Prevalence of Ligamentous Knee Injuries in Pedestrian Versus Motor Vehicle Accidents

Prevalence of Ligamentous Knee Injuries in Pedestrian Versus Motor Vehicle Accidents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Prevalence of Ligamentous Knee Injuries in Pedestrian Versus Motor Vehicle Accidents Raymond Garrett Steinmetz, Matthew McDonald, Shaun Tkach, John Hamilton, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-16953/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Jun, 2020 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: The purpose of this study was to determine the prevalence and characteristics of ligamentous knee injuries and to compare patient demographics, associated injuries and hospital stay to pedestrians who did not sustain a ligamentous knee injury. Methods: A retrospective review of all adult patients presenting as pedestrians struck by a motor vehicle to a level 1 trauma center over a three-year period was performed. Demographics, length of stay, orthopedic and non-orthopedic traumatic injuries were recorded. Magnetic resonance imaging was reviewed for ligamentous, bony and chondral injuries. Results: 539 patients were included. 67 (12.4%) patients sustained a ligamentous knee injury and the majority of these were multi-ligamentous in nature. Patients with ligamentous knee injury were more likely to sustain traumatic brain injury, solid organ injury, cervical and lumbar spine injury, pelvic ring injuries, distal femur fractures, patella fractures, knee dislocations, tibial plateau fractures, tibial pilon fractures, and deep vein thrombosis when compared to patients who did not sustain ligamentous knee injury. Patients who sustained ligamentous knee injury were more likely to require hospital and intensive care admission and had a longer overall hospital stay. Conclusion: Given the high prevalence of ligamentous knee injuries in this patient population, these patients should be thoroughly evaluated for a ligamentous knee injury. If ligamentous knee injury is suspected, MRI should be considered as a majority of these injuries involved multiple structures. Patients with ligamentous knee injuries often had multi-system injuries with resulting longer hospital stay when compared to those without ligamentous knee injuries. Orthopedics Introduction Pedestrian versus motor vehicle accidents are a common mechanism of injury in patients presenting to trauma facilities, especially in urban areas. Given the high energy associated with these injuries, the patients often have multiple systems injured, which leads to substantial morbidity and mortality [1]. Orthopedic injuries are very common and as shown by Brainard et al, lower extremity injuries are the most common orthopedic injuries in patients presenting as pedestrian versus motor vehicle accidents [2]. Despite this, not much is known about the prevalence of ligamentous knee injuries in this patient population. The purpose of this study is to determine the prevalence and characteristics of ligamentous knee injuries in patients presenting as pedestrian versus motor vehicle accidents. We also sought to compare patient demographics, associated orthopedic and non-orthopedic injuries, intensive care stay and overall hospital stay to patients who did not have ligamentous knee injuries. Materials And Methods Institutional Review Board approval was obtained for this retrospective study. All patients greater than 18 years of age involved in pedestrian accidents presenting to a single institution level 1 trauma center from 2013–2017 were queried through our institution’s trauma database. Patients who died within 24 hours of admission or died prior to orthopedic examination were excluded. Charts were retrospectively reviewed for age at time of injury, gender, height, weight, insurance status, hospital stay, intensive care stay, discharge destination, chest trauma, solid organ injury, vascular injury, facial and skull fractures, traumatic brain injury, gastrointestinal injury, genitourinary injury, spine and spinal cord injury, associated upper and lower extremity injuries. Ligamentous knee injuries were diagnosed either with physical exam or magnetic resonance imaging (MRI). For patients with ligamentous knee injuries, charts were reviewed for magnetic resonance imaging, specific ligaments or ligamentous complexes injured, meniscal injury, nerve injury, arterial injury, knee dislocation, chondral injury, bone bruise and subchondral fracture. For this studies, ligaments included were the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament/posterior lateral corner complex (LCL/PLC). For this study, the LCL/PLC complex includes the lateral collateral ligament, popliteus, popliteofibular ligament, arcuate ligament, fabellofibular ligament, long head of biceps femoris tendon and iliotibial band. Statistical Analysis Demographic and clinical characteristics were compared among patients with a ligamentous knee injury and patients without the injury. Chi-square tests were used to compare proportions and a T-test was used to compare continuous data. Wilcoxon rank sum p-value was used for length of stay data. The incidence of identified injuries was calculated along with a 95% confidence interval. Results 557 patients were identified in our review and 18 patients were excluded due to death within 24 hours or death prior to adequate orthopedic evaluation leaving 539 patients to be included in this study. Table 1 shows the demographics of all included patients. 