Abstract  Objectives  To summarize our experience and mid-term resultsof reconstruction with Iliotibial tract grafts for multiple ligament injuries.

Methods  Between July 1997 and December 2003, mul­tipleligament injuries of 15 patients were reconstructed with Iliotibial tractgrafts in arthroscopy. There were 5 women and 10 men. The mean age at the timeof the surgery was 30.5 years (range 25–43 years). There were 7cases who were injured with combined ACL rupture and the PCL, and 8 cases werewith disruption of both the ACL and the PCL, combined with damage of the medialcol­lateral ligament.

Results  Fifteen patients were followed up for a mean of 7.5 years (range 6–12 years). The overall mean postop­erative Lysholm score was 84.3 ± 5.7. At final IKDC qual­ification, 60.0 % of the knees were normal or nearly normal. The overallaverage Tegner activity score decreased signifi­cantly at the re-examination compared to the activity score beforeaccident (3.6 ± 0.5 vs. 5.1 ± 0.6).

Conclusions  Reconstruction with Iliotibial tract grafts inarthroscopy was a reliable treatment for multiple ligament injuries.

Keywords   Multipleligament injuries  Iliotibial tract grafts Arthroscopy

Introduction

Diagnosis and treatment of multiple ligament injuries of the knee remaina real challenge for most surgeons. These inju­ries involve rupture of at leasttwo main ligaments of the knee associated with meniscus ruptures, cartilageinjuries, and osseous fractures ^[1]. Multiple ligamentinjuries basically concern ruptures of the cruciate ligaments combined withdamage of the collateral ligaments. The purpose of this study was to describeour management of multiple knee ligament injuries through reconstruction withIliotibial tract grafts and to present the mid-term results of this surgicaltreatment.

Materials and methods

Patients

Retrospective review of ourpatients’ records revealed 18 patients (acute and chronic) with rupture ofat least two main ligaments of the knee, who were evaluated at the Li’s institution between July 1997 and December 2003.

Three patients were excludedbecause of conflicting variables that affected their treatment. Theexclusion cri­teria included open trauma, any vascular injury requiringemergent surgery, any associated fracture requiring exter­nal fixation, and other severeassociated injuries (head injury, spine injury).

The remaining 15 cases included 5 women and 10 men. The mean age atthe time of the surgery was 30.5 years (range 25–43 years). The ligament injurieswere at the right knees in 9 patients and at theleft knees in 6. According to the damaged anatomical structures, they wereclassified in two groups: group A included injuries with combined rupturesof the ACL and the PCL (7 cases), and group B included dis­ruption of both theACL and the PCL which also combined damage of the medial collateral ligament (8cases).

The causes of the injury in these 15 cases were traffic accidents in 10, sport accidents in 2, and fallingsfrom height in 3. Six patients were surgically treated during the acute phaseand 9 patients were treated chronically (group A: 3 acute,4 chronic; group B: 3 acute, 5 chronic). The averagetimebetweeninjuryandsurgerywas10.5 ± 6.9 days for the acute cases,and 186.5 ± 140.1 days for the chronic cases. The cases treated withinthe first 3 weeks after injuries were defined as acute and the casestreated after 3 weeks were defined as chronic.

Methods

The preoperative evaluation ofthe patients included history and physical examination, standard and dynamicradio­graphs, and magnetic resonance imaging (MRI). In acute cases, theexamination under anesthesia was carried out toevaluatethekneelaxity.Inchronicpatients,theaxisoftheleg and the gait of thepatients were additionally evaluated.

It is suggested that the optimaltime for surgery is during 1–2 weeks after the injury, as thesoft tissue swelling is well resolved by that time, the range of motion isrestored, and the ligament structures are still recognizable.

Due to severe capsular damage inthese injuries, the treatment was started with arthroscopy to check the statusof the cruciate ligaments, meniscus, and cartilage and then continued toharvest iliotibial band.

A strip of iliotibial tract(approximately 3.5–4.0 cm wide and 25–30 cm long) was dissected fromthe upper 1/3 thigh, keeping the other end of this strip connected with the endof tibia, namely the Gerdy tubercle. This strip of ili­otibial tract was thenrolled and sutured to form a column (see Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11).

