Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada.
J Bone Joint Surg Am. 2024 Oct 16;106(20):1903-1909. doi: 10.2106/JBJS.23.00795. Epub 2024 Aug 22.
The purpose of this study was to compare outcomes following early compared with delayed reconstruction in patients with multiligament knee injury (MLKI).
A retrospective cohort analysis of patients with MLKI from 2007 to 2019 was conducted. Patients who underwent a reconstructive surgical procedure with ≥12 months of postoperative follow-up were included. Patients were stratified into early reconstruction (<6 weeks after the injury) and delayed reconstruction (12 weeks to 2 years after the injury). Multivariable regression models with inverse probability of treatment weighting (IPTW) were utilized to compare the timing of the surgical procedure with the primary outcome (the Multiligament Quality of Life questionnaire [MLQOL]) and the secondary outcomes (manipulation under anesthesia [MUA], Kellgren-Lawrence [KL] osteoarthritis grade, knee laxity, and range of motion).
A total of 131 patients met our inclusion criteria, with 75 patients in the early reconstruction group and 56 patients in the delayed reconstruction group. The mean time to the surgical procedure was 17.6 days in the early reconstruction group compared with 280 days in the delayed reconstruction group. The mean postoperative follow-up was 58 months. The early reconstruction group, compared with the delayed reconstruction group, included more lateral-sided injuries (49 patients [65%] compared with 23 [41%]; standardized mean difference [SMD], 0.44) and nerve injuries (36 patients [48%] compared with 9 patients [16%]; SMD, 0.72), and had a higher mean Schenck class (SMD, 0.57). After propensity adjustment, we found no difference between early and delayed reconstruction across the 4 MLQOL domains (p > 0.05). Patients in the early reconstruction group had higher odds of requiring MUA compared with the delayed reconstruction group (24 [32%] compared with 8 [14%]; IPTW-adjusted odds ratio [OR], 3.85 [95% confidence interval (CI), 2.04 to 7.69]; p < 0.001) and had less knee flexion at the most recent follow-up (β, 6.34° [95% CI, 0.91° to 11.77°]; p = 0.023). Patients undergoing early reconstruction had lower KL osteoarthritis grades compared with patients in the delayed reconstruction group (OR, 0.46 [95% CI, 0.29 to 0.72]; p < 0.001). There were no differences in clinical laxity between groups.
Early reconstruction of MLKIs likely increases the likelihood of postoperative arthrofibrosis compared with delayed reconstruction, but it may be protective against the development of osteoarthritis. When considering the timing of MLKI reconstruction, surgeons should consider the benefit that early reconstruction may convey on long-term outcomes but should caution patients regarding the possibility of requiring an MUA.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
本研究旨在比较多韧带膝关节损伤（MLKI）患者早期重建与延迟重建的结果。
对 2007 年至 2019 年多韧带膝关节损伤患者进行回顾性队列分析。纳入接受≥12 个月术后随访的重建手术患者。患者分为早期重建（伤后<6 周）和延迟重建（伤后 12 周至 2 年）。采用逆概率治疗加权（IPTW）多变量回归模型比较手术时机与主要结局（多韧带生活质量问卷[MLQOL]）和次要结局（关节内松解术[MUA]、Kellgren-Lawrence [KL]骨关节炎分级、膝关节松弛度和活动范围）。
共纳入 131 例符合纳入标准的患者，早期重建组 75 例，延迟重建组 56 例。早期重建组的手术时间平均为 17.6 天，而延迟重建组为 280 天。平均术后随访 58 个月。与延迟重建组相比，早期重建组更常见外侧损伤（49 例[65%]比 23 例[41%]；标准化均数差值[SMD]，0.44）和神经损伤（36 例[48%]比 9 例[16%]；SMD，0.72），Schenck 分级更高（SMD，0.57）。在倾向评分调整后，我们发现早期重建与延迟重建在 4 个 MLQOL 领域均无差异（p>0.05）。与延迟重建组相比，早期重建组需要 MUA 的可能性更高（24 例[32%]比 8 例[14%]；IPTW 调整后的优势比[OR]，3.85[95%置信区间（CI），2.04 至 7.69]；p<0.001），最近随访时膝关节屈曲度较小（β，6.34°[95%CI，0.91°至 11.77°]；p=0.023）。与延迟重建组相比，早期重建组的 KL 骨关节炎分级较低（OR，0.46[95%CI，0.29 至 0.72]；p<0.001）。两组间临床松弛度无差异。
与延迟重建相比，早期重建多韧带膝关节损伤可能增加术后关节纤维化的可能性，但可能对骨关节炎的发生有保护作用。在考虑多韧带膝关节损伤重建的时机时，外科医生应考虑早期重建可能对长期结果带来的益处，但应告知患者可能需要进行 MUA。
治疗性 III 级。有关完整的证据水平描述，请参见作者说明。