67 patients sustained ligamentous knee injuries giving a prevalence of 12.4%. Seventeen patients sustained bilateral ligamentous knee injuries, giving a total of eighty-four ligamentous knee injuries. There were six knee dislocations, three vascular injuries and three peroneal nerve injuries. MRI was available for 55/84 injured knees, the most common ligaments injured were anterior cruciate ligament (47), medial collateral ligament (45), lateral collateral ligament/ posterior lateral corner ligamentous complex (44) and the posterior cruciate ligament (38). Additionally, on MRI there were 37 instances of bone bruises or subchondral impaction fractures involving either the femoral condyles or tibial plateaus, 47 meniscal injuries and 9 acute chondral injuries. Table 2 shows the most common patterns of ligamentous injuries. Tables 3 and 4 shows associated non-orthopedic and orthopedic injuries of both patients who sustained ligamentous knee injuries and those who did not. Patients who sustained ligamentous knee injuries were significantly more likely to have associated traumatic brain injury, solid organ injury and deep vein thrombosis of the lower extremity. As far as associated orthopedic injuries, patients who had ligamentous knee injuries were more likely to have cervical spine injury, lumbar spine injury, pelvic ring injuries, acetabular fractures, distal femur fractures, patella fractures, tibial plateau fractures, tibial pilon fractures and knee dislocations when compared to those who did not have ligamentous knee injuries. Table 1 and Table 5 shows hospital and intensive care stay characteristics. Patients with ligamentous knee injuries were more likely to be admitted to the hospital and to the intensive care unit and had significantly longer hospital stay compared to those who did not have ligamentous knee injuries. Discussion Pedestrian versus motor vehicle accidents represent a high-energy mechanism that is common in urban areas and is associated with substantial morbidity and mortality [1]. Peng et al reviewed 5,000 pedestrians injured over a three year period by accessing a county database [1]. Their review showed that most common injuries included musculoskeletal (34.3%), head and neck (30.0%), external (24.4%), abdomen and pelvis (3.9%), chest (2.4%) and spine (1.8%). Additionally, they showed that at the time of discharge, 78% of patients had a temporary disability, 4% had a permanent handicap, and only 16% were functioning at preadmission capacity [1]. In another large review of 4,435 patients, Reith et al compared pedestrian versus motor vehicle patients to patients presenting as motor vehicle occupants [7]. They showed that the pedestrian cohort was more severely injured and had a higher rate of head injuries, pelvis injuries and lower extremity injuries [7]. In our review, patients who sustained a ligamentous knee injury were more likely to sustain traumatic brain injury and solid organ injury. Additionally, cervical spine injury, lumbar spine injury, pelvic ring injuries, acetabular fractures, distal femur fractures, patella fractures, tibial plateau fractures, tibial pilon fractures and knee dislocations when more common when compared to those patients who did not have ligamentous knee injuries. Lower extremity DVT was more common in patients who sustained ligamentous knee injury as well. These co-existing injuries should be acknowledged by the treating physician and could complicate the management of the ligamentous knee injury. Orthopedic injuries, especially of the lower extremity, are very common in the pedestrian versus motor vehicle accident population. In one of the largest reviews of orthopedic trauma in this population, Brainard et al showed 96 injuries of the lower extremities in 115 patients who presented with this mechanism of injury [2]. Despite this, there has been little literature which looks specifically at ligamentous knee injuries in the pedestrian versus motor vehicle patient population. Our review shows a prevalence of 12.4% for ligamentous knee injuries in the pedestrian versus motor vehicle population. Becker et al reviewed 100 ligamentous