Meghana Nair

Background: Heterotopic ossification (HO) is a common complication following knee dislocation (KD) and multi-ligament knee injury (MLKI). The patterns of HO in the knee following KD or MLKI are not well understood.Purpose: The purpose of this exploratory study was to describe the spatial distribution of HO following KD and MLKI using a radiographic grid-based mapping system.Methods: Patients who had sustained a KD or MLKI from January 2001 to May 2023 at a level I trauma center were identified using a MLKI database. Patients who developed HO following complete injury of ≥2 of the four primary knee ligaments, with initial and ≥6-month follow-up x-rays available, were included. Two senior musculoskeletal radiologists independently assessed HO presence and location. Primary outcome measures included location and timing of HO and grid inter-rater reliability. Univariable Cox proportional hazards models were used to describe spatiotemporal HO patterns using exploratory, unadjusted analyses.Results. Thirty-five patients were ultimately included. Inter-rater reliability for HO localization was good (intraclass correlation coefficient (ICC) = 0.83, 95%CI:0.82-0.84). HO most frequently occurred in the medial, posterior, and proximal knee. Proximal patellar tendon avulsions were associated with medial HO (HR=5.93; 95%CI:2.02-17.4; p=0.001) whereas distal avulsions were associated with central HO (HR=15.81; 95%CI:2.58-96.73; p=0.003). Femoral-sided lateral collateral ligament (LCL) avulsions were associated with lateral-proximal (HR 2.27, 95% CI 1.18-4.35; p=0.014) and lateral-mid HO (HR=2.09, 95%CI:1.12-3.91; p=0.02). Surgery involving the proximal central regions, including patellar fixation, multi-ligament reconstruction, medial soft-tissue repair, and knee-spanning external fixation, was associated with lateral (HR=3.02; 95%CI:1.18-7.73; p=0.021), medial (HR=2.82; 95%CI:1.15-6.93; p=0.024), posterior (HR=3.31; 95%CI:1.18-9.27; p=0.023), and central HO (HR=4.91; 95%CI:1.63-14.74; p=0.005). Surgery involving the anterior regions, typically extensor mechanism repair performed alongside multi-ligament reconstruction, was associated with medial (HR=2.79; 95%CI:1.04-7.50; p=0.042) and central HO (HR=6.31; 95%CI:2.08-19.11; p=0.001).Conclusion. The radiographic grid-based mapping system demonstrated good inter-rater reliability and enabled consistent spatial localization of HO following KD/MLKI. HO occurred most frequently in the medial, posterior, and proximal peri-articular regions and was spatially associated with several injury and surgical patterns. This work provides a framework for localizing HO after KD/MLKI and identifies regions and injury patterns that warrant further investigation.

Background: Heterotopic ossification (HO) may occur after multiligament knee injuries (MLKIs), with the potential to cause significant functional deficits. However, risk factors for HO after MLKI are not well understood. Purpose: To identify the incidence and risk factors for HO after MLKI. Study Design: Case-control study; Level of evidence, 3. Methods: Patients were included if they had undergone treatment for an MLKI by a single surgeon at a level 1 trauma center between 2001 and 2023, with radiographs at the time of injury and at a minimum 6-month follow-up. All data were obtained from electronic medical records. Two senior musculoskeletal radiologists reviewed all cases for the presence of HO in the most recent radiographs, using the initial radiographs obtained at the time of injury for comparison. Patients were grouped by whether they had developed HO after MLKI. Univariable analyses were performed to compare patient, injury, and treatment characteristics between groups. Odds ratios (ORs) for HO were assessed by multivariable logistic regression, adjusted for ligament injury classification, mechanism of injury, documented dislocation, central nervous system (CNS) trauma, and knee-spanning external fixation (KSEF). Results: The studied cohort included 128 patients, of whom 28 were excluded due to insufficient follow-up. Of the remainder, 35 (35%) developed HO, with a mean follow-up of 35.17 months. In the univariable analysis, the HO group had significantly higher rates of documented dislocation, CNS trauma, and KSEF. In the multivariable analysis, KSEF (OR, 8.51; 95% CI, 21.81-31.717; P = .001) and CNS trauma (OR, 6.63; 95% CI, 1.507-29.209; P = .012) remained independent predictors of HO after MLKI. Conclusion: The incidence of HO after MLKI was 35%. KSEF and CNS trauma were independently associated with HO. Recognition of these risk factors may help identify at-risk patients for closer monitoring and consideration of HO prophylaxis and should therefore be included in the decision-making strategy for KSEF versus early surgical treatment after MLKI.

