• Can dislocate with only one cruciate torn, but typcially multiple ligaments torn
• Can be High-, Low- or Ultra Low-Velocity
• High incidence of Peroneal Nerve Injury (~25%)
• High incidence of Popliteal Artery injury (10-30%)
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Knee Dislocation: Controversies
• Operative vs Non-operative
• Early vs Late repair/reconstruction
• Staged vs All-at-Once
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Knee Dislocation: Controversies
• Operative vs Non-operative – Lysholm scores 85 vs 67
• Early vs Late repair/reconstruction
– <3 weeks – Staged with ACL later supported in some studies
• Repair vs Reconstruction
– Reconstruction fewer failures/re-operations
» Vicenti, Injury 2019 » Systematic Review , Majority Level IV studies
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THANK YOU!!!
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References
• Wijdicks CA, Griffith CJ, Steinar J, et al. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 2010; 92:1266-1280
• Amiel D, Akeson WH, Harwood FL, et al. Stress deprivation effect on metabolic turnover of the medial collateral ligament collagen: A comparison between nine- and 12-week immobilization. Clin Orthop Relat Res 1983;172:265-270
• Padgett LR, Dahners LE. Rigid immobilization alters matrix organization in the injured rat medial collateral ligament. J Orthop Res 1992:10:895-900
• Dong J, Wang XF, Men X, et al. Surgical treatment of acute grade III medial collateral ligament injury combined with anterior cruciate ligament injury: Anatomic ligament repair versus triangular ligament reconstruction. Arthroscopy 2015; 31:1108-1116
• Wijdicks CA, Michalski MP, Rasmussen MT, et al. Superficial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: an in vitro biomechanical analysis. Am J Sports Med 2013: 41:2858-2866
• Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am J Sports Med 2010; 38: 2502-2508
• Stannard JP, Brown SL, Farris RC, et al. The posterolateral corner of the knee: Repair vs Reconstruction. Am J Sports Med 2005; 33:881-888
• Levy BA, Dajani KA, Morgan JA: Repair vs Reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 2010; 38:804-809
• Reider B. Slippery Slope. Am J Sports Med 2019; 47:273-276
• Sonnery-Cottet B, Daggett M, Fayard J et al. Anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol 2017; 18:91-106
• van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament? A systematic literature review. Am J Sports Med 2017; 46:2291-2298
• Perrone GS, Proffen BL, Klapour AM, et al. Bench-to-Bedside: Bridge-Enhanced Anterior Cruciate Ligament Repair. J Orthop Res 2017; 35:2606-2612
• Gagliardi AG, Carry PM, Parikh HB et al. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med 2019; 47:560-566
• Smith HC, Vacek P, Johnson RJ, et al. Risk factors for anterior cruciate ligament injury: A review of the literature—Part 1: Neuromuscular and anatomic risk. Sports Health 2012; 4:155-161
• Smith HC, Vacek P, Johnson RJ, et al. Risk factors for anterior cruciate ligament injury: A review of the literatrue—Part 2: Hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors. Sports Health 2012; 4:69-78
• Andernord D, Desai N, Bjornsson H, et al. Predictors of contralateral anterior cruciate ligament reconstruction: a cohort study of 9061 patients with 5-year follow-up. Am J Sports Med 2015; 43:295-302
• Paterno MV, Rauh MJ, Schmitt LC, et al. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med 2014; 42:1567-1573
• Vicenti G, Solarino G, Carrozzo M, et al. Major concern in the multiligament-injured knee treatment: A systematic review. Injury 2019
• Mayr HO, Bruder S, Hube R. Single-bundle versus double-bundle anterior cruciate ligament reconstruction-5-year results. Arthroscopy 2018; 34:2647-2653
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