knee injuries that presented to a level 1 trauma center, and found 23 patients (23%) presented as pedestrians struck by a motor vehicle [3]. Moatshe et al evaluated 303 patients with a knee dislocation and showed that 5.9% of patients were pedestrians struck by a motor vehicle [4]. Ferry et al reviewed all patients who had a knee injury over a 14 year period and found that 14% of these patients were pedestrians who were struck by motor vehicles [5]. Forward et al showed that nearly half of the patients in their cohort sustained a knee injury following pedestrian versus motor vehicle accidents and 22% of those knee injuries were ligamentous in nature [6]. It can be difficult to diagnose a ligamentous knee injury in this patient population given that they often have injuries of multiple systems, thus a high index of suspicion is necessary. We recommend performing a thorough ligamentous knee exam in patients presenting with this mechanism. Not all patients in our review received MRI, however, in those that did, the most common pattern of injury was ACL+PCL+MCL+LCL/PLC complex and all but two were multi-ligamentous in nature. Additionally, we had a large number of concomitant intra-articular injuries which were identified on MRI. Given that a majority of these are multi-ligamentous, we recommend obtaining MRI in patients with suspected ligamentous knee injury who are stable enough to have the study and would benefit from potential repair or reconstruction. Previous studies have reported on length of intensive care and hospital stay following pedestrian versus motor vehicle accidents. Peng et al showed that intensive care 6.5 ± 0.3 days and overall hospital stay was 7.4 ± 0.2 days [1]. In their comparison to patients who were occupants of motor vehicle accidents, Reith et al showed that pedestrians had a similar length of intensive care and overall hospital stay [7]. McElroy et al showed that pedestrian versus motor vehicle victims had an average hospital stay of 10.8 days and intensive care stay of 6 ± 7.5 days [8]. Specifically looking at knee injuries, Georgiadis et al showed that the average length of hospital stay in trauma patients who sustained a knee dislocation was 11.4 days [9]. Woodmass et showed that the average ICU stay in patients who sustained multi-ligamentous knee injuries was 2.8 days [10]. Additionally, they showed that 48% of patients with multi-ligamentous knee injuries required intensive care stay [10]. In our review, pedestrians who sustained a ligamentous knee injury had a longer overall hospital stay and were more likely to need inpatient admission and intensive care stay when compared to those who did not sustain a ligamentous knee injury. This study does have limitations which need mentioned. This is a retrospective study and thus subject to selection bias. For this review the clinical follow up was very poor, therefore there could have been patients who were lost to follow up which sustained a ligamentous knee injury that was missed while inpatient. Additionally, patients were excluded if they died within 24 hours or died prior to orthopedic evaluation. These patients were often severely injured and potentially could have had ligamentous knee injuries as well. Given the poor follow up, we chose not to investigate how these patients fared after surgical or non-surgical management, thus this is a practice gap which could be evaluated with future studies. MRI was not obtained in all patients who sustained a ligamentous knee injury, typically this was due to patients who were clinically too unstable or if the knee injury was managed conservatively by the attending surgeons. Conclusion In conclusion, patients presenting as pedestrian versus motor vehicle have a high prevalence of ligamentous knee injuries and thus a high index of suspicion is necessary when evaluating these patients. Pedestrian versus motor vehicle accidents with ligamentous knee injuries were more likely to have multiple orthopedic and non-orthopedic injuries when compared to those without ligamentous knee injuries, thus representing the high energy of this mechanism. Patients sustaining ligamentous knee injuries were also more likely to be admitted to the hospital and intensive care unit and the length of overall hospital stay were also longer when compared to those who did not sustain ligamentous knee injury. Declarations Ethics Approval and Consent to Participate: Not Applicable Consent for Publication: Not Applicable Availability of Data and Materials: The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests Funding: No funding was obtained for this research Authors Contributions: RS made substantial contributions to the conception and design work of the research, the acquisition and analysis of data, the interpretation of data, and drafted the work. MM made substantial contributions to the conception and design work of the research and the acquisition of data. ST made substantial contributions in the acquisition and analysis of data and substantively revised the drafted manuscript. JH made substantial contributions to the conception and design work of the research and the acquisition of data. GH made substantial contributions in the acquisition and analysis of data. KH made substantial contributions to the interpretation of data. DT acted as a faculty sponsor as well as provided feedback and direction during the research process DR acted as a faculty sponsor as well as provided feedback and direction during the research process Acknowledgements: Not Applicable References Peng, R. Y., & Bongard, F. S. (1999). Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients. Journal of the American College of Surgeons, 189(4), 343–348. doi: 10.1016/s1072–7515(99)00166–0 Brainard, B. J., Slauterbeck, J., & Benjamin, J. B. (1992). Fracture Patterns and Mechanisms in Pedestrian Motor-Vehicle Trauma. Journal of Orthopaedic Trauma, 6(3), 279–282. doi: 10.1097/00005131–199209000–00002 Becker, E. H., Watson, J. D., & Dreese, J. C. (2013). Investigation of Multiligamentous Knee Injury Patterns With Associated Injuries Presenting at a Level I Trauma Center. Journal of Orthopaedic Trauma, 27(4), 226–231. doi: 10.1097/bot.0b013e318270def4 Moatshe, B. G., Dornan, G., Løken, S., Ludvigsen, T. C., Laprade, R. F., & Engebretsen, L. (2017). Knee Dislocations Demographics and Associated Injuries: A Prospective Review of 303 Patients. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(10). doi: 10.1016/j.arthro.2017.08.195 Ferry, T., Bergström, U., Hedström, E. M., Lorentzon, R., & Zeisig, E. (2013). Epidemiology of acute knee injuries seen at the Emergency Department at Umeå University Hospital, Sweden, during 15 years. Knee Surgery, Sports Traumatology, Arthroscopy, 22(5), 1149–1155. doi: 10.1007/s00167–013–2555–3 Forward, D. P., Coffey, F., Wallace, W. A., & Ellis, J. (2003). Knee injuries sustained in pedestrian road traffic accidents. Orthopaedic Proceedings, 85-B(supp), 13–13. Reith, G., Lefering, R., Wafaisade, A., Hensel, K. O., Paffrath, T., Bouillon, B., & Probst, C. (2015). Injury pattern, outcome and characteristics of severely injured pedestrian. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23(1). doi: 10.1186/s13049–015–0137–8 McElroy, L. M., Juern, J. J., Bertleson, A., Xiang, Q., Szabo, A., & Weigelt, J. (2013). A single urban center experience with adult pedestrians struck by motor vehicles. WMJ, 112(3), 117–122. Georgiadis, A. G., Mohammad, F. H., Mizerik, K. T., Nypaver, T. J., & Shepard, A.D. (2012). Changing Presentation of Knee Dislocation and Vascular Injury: From High-Energy Trauma to Low-Energy Falls in the Morbidly Obese. Journal of Vascular Surgery, 56(4), 1189. doi: 10.1016/j.jvs.2012.08.018 Woodmass, J. M., Johnson, N. R., Mohan, R., Krych, A. J., Levy, B. A., & Stuart, M. J. (2017). Poly-traumatic multi-ligament knee injuries: is the knee the limiting factor? Knee Surgery, Sports Traumatology, Arthroscopy, 26(9), 2865–2871. doi: 10.1007/s00167–017–4784–3 Tables Due to technical limitations, Tables 1 - 5 are only available for download from the Supplementary Files section. Supplementary Files Table2.docx Table3.docx Table5.docx Table4.docx Table1.docx Cite Share Download PDF Status: Published Journal Publication published 10 Jun, 2020 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Review # 2 received at journal 30 Apr, 2020 Editorial decision: Minor revision 30 Apr, 2020 Review # 1 received at journal 24 Apr, 2020 Reviewer # 2 agreed at journal 08 Apr, 2020 Reviewer # 1 agreed at journal 06 Apr, 2020 Reviewers invited by journal 18 Mar, 2020 Editor assigned by journal 06 Mar, 2020 First submitted to journal 05 Mar, 2020 Submission checks completed at journal 05 Mar, 2020 Editor invited by journal 05 Mar, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Given the high energy associated with these injuries, the patients often have multiple systems injured, which leads to substantial morbidity and mortality [1]. Orthopedic injuries are very common and as shown by Brainard et al, lower extremity injuries are the most common orthopedic injuries in patients presenting as pedestrian versus motor vehicle accidents [2]. Despite this, not much is known about the prevalence of ligamentous knee injuries in this patient population.\u003c/p\u003e\n\n\u003cp\u003eThe purpose of this study is to determine the prevalence and characteristics of ligamentous knee injuries in patients presenting as pedestrian versus motor vehicle accidents. We also sought to compare patient demographics, associated orthopedic and non-orthopedic injuries, intensive care stay and overall hospital stay to patients who did not have ligamentous knee injuries.