Management of cruciate ligaments: Bony avulsed cru­ciateligaments were directly repaired, using wire or sutures through transosseoustunnels. All midsubstance lesions of the cruciate ligaments were reconstructed.In some cases with complete rupture of the PCL, neither the ACL was normal. Itappeared in continuity, and there was damage at the tibia insertion with some fibers avulsed from the bone, while others were stillattached. If the avulsed fibers were less thantwo-thirds of the ACL tibial insertion, this peel-off injury was treated byreattachment due to strong sutures. However, if the avulsed fibers were more than two-thirds of the ACL tibialinsertion, the ACL was performed reconstruction. For cruciate ligamentsreconstruction, ilio­tibial band was used (see Fig. 12).

Fig. 1–3 Measuring the surface projection of iliotibial tract preoperation (approximately 3.5–4.0 cm wide and 25–30 cm long)

Management of the medialstructures: The ruptures or avulsions of the capsule and the posteromedialanatomical structures (posterior oblique ligament, semimembranosus) wererepaired using sutures or anchors, while the midsub­stance tears of the MCLwere primarily sutured using non­absorbable sutures. The avulsion fractures ofthe MCL insertions were fixed using screw or transosseous techniques;meanwhile, the abruptions of the same insertions were fixed by screws and washers.Basically, the medial ligament structures were repaired in acute cases, whilethe MCL in chronic cases was reconstructed using iliotibial band.

Management of other lesions: The peripheral meniscaltears in the red–red zone were sutured in acute cases. Other type ofmeniscal tears or tears in chronic cases could not be repaired and so a partialmeniscetomy was carried out. Fourth degree articular cartilage lesions were microfractured.

Postoperatively, a long leg cast allowing 30^。flexion was applied for 4 weeks. Aknee brace was used for a month thereafter. Partial weight bearing was allowedfor 3 weeks with crutches after surgery and gradually increased as tolerated.Straight leg raising exercise was started the day after surgery, straightrunning was allowed 3 months later, and pivoting sports were allowed 10 monthslater, but generally this was individualized among patients.

Fig. 4–6 A strip of iliotibial tract was dissected from the upper 1/3 thigh

Follow-up evaluations

All patients were followed upfor a mean of 7.5 years (range 6–12 years). Clinical evaluationwas performed using the Lysholm score, the Tegner rating system, and theInterna­tional Knee Documentation Committee (IKDC) form.

Regarding pre-and postoperative knee function assessedusing the Lysholm score and IKDC form. A Lysholm score of 95–100 was graded as excellent, 84–94 as good, 65–83 as fair, and B64 as poor, according to the Tegner and Lysholmcriteria ^[2].

Fig. 7 Iliotibial band was showed under arthroscopy

The IKDC form was used accordingto the guidelines reported by Hefti et al. ^[3]. The rating in this form isbased on an evaluation and a qualification section. The evaluationsec­tion includes four different problem areas: subjective assess­ment,symptoms, range of motion, and ligament examination. Each problem area includesmore parameters, which are qualified as normal, nearly normal,abnormal, and severely abnormal.Theworstqualificationforanyparameterwithintheareadefinestheproblemareaqualification.Theworstproblem areaqualification defines the overall final qualification.

Activity level was assessedusing the Tegner activity score^[2].TheTegnerscorewascategorizedasfollows:level0–3 corresponded to daily activities without any sports, 4–6 to recreational sports, and 7–10 to competitive sports.

Postoperative laxitymeasurements were performed using the manual Lachman test. The Lachman test wasperformed at all follow-ups and was graded as (-)or (+).

Student’s t tests were used for dataanalysis. Level of significance was set up at P B 0.05. All data are given in mean± SD.

Results

Lysholm score

The overall mean postoperative Lysholm score was chronic lesions were 87.7 ± 5.6 and 82.1 ± 6.4, respec­tively (see Table 1). Thedifference between the acute and chronic cases approached significance (P < 0.05).

