Summary

The suggested all-autograft algorithm effectively addresses multiple scenarios of multiligament knee injuries, supported by good outcomes in daily activities and return to moderate activities at medium-term follow-up. It is valuable in facilities where high-quality allograft tissue is not available, but can also become partially adopted to optimize cost-effective management of medical resources.

Abstract

Objective

To describe all-autograft algorithm for the management of the multiligament-injured knee and report medium-term outcomes.

Methods

Due to unavailability of non-irradiated allograft tendons until 2020 in a specific medical facility, an all-autograft algorithm for managing multiligament knee injuries was developed and implementedin since 2013 a single sports medicine center. Accordingly, bone-Patellar tendon-bone, Quadriceps tendon-bone, Hamstrings and contralateral Semitendinosus autografts were used to address a spectrum of injury scenarios. At medium-term follow-up, patients underwent physical examination and completed outcome questionnaires (PROMs) and activity level scales, in addition to undergoing functional evaluations, including quadriceps strength measurements, sit-to-stand test, jump-squat test, and single-legged balance test, calculating their symmetry indices (SI).

Results

Twenty-five patients (20 men) were treated due to multiligament knee injuries between 2013 and 2020. Of these, 20 had clinical assessments at 4 to 10-year follow-up (6 KD-V; 2 KD-IV; 2 KD-III;2 KD-II; 8 KD-I). Age at operation=24 [mean] (range, 17.5-32). At follow-up, IKDC-subjective=79±16, KOOS-ADL=88±15, KOOS-Sports=66±27, MLQOL-Physical impairment=25±20, MLQOL-Activity limitation=29±22. Tegner [median]=4 (range, 1-7) compared to 7 (range, 3-10) at pre-injury. Quadriceps strength SI=14±16[%], Jump-squat SI=9±10[%]. Three cases underwent release of adhesions to improve flexion range at 2 months post-operatively. Schenk severity grade was associated with IKDC-subjective, KOOS, MLQOL, Tegner and Marx scales, and with Quadriceps strength at follow-up (r=0.4-0.6, p≤0.05). Among the entire cohort of 25 patients, there were no major intra- or postoperative complications (i.e no infections, significant harvest-site morbidities, iatrogenic neurovascular injuries, or VTE events).

Conclusions

The suggested all-autograft algorithm can effectively address multiple scenarios of multiligament knee injuries. This is supported by overall good functional outcomes in daily activities and return to moderate activities at medium-term follow-up although high activity levels in sports are generally not restored. This algorithm is valuable for medical facilities where high-quality allograft tissue is not readily available, but it can also become partially adopted elsewhere to limit the use of allograft tendons in complex knee surgery, thereby optimizing cost-effective management of medical resources.