\u003c/p\u003e\n\n\n"},{"header":"Materials And Methods","content":"\n\n\u003cp\u003eInstitutional Review Board approval was obtained for this retrospective study. All patients greater than 18 years of age involved in pedestrian accidents presenting to a single institution level 1 trauma center from 2013–2017 were queried through our institution’s trauma database. Patients who died within 24 hours of admission or died prior to orthopedic examination were excluded. Charts were retrospectively reviewed for age at time of injury, gender, height, weight, insurance status, hospital stay, intensive care stay, discharge destination, chest trauma, solid organ injury, vascular injury, facial and skull fractures, traumatic brain injury, gastrointestinal injury, genitourinary injury, spine and spinal cord injury, associated upper and lower extremity injuries. Ligamentous knee injuries were diagnosed either with physical exam or magnetic resonance imaging (MRI). For patients with ligamentous knee injuries, charts were reviewed for magnetic resonance imaging, specific ligaments or ligamentous complexes injured, meniscal injury, nerve injury, arterial injury, knee dislocation, chondral injury, bone bruise and subchondral fracture. For this studies, ligaments included were the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament/posterior lateral corner complex (LCL/PLC). For this study, the LCL/PLC complex includes the lateral collateral ligament, popliteus, popliteofibular ligament, arcuate ligament, fabellofibular ligament, long head of biceps femoris tendon and iliotibial band.\u003c/p\u003e\n\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\n\u003cp\u003eDemographic and clinical characteristics were compared among patients with a ligamentous knee injury and patients without the injury. Chi-square tests were used to compare proportions and a T-test was used to compare continuous data. Wilcoxon rank sum p-value was used for length of stay data. The incidence of identified injuries was calculated along with a 95% confidence interval.\u003c/p\u003e\n\n\n\n\n"},{"header":"Results","content":"\n\n\u003cp\u003e557 patients were identified in our review and 18 patients were excluded due to death within 24 hours or death prior to adequate orthopedic evaluation leaving 539 patients to be included in this study. Table 1 shows the demographics of all included patients. 67 patients sustained ligamentous knee injuries giving a prevalence of 12.4%. Seventeen patients sustained bilateral ligamentous knee injuries, giving a total of eighty-four ligamentous knee injuries. There were six knee dislocations, three vascular injuries and three peroneal nerve injuries.\u003c/p\u003e\n\n\u003cp\u003eMRI was available for 55/84 injured knees, the most common ligaments injured were anterior cruciate ligament (47), medial collateral ligament (45), lateral collateral ligament/ posterior lateral corner ligamentous complex (44) and the posterior cruciate ligament (38). Additionally, on MRI there were 37 instances of bone bruises or subchondral impaction fractures involving either the femoral condyles or tibial plateaus, 47 meniscal injuries and 9 acute chondral injuries. Table 2 shows the most common patterns of ligamentous injuries.\u003c/p\u003e\n\n\u003cp\u003eTables 3 and 4 shows associated non-orthopedic and orthopedic injuries of both patients who sustained ligamentous knee injuries and those who did not. Patients who sustained ligamentous knee injuries were significantly more likely to have associated traumatic brain injury, solid organ injury and deep vein thrombosis of the lower extremity. As far as associated orthopedic injuries, patients who had ligamentous knee injuries were more likely to have cervical spine injury, lumbar spine injury, pelvic ring injuries, acetabular fractures, distal femur fractures, patella fractures, tibial plateau fractures, tibial pilon fractures and knee dislocations when compared to those who did not have ligamentous knee injuries.\u003c/p\u003e\n\n\u003cp\u003eTable 1 and Table 5 shows hospital and intensive care stay characteristics. Patients with ligamentous knee injuries were more likely to be admitted to the hospital and to the intensive care unit and had significantly longer hospital stay compared to those who did not have ligamentous knee injuries.\u003c/p\u003e\n\n\n"},{"header":"Discussion","content":"\n\u003cp\u003ePedestrian versus motor vehicle accidents represent a high-energy mechanism that is common in urban areas and is associated with substantial morbidity and mortality [1]. Peng et al reviewed 5,000 pedestrians injured over a three year period by accessing a county database [1]. Their review showed that most common injuries included musculoskeletal (34.3%), head and neck (30.0%), external (24.4%), abdomen and pelvis (3.9%), chest (2.4%) and spine (1.8%). Additionally, they showed that at the time of discharge, 78% of patients had a temporary disability, 4% had a permanent handicap, and only 16% were functioning at preadmission capacity [1]. In another large review of 4,435 patients, Reith et al compared pedestrian versus motor vehicle patients to patients presenting as motor vehicle occupants [7]. They showed that the pedestrian cohort was more severely injured and had a higher rate of head injuries, pelvis injuries and lower extremity injuries [7]. In our review, patients who sustained a ligamentous knee injury were more likely to sustain traumatic brain injury and solid organ injury. Additionally, cervical spine injury, lumbar spine injury, pelvic ring injuries, acetabular fractures, distal femur fractures, patella fractures, tibial plateau fractures, tibial pilon fractures and knee dislocations when more common when compared to those patients who did not have ligamentous knee injuries. Lower extremity DVT was more common in patients who sustained ligamentous knee injury as well. These co-existing injuries should be acknowledged by the treating physician and could complicate the management of the ligamentous knee injury.\u003c/p\u003e\n\n\u003cp\u003eOrthopedic injuries, especially of the lower extremity, are very common in the pedestrian versus motor vehicle accident population. In one of the largest reviews of orthopedic trauma in this population, Brainard et al showed 96 injuries of the lower extremities in 115 patients who presented with this mechanism of injury [2]. Despite this, there has been little literature which looks specifically at ligamentous knee injuries in the pedestrian versus motor vehicle patient population. Our review shows a prevalence of 12.4% for ligamentous knee injuries in the pedestrian versus motor vehicle population. Becker et al reviewed 100 ligamentous knee injuries that presented to a level 1 trauma center, and found 23 patients (23%) presented as pedestrians struck by a motor vehicle [3]. Moatshe et al evaluated 303 patients with a knee dislocation and showed that 5.9% of patients were pedestrians struck by a motor vehicle [4]. Ferry et al reviewed all patients who had a knee injury over a 14 year period and found that 14% of these patients were pedestrians who were struck by motor vehicles [5]. Forward et al showed that nearly half of the patients in their cohort sustained a knee injury following pedestrian versus motor vehicle accidents and 22% of those knee injuries were ligamentous in nature [6]. It can be difficult to diagnose a ligamentous knee injury in this patient population given that they often have injuries of multiple systems, thus a high index of suspicion is necessary. We recommend performing a thorough ligamentous knee exam in patients presenting with this mechanism. Not all patients in our review received MRI, however, in those that did, the most common pattern of injury was ACL+PCL+MCL+LCL/PLC complex and all but two were multi-ligamentous in nature. Additionally, we had a large number of concomitant intra-articular injuries which were identified on MRI. Given that a majority of these are multi-ligamentous, we recommend obtaining MRI in patients with suspected ligamentous knee injury who are stable enough to have the study and would benefit from potential repair or reconstruction.\u003c/p\u003e\n\u003cp\u003ePrevious studies have reported on length of intensive care and hospital stay following pedestrian versus motor vehicle accidents. Peng et al showed that intensive care 6.5 ± 0.3 days and overall hospital stay was 7.4 ± 0.2 days [1]. In their comparison to patients who were occupants of motor vehicle accidents, Reith et al showed that pedestrians had a similar length of intensive care and overall hospital stay [7]. McElroy et al showed that pedestrian versus motor vehicle victims had an average hospital stay of 10.8 days and intensive care stay of 6 ± 7.5 days [8]. Specifically looking at knee injuries, Georgiadis et al showed that the average length of hospital stay in trauma patients who sustained a knee dislocation was 11.4 days [9]. Woodmass et showed that the average ICU stay in patients who sustained multi-ligamentous knee injuries was 2.8 days [10]. Additionally, they showed that 48% of patients with multi-ligamentous knee injuries required intensive care stay [10]. In our review, pedestrians who sustained a ligamentous knee injury had a longer overall hospital stay and were more likely to need inpatient admission and intensive care stay when compared to those who did not sustain a ligamentous knee injury.\u003c/p\u003e\n\n\u003cp\u003eThis study does have limitations which need mentioned. This is a retrospective study and thus subject to selection bias. For this review the clinical follow up was very poor, therefore there could have been patients who were lost to follow up which sustained a ligamentous knee injury that was missed while inpatient. Additionally, patients were excluded if they died within 24 hours or died prior to orthopedic evaluation. These patients were often severely injured and potentially could have had ligamentous knee injuries as well. Given the poor follow up, we chose not to investigate how these patients fared after surgical or non-surgical management, thus this is a practice gap which could be evaluated with future studies. MRI was not obtained in all patients who sustained a ligamentous knee injury, typically this was due to patients who were clinically too unstable or if the knee injury was managed conservatively by the attending surgeons.\u003c/p\u003e\n\n"},{"header":"Conclusion","content":"\n\n\u003cp\u003eIn conclusion, patients presenting as pedestrian versus motor vehicle have a high prevalence of ligamentous knee injuries and thus a high index of suspicion is necessary when evaluating these patients. Pedestrian versus motor vehicle accidents with ligamentous knee injuries were more likely to have multiple orthopedic and non-orthopedic injuries when compared to those without ligamentous knee injuries, thus representing the high energy of this mechanism. Patients sustaining ligamentous knee injuries were also more likely to be admitted to the hospital and intensive care unit and the length of overall hospital stay were also longer when compared to those who did not sustain ligamentous knee injury.\u003c/p\u003e\n\n\n"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate: Not Applicable\u003c/p\u003e\n\u003cp\u003eConsent for Publication: Not Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials: The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting Interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: No funding was obtained for this research\u003c/p\u003e\n\u003cp\u003eAuthors Contributions:\u003c/p\u003e\n\u003cp\u003eRS made substantial contributions to the conception and design work of the research, the acquisition and analysis of data, the interpretation of data, and drafted the work.\u003c/p\u003e\n\u003cp\u003eMM made substantial contributions to the conception and design work of the research and the acquisition of data.\u003c/p\u003e\n\u003cp\u003eST made substantial contributions in the acquisition and analysis of data and substantively revised the drafted manuscript.\u003c/p\u003e\n\u003cp\u003eJH made substantial contributions to the conception and design work of the research and the acquisition of data.\u003c/p\u003e\n\u003cp\u003eGH made substantial contributions in the acquisition and analysis of data.\u003c/p\u003e\n\u003cp\u003eKH made substantial contributions to the interpretation of data.\u003c/p\u003e\n\u003cp\u003eDT acted as a faculty sponsor as well as provided feedback and direction during the research process\u003c/p\u003e\n\u003cp\u003eDR acted as a faculty sponsor as well as provided feedback and direction during the research process\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not Applicable\u003c/p\u003e"},{"header":"References","content":"\n\n\u003col\u003e\u003cli\u003ePeng, R. Y., \u0026amp; Bongard, F. S. (1999). Pedestrian versus motor vehicle accidents: an analysis of 5,000 patients. Journal of the American College of Surgeons, 189(4), 343–348. doi: 10.1016/s1072–7515(99)00166–0\u003c/li\u003e\u003cli\u003eBrainard, B. J., Slauterbeck, J., \u0026amp; Benjamin, J. B. (1992). Fracture Patterns and Mechanisms in Pedestrian Motor-Vehicle Trauma. Journal of Orthopaedic Trauma, 6(3), 279–282. doi: 10.1097/00005131–199209000–00002\u003c/li\u003e\u003cli\u003eBecker, E. H., Watson, J. D., \u0026amp; Dreese, J. C. (2013). Investigation of Multiligamentous Knee Injury Patterns With Associated Injuries Presenting at a Level I Trauma Center. Journal of Orthopaedic Trauma, 27(4), 226–231. doi: 10.1097/bot.0b013e318270def4\u003c/li\u003e\u003cli\u003eMoatshe, B. G., Dornan, G., Løken, S., Ludvigsen, T. C., Laprade, R. F., \u0026amp; Engebretsen, L. (2017). Knee Dislocations Demographics and Associated Injuries: A Prospective Review of 303 Patients. Arthroscopy: The Journal of Arthroscopic \u0026amp; Related Surgery, 33(10). doi: 10.1016/j.arthro.2017.08.195\u003c/li\u003e\u003cli\u003eFerry, T., Bergström, U., Hedström, E. M., Lorentzon, R., \u0026amp; Zeisig, E. (2013). Epidemiology of acute knee injuries seen at the Emergency Department at Umeå University Hospital, Sweden, during 15 years. Knee Surgery, Sports Traumatology, Arthroscopy, 22(5), 1149–1155. doi: 10.1007/s00167–013–2555–3\u003c/li\u003e\u003cli\u003eForward, D. P., Coffey, F., Wallace, W. A., \u0026amp; Ellis, J. (2003). Knee injuries sustained in pedestrian road traffic accidents. Orