Postoperative rehabilitation of the multiple-ligament reconstructed knee

Rehabilitation following multiple-ligament reconstruction continues to evolve although basic scientific principles continue to form the foundation for all current protocols. The protocols presented have been implemented following anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL), ACL/PCL/posterolateral complex (PLC), ACL/PCL/medial cruciate ligament (MCL), and ACL/PLC reconstructive procedures. They are designed to allow for optimal healing during the maximum and moderate protection phases, and to restore mobility and function during the final stage. These protocols should serve as guidelines only, and modifications may be necessary based on graft selection, presence of articular cartilage involvement, and surgeon preference.     

Nonoperative Management of Complete Lateral Elbow Ligamentous Disruption in an NFL Player: A Case Report

Disruptions of the lateral soft tissue restraints of the elbow, including the lateral ulnar collateral ligament, are a well-recognized clinical entity which may result in chronic elbow instability. When symptomatic, most authors recommend surgery to reconstruct the LUCL. We report on a case of a professional football player who sustained complete disruption of the lateral collateral ligamentous complex from the lateral humeral epicondyle with extension of his injury into his common extensor origin. He was treated conservatively and returned to play after 4 weeks. Treatment algorithm and a review of the literature are discussed.     

Recalibration and Validation of the Cumberland Ankle Instability Tool Cutoff Score for Individuals With Chronic Ankle Instability

Objective

To independently recalibrate and revalidate the Cumberland Ankle Instability Tool (CAIT) cutoff score for discriminating individuals with and without chronic ankle instability (CAI). There are concerns the original cutoff score (≤27) may be suboptimal for use in the CAI population.

Design

Case control.

Setting

Research laboratory.

Participants

Two independent datasets were used (total N=200). Dataset 1 included 61 individuals with a history of ≥1 ankle sprain and ≥2 episodes of giving way in the last year (CAI group) and 57 participants with no history of ankle sprain or instability in their lifetime (uninjured group). Dataset 2 included 27 uninjured participants, 29 participants with CAI, and 26 individuals with a history of a single ankle sprain and no subsequent instability (copers).

Interventions

All participants completed the CAIT during a single session. In dataset 1, a receiver operating characteristic (ROC) curve was calculated using the CAIT score and group membership as test variables. The ideal cutoff score was identified using the Youden index. The recalibrated cutoff score was validated in dataset 2 using the ROC analysis and clinimetric characteristics.

Main Outcome Measures

CAIT cutoff score and clinimetrics.

Results

In dataset 1, the optimal cutoff score was ≤25, which is lower than previously reported. In dataset 2, the recalibrated cutoff score demonstrated a sensitivity of 96.6%, specificity of 86.8%, positive likelihood ratio of 7.318, and negative likelihood ratio of .039. There were 7 false positives and 1 false negative.

Conclusions

The recalibrated CAIT score demonstrated very good clinimetric properties; all properties improved compared with the original cutoff score. Clinicians using the CAIT should use the recalibrated cutoff score to maximize test characteristics. Caution should be taken with copers, who had a high rate of false positives.     

Medial Injury in Knee Dislocations: What Are the Common Injury Patterns and Surgical Outcomes?

Background

When associated with a knee dislocation, management of the medial ligamentous injury is challenging, with little literature available to guide treatment.

Questions/purposes

We (1) compared MRI findings of medial ligament injuries between Schenck KDIIIM and KDIV injuries, (2) compared clinical outcomes and health-related quality of life as determined by Lysholm and Veterans Rand 36-Item Health Survey (VR-36) scores, respectively, of reconstructed KDIIIM and KDIV injured knees, and (3) determined reoperation rates of reconstructed KDIIIM and KDIV injured knees.

Methods

Over a 12-year period, we treated 65 patients with knee dislocations involving bicruciate ligament injury and concomitant medial ligament injuries, without or with posterolateral corner injuries (Schenck KDIIIM and KDIV, respectively); 57% were available for followup at a mean of 6.2 years (range, 1.1–11.6 years). These patients were contacted, and prospectively measured clinical outcomes scores (Lysholm and VR-36) were obtained and compared between subsets of patients. Preoperative MRIs (available for review on 49% of the patients) were rereviewed to characterize the medial ligament injuries.

Results

KDIIIM injuries more frequently had complete deep medial collateral ligament tears and posterior oblique ligament tears compared to KDIV injuries. KDIIIM knees had better Lysholm scores (88 versus 67, p = 0.027) and VR-36 scores (88 versus 70, p = 0.022) than KDIV knees. Female sex (Lysholm: 55 versus 85, p = 0.005; VR-36: 59 versus 85, p = 0.003) and an ultra-low-velocity mechanism (injury that occurs during activity of daily living in obese patients) (Lysholm: 55 versus 80–89, p = 0.002–0.013; VR-36: 60 versus 79–88, p = 0.001–0.017) were associated with worse outcomes. The overall reoperation rate was 28%, and the most common indication for reoperation was stiffness.

Conclusions

Medial ligament injury is common in knee dislocations. Females who sustain these injuries and patients who have an ultra-low-velocity mechanism should be counseled at the time of injury about the likelihood of inferior outcomes. As ROM deficits are the most commonly encountered complication, postoperative rehabilitation should focus on early ROM exercises as stability and wound healing allow. Future prospective studies are needed to definitively determine whether operative or nonoperative management is appropriate for particular medial ligamentous injury patterns.