Fig. 8–10 Measuring the strip of iliotibial tract (approximately 3.5–4.0 cm wide and 25–30 cm long)

Fig. 11 The strip of iliotibial tract was then rolled and sutured to form a column

Fig. 12 Reconstruction of ACL and PCL by iliotibial band under arthroscopy

IKDC evaluation

Patient subjective assessment:Ten patients (66.7 %) con­sidered their knees to be normal (A) or nearly normal(B) at follow-up [4 (A) and 6 (B)]. The rest (33.3 %) graded as abnormal (C) orseverely abnormal (D) [4 (C) and 1 (D)]. From the six patients treated in theacute phase, 83.3 % graded as (A) or (B), while from the nine patients treatedin the chronic phase, only 55.5 % graded as (A) or (B). This difference was significant (P < 0.05).

Symptoms: Nine patients (60.0 %)of the total graded their symptoms as (A) or (B). From the six patients treatedin the acute phase, 83.3 % graded as (A) or (B), while from the nine patientstreated in the chronic phase, only 44.4 % gra­dedas(A)or(B).This difference was significant(P <0.05).

Range of motion: Significant differences in ROM, loss ofextension and no significant differences in loss of flex­ion, respectively, were seenamong the different groups of our patients (Table 2).

Ligament examination: Onclinical examination, nine patients (60.0 %) had a firm end point on the Lachmantest. 13 (86.7 %) knees were graded as normal (A) or nearly normal (B) on thesame test. On posterior drawer test, 14 (93.3 %) knees were graded as(A) or (B), while 1 (6.7 %) knees were graded as (C). On the overall grading inliga­ment examination, 13 of the 15 (86.7 %) patients had a normal (A) ornearly normal (B) knee, while 2 (13.3 %) patients had an abnormal (C) orseverely abnormal (D) knee. 5 (83.3 %) of theacute patients got either an (A) or (B), compared to 5 (55.6 %) of thechronic patients who got an (A) or (B) and this difference was significant.

Overall final IKDC qualification: The results of final IKDC rating are listed in Table 3. At final IKDC qualifi­cation, 60.0 % of the kneeswere normal or nearly normal. From the six patients treated in the acute phase,4 patients (66.7 %) graded as (A) or (B),while from the nine patients treated in the chronic phase, 5 patients (55.5 %)graded as (A) or (B). There was no significant difference.

Tegner rating system

The overall average Tegneractivity score decreased sig­nificantly at the re-examinationcompared to the activity score before accident (3.6 ± 0.5 vs. 5.1 ± 0.6; P < 0.05). Moreover, the activity level decreased significantly in the group with thetotal of chronic cases (3.40 ± 0.5 vs.4.9 ± 0.6; P <0.05) (see Table 1).

Discussion

Historically, treatment of the multipleligament injured knee was conservative, with prolonged immobilization and cast­ing[4, 5]. More recently, several studies have shownbetter results following surgical versus nonsurgical treatment. A recentretrospective study by Richter et al. [6] looked at 89 traumatic kneedislocations, 63 of which were treated sur­gically and 26 of which were treatedconservatively. At an average follow-up of over 8 years, the Lysholm and Tengerscores were found to be better in the surgical group. They found thatfunctional rehabilitation following ligament repair/reconstruction was the mostimportant prognostic factor. Wong et al. [7] also published a recent studyshowing superior results in knee dislocations treated operatively compared withconservative management and the authors recommended surgical treatment withreconstruction/repair of all ligamentous structures to achieve the most stableknee and the greatest degree of patient satisfaction.

While most authors currentlyagree that ligamentous instability necessitates surgical treatment, there is nocon­sensus regarding the timing of surgery, the need for staging of the repair,which ligaments to repair or reconstruct, and which grafts to use [8].

Surgical timing of multiple kneeligament knee injuries is controversial. Most authors advocate the surgical man­agementof these injuries in the acute phase, and it is gen­erally recommended thatrepair should be done within 3 weeks prior to scar formation [9, 10]. Liow etal. [10] treated 21 patients with 22 knee dislocations, 8 of which were treatedin the acute phase (less than 2 weeks after injury) while the remainder weretreated more than 6 months after injury. Their results suggested that earlyrepair or reconstruction of all injured ligaments may pro­duce a betterfunctional outcome and a more stable knee. Meanwhile, their results did notsupport the view that early intervention ran a higher risk of producing arthrofibrosis and loss of movement. Incontrast, there are some studies comparing acute and chronic cases, which donot reveal any significant differences [11, 12]. Tzurbakis et al. [1] evalu­atedthe mid-term results of surgical treatment in different groups of patients withmultiple knee ligament injuries. In their study, patients who underwentsurgical treatment during the acute phase had better scores in some groups ofthe IKDC evaluation, but in the final IKDC qualification the difference was notstatistically significant. Our results were similar to that of Tzurbakiset al. In our experience, we advocated a delay of 1–2 weeks for the multi-traumapatients to recover and the soft tissue injury to diminish. Delaying surgerybeyond 3 weeks may result in scarring of the collateral ligaments andposterolateral corner structures that may preclude an early repair. In caseswhere other factors indicate that surgery must be delayed beyond 3 weeks, werecommend waiting until full range of motion has returned and then tailoringany reconstruction (not repair) to residual laxity and functional instabilitythat remains. These opinions were similar to the experience of Anikar C et al.[13]. Some authors suggested [14, 15]reconstructing PCL and collateralligament injuries alone, and deferring ACL reconstruction until the patientdevel­oped rotatory instability. Some authors [16] advocated a two-stagereconstruction of traumatic knee dislocations, with early PCL reconstructionfollowed by reconstruction of the ACL and collateral structures’ injuries several months later. And others [10, 17, 18] advocatedrecon­struction of all injured ligaments, including ACL, and employ early,controlled range of movement exercises in a brace. The present study reportsour experience with reconstruction or repair of all the injured ligaments in agroup of patients with a major knee injury.

Currently, reconstruction usingautogenous tendonous tissue has emerged as the most popular method forreconstruction and has produced good clinical results. Ili­otibial tract (ITT)graft was widely used in the 1980s, and it has been the standard method in someclinics [19]. Com­bined intra-and extra-articular reconstruction with ITT isthought to have several advantages over other types of grafts. For example,lateral tenodesis is believed to prevent excess pivoting [20]. In addition, ITTreconstruction does not disturb the extensor mechanism and reduces the risk ofanterior knee pain [21]. Yamaguchi et al. [22] reported outcomes of ACLreconstruction with ITT whose width was approximately 2.5 cm. They consideredthat width of 2.5 cm did not provide sufficient strength for the ACLgraft. In our study, the width of the ITT harvested for the ACL and PCL graftwas approximately 4.0 cm and good results were got. Jorgensen et al. [21] alsosuggested that harvesting a 4­to 6-cm wide ITT graft was necessary. Inaddition, the ITT could be harvested as long as 30–40 cm, which would meet the needof reconstructing ACL and PCL simultaneously.

Conclusions

Overall, surgical treatment ofmultiple knee ligaments injuries, using Iliotibial tract grafts, has providedsatisfac­tory stability, range of motion, and subjective functional results.However, despite the improvement of the quality of life, the activity level ofpre-injury patients has not been fully achieved. In addition, the present studyalso has some limitations. The sample is small somehow, and the obser­vationperiod is not long enough as longer follow-up is crucial in ascertaininglong-term implications.

Conflict of interest None.

References

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2     Tegner Y, Lysholm J (1985) Rating systems in theevaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

3     Hefti F, Muller W, Jakob RP et al (1993) Evaluationof knee ligament injuries with the IKDC form. Knee Surg Sports Trau­matolArthrosc 3–4:226–234

4     Kennedy  JC(1963) Complete dislocation of the knee joint. J Bone Joint Surg Am 45:889–904

5     Taylor AR, Arden GP, Rainey HA (1972) Traumaticdisloca­tion of the knee: a report of forty-three cases with special referenceto conservative treatment. J Bone Joint Surg Br 54(1):96–102

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7     Wong CH, Tan JL, Chang HC et al (2004) Kneedislocations-a retrospective study comparing operative versus closed