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Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness.

Methods

This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries.

Results

Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07–0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26–0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11–4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.).

Conclusion

Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured.

Level of evidence

Level IV.

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Data availability

Not applicable.

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Acknowledgements

In memoriam and appreciation of Dr. Freddie H. Fu (1950–2021). Emre Anil Özbek, MD was awarded a grant by ESSKA- University of Pittsburgh Sports Medicine Clinical and Research Fellowship, and The Scientific and Technological Research Council of Turkey (TUBITAK) outside the submitted work.

Funding

This study and all authors have received no funding.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Emre Anil Özbek, Sahil Dadoo, Camila Grandberg, Armin Runer, Ting Cong, Jonathan D. Hughes & Volker Musahl

  2. Department of Orthopedics and Traumatology, Ibni Sina Hospital, Ankara University, Ankara, Turkey

    Emre Anil Özbek

  3. Department for Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany

    Armin Runer

  4. Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA

    James J. Irrgang

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  1. Emre Anil Özbek
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  2. Sahil Dadoo
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Contributions

EAO was contributed to Literature search and manuscript writing. SD was contributed to Literature search. CG was contributed to Literature search. AR was contributed to Manuscript writing and review. TC was contributed to Manuscript writing and review. JDH was contributed to Manuscript writing and review. JJI was contributed to Critical review. VM was contributed to Critical review.

Corresponding author

Correspondence to Emre Anil Özbek.

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Conflict of interest

No Disclosure: Emre Anil Özbek, M.D. Sahil Dadoo, B.S., Camila Grandberg, M.D., Armin Runer, M.D. Jonathan Hughes, MD: Arthrex, Inc: Other financial or material support, DJ Orthopedics: Other financial or material support, Exactech, Inc: Other financial or material support, Globus Medical: Other financial or material support, Pylant Medical: Other financial or material support, SI Bone: Other financial or material support, Stryker: Other financial or material support. Synthes: Other financial or material support, Tornier: Other financial or material support, Zimmer: Other financial or material support. James J Irrgang PT, PhD, FAPTA: American Physical Therapy Association—Biomechanics Special Interest Group: Board or committee member. Volker Musahl, MD: ACL Study Group: Board or committee member, American Orthopedic Society for Sports Medicine: Board or committee member, Arthrex, Inc: Other financial or material support, International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine: Board or committee member, JISAKOS: Board or committee member, Knee Surgery, Sports Traumatology, Arthroscopy: Editorial or governing board, Smith & Nephew: Other financial or material support; Paid consultant, Springer: Publishing royalties, financial or material support. Ting Cong, M.D. Sustain Surgical Inc.: Founder and CEO, shareholder.

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Özbek, E.A., Dadoo, S., Grandberg, C. et al. Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 31, 4448–4457 (2023). https://doi.org/10.1007/s00167-023-07514-9

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