Background: External fixator devices are an additional treatment option for traumatic injuries to help immobilization of periarticular fractures and the tissue around it. Purpose: The purpose of this review is to synthesize the literature centered around external fixation devices and the impact that they can have on the mental and psychological well-being of the patient. Methods: The study aimed to examine the psychological impact of external fixation on patients through survey-based research design. This study assessed factors such as body image, anxiety and depressive symptoms during the post-operative period. Patients who had undergone external fixation for traumatic injuries were asked about their experience pre- and post-operative period to see the impact that external fixation devices can have on a patient’s psychological well-being. Results: Findings showed that psychological distress was greatest in patients undergoing external fixation devices post-traumatic injury. However, findings across studies vary widely regarding the psychological effects on patients, underscoring the need for further research to better understand these outcomes. Conclusion: This review examined the psychological impact of external fixation following a traumatic injury, emphasizing the emotional challenges faced by patients during recovery. Existing studies highlight early postoperative distress characterized by anxiety, loss of independence and altered body image. While some evidence suggests that patients gradually adapt to their circumstances overtime, findings across studies vary widely. Future research should continue to explore these factors with greater stratification by frame type and duration to better understand emotional recovery. Addressing these gaps will not strength the evidence base, but also enable orthopedic surgeons to deliver more holistic, patient-centered care that supports both physical healing and psychological well-being.

External fixation is widely used in trauma care for managing bone and soft tissue injuries. These devices are often associated with psychological challenges and are often not followed up with sufficient psychological support for the patient. The specific psychological impact of external fixation following traumatic injuries remains underexplored. This scoping review aimed to synthesize the current literature on the psychological impact of external fixation in trauma patients. A systematic search of CINAHL, Cochrane Library, PsycInfo, PubMed, Scopus, Google Scholar, and EBSCO identified ten studies (2006–2024), from the USA, Europe, Asia, and Oceania to be included based on inclusion criteria of using the device for traumatic injuries (excluding limb lengthening procedures) and assessing psychological outcomes using validated tools. Data extracted included injury type, fixator application, survey type, and mental health outcomes. Common measures included HADS, SF-36/SF-12, PedsQL, CRIES-13, EQ-5D-5L, and patient-reported questionnaires. The findings showed that elevated psychological distress was greatest during early recovery (~1 month). Body image concerns were frequently reported with the fixator in place; however, partial recovery of mental health scores was seen by 12–24 months. These findings emphasize the need for additional research and a greater integration of mental health resources in trauma care protocols involving external fixation.

Knee dislocations (KD) and multiligamentous knee injuries (MLKI) are challenging injuries to manage due to the high incidence of associated neurovascular compromise, extensive peri-articular soft-tissue trauma, and long-term functional deficits. Knee-spanning external fixation (KSEF) is occasionally utilized in the acute management of these injuries with the aim of maintaining alignment, protecting vascular repairs, allowing soft-tissue recovery prior to definitive treatment, and protecting freshly reconstructed or repaired ligaments. Despite its use in 5% of MLKIs and up to 50% of KDs, the clinical indications, outcomes, and complications associated with KSEF in the setting of KD/MLKI remain incompletely defined. Furthermore, KD/MLKI treatment algorithms incorporating decision-making related to KSEF application are limited both institutionally and within the literature. Thus, the purpose of this study was to consolidate the existing evidence related to the use of KSEF in the setting of KD/MLKI to support clinical decision-making and identify avenues for future investigation. Following a narrative review of the literature, the identified indications for KSEF in the setting of KD/MLKI were vascular injury, knee fracture-dislocation, extensive soft-tissue injury, persistent instability following reduction, open KDs, and when bracing is not feasible due to patient factors such as morbid obesity. Both rigid and hinged KSEF constructs have been described, with hinged fixators potentially permitting early motion while providing joint stability. Reported complications of KSEF include arthrofibrosis, infection, heterotopic ossification, and compartment syndrome, though available data are primarily retrospective and heterogeneous. Other topics that have been addressed in the literature include biomechanics, cost, magnetic resonance imaging (MRI) compatibility, and psychological impact. However, further research is needed to clarify its specific role, define standardized indications, and compare outcomes with non-invasive or alternative fixation and immobilization strategies. Plain Language Summary: Knee dislocations and multiple ligament knee injuries are serious injuries that can cause damage to blood vessels, nerves, and soft tissues around the knee, leading to long-term challenges with movement. Doctors sometimes use a device called a knee-spanning external fixator to treat these injuries, which is a metal frame that surgeons place outside of the leg to hold the knee stable This article summarizes what doctors and researchers currently know about knee-spanning external fixators, including their risks and benefits, and explains why more research is needed to guide treatment decisions related to the use of these devices in the management of severe knee injuries. This device is mainly used when the knee is too unstable for a brace, when there is a blood vessel injury, when the skin around the knee is severely damaged, and when the patient has multiple other injuries that need to be managed before their knee injury. While knee-spanning external fixators can help protect the knee and allow it to heal, they also carry several risks like stiffness, infections where the pins enter the skin, unwanted bone growth in the knee, and excessive pressure build-up within the leg. There are also psychological and cost-related concerns associated with the use of these devices. Despite being used frequently, doctors and researchers have not reached a clear agreement about exactly when to use or avoid these devices.