Analysis of Health-Related Quality of Life and Clinical Evaluations in Patients with the Triad of Combined Knee Injuries

Abstract

Combined knee injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and medial meniscus were called “the unhappy triad” in the past. With recent advances in diagnostic technology, combined ACL, MCL, and lateral meniscus injuries are now known to be the predominant triad. We examined and verified the treatment outcomes of the triad of combined knee injuries from both patient-based subjective evaluation and objective assessments. We studied 49 knees (49 patients) with combined injuries of the ACL, MCL, and lateral meniscus. These cases were divided into those who underwent simultaneous ACL and MCL reconstruction (group A, 18 cases) and those who underwent ACL reconstruction only because MCL injury could be treated conservatively (group B, 31 cases). Clinical evaluation was conducted preoperative and 24 months or longer after surgery. The methods included patient-reported outcomes using Short Form-36, and conventional assessments using Lysholm's score, visual analogue scale (VAS), and quantitative measurement of knee instability using Telos SE. Compared with presurgical scores, the postsurgical Short Form-36 scores showed improvements in all eight subscales, all reaching the national standard values. Significant improvements were observed in the five subscales in group A and seven subscales in group B. Furthermore, significant improvements in Lysholm's score, VAS pain score, and quantitative knee instability were achieved in both groups. This study demonstrated successful clinical outcomes in patients with a triad of knee injuries who were treated with lateral meniscus repair or partial meniscectomy and either combined MCL/ACL reconstruction or ACL reconstruction alone.

Keywords

unhappy triad - combined knee injuries - Short Form-36 - treatment outcome

Availability of Data and Materials

All data and materials were in the compliance with the journal's policy fully.

Authors' Contributions

S.O. designed and prepared the manuscript. S.S., T.Y., N.T., and T.A. collected and analyzed research data. T.H. and H.H. interpreted research data and edited the manuscript. All authors read and approved the final manuscript.

Publikationsverlauf

Eingereicht: 11. Juni 2020

Angenommen: 26. April 2022

Artikel online veröffentlicht:
11. Juli 2022

• References

• 1 Campbell WC. Repair of the ligaments of the knee: report of a new operation for repair of the anterior crucial ligament. Surg Gynecol Obstet 1936; 62: 964-968
• 2 O'Donoghue DH. Surgical treatment of fresh injuries to the major ligaments of the knee. J Bone Joint Surg Am 1950; 32 A [phone]
• 3 Shelbourne KD, Nitz PA. The O'Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med 1991; 19 (05) 474-477
• 4 Barber FA. What is the terrible triad?. Arthroscopy 1992; 8 (01) 19-22
• 5 Ochiai S, Hagino T, Senga S, Yamashita T, Haro H. Treatment outcome of reconstruction for isolated posterior cruciate injury: subjective and objective evaluations. J Knee Surg 2019; 32 (06) 506-512
• 6 Ochiai S, Hagino T, Senga S, Yamashita T, Ando T, Haro H. Prospective analysis using a patient-based health-related scale shows lower functional scores after posterior cruciate ligament reconstructions as compared with anterior cruciate ligament reconstructions of the knee. Int Orthop 2016; 40 (09) 1891-1898
• 7 Ochiai S, Hagino T, Senga S, Saito M, Haro H. Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques. Arch Orthop Trauma Surg 2012; 132 (03) 393-398
• 8 Fukuhara S, Suzukamo Y. Manual of SF-36v2 Japanese version. Accessed May 12, 2022 at: https://www.scirp.org/(S(czeh2tfqyw2orz553k1w0r45))/reference/ReferencesPapers.aspx?ReferenceID=2308768
• 9 Fukuhara S, Ware Jr JE, Kosinski M, Wada S, Gandek B. Psychometric and clinical tests of validity of the Japanese SF-36 Health Survey. J Clin Epidemiol 1998; 51 (11) 1045-1053
• 10 Aitken RCB. Measurement of feelings using visual analogue scales. Proc R Soc Med 1969; 62 (10) 989-993
• 11 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985; (198) 43-49
• 12 Rijke AM, Tegtmeyer CJ, Weiland DJ, McCue III FC. Stress examination of the cruciate ligaments: a radiologic Lachman test. Radiology 1987; 165 (03) 867-869
• 13 American Medical Association. Committee on the Medical Aspects of Sports. Subcommittee on Classification of Sports Injuries.. Standard Nomenclature of Athletic Injuries. Chicago, IL: American Medical Association; 1966. :157
• 14 Lewek MD, Rudolph KS, Snyder-Mackler L. Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis. Osteoarthritis Cartilage 2004; 12 (09) 745-751
• 15 Rosenberg TD. Technique for Endoscopic Method of ACL Reconstruction Technical Bulletin. Mansfield, MA: Acufex Microsurgical; 1993
• 16 Yau WP, Fok AW, Yee DK. Tunnel positions in transportal versus transtibial anterior cruciate ligament reconstruction: a case-control magnetic resonance imaging study. Arthroscopy 2013; 29 (06) 1047-1052
• 17 Yasuda K, Tsujino J, Tanabe Y, Kaneda K. Effects of initial graft tension on clinical outcome after anterior cruciate ligament reconstruction. Autogenous doubled hamstring tendons connected in series with polyester tapes. Am J Sports Med 1997; 25 (01) 99-106
• 18 Yasuda K, Ohkoshi Y, Ozeki S. Development of hybrid substitute composed of autogenous tendons and artificial ligaments for cruciate ligament reconstruction. Hiza 1991; 17: 128-134
• 19 Adachi N, Ochi M, Deie M, Izuta Y, Kazusa H. New hamstring fixation technique for medial collateral ligament or posterolateral corner reconstruction using the mosaicplasty system. Arthroscopy 2006; 22 (05) 571.e1-571.e3
• 20 Hagino T, Ochiai S, Senga S. et al. Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg 2015; 135 (12) 1701-1706
• 21 Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res 1988; (226) 103-112
• 22 Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study. J Bone Joint Surg Am 1987; 69 (08) 1120-1126
• 23 Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med 2005; 33 (09) 1380-1385
• 24 Donatelli R, Owens-Burkhart H. Effects of immobilization on the extensibility of periarticular connective tissue. J Orthop Sports Phys Ther 1981; 3: 67-72
• 25 Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med 1992; 11 (03) 533-578
• 26 Grant JA, Tannenbaum E, Miller BS, Bedi A. Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments. Arthroscopy 2012; 28 (01) 110-122
• 27 Ware Jr. JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30 (06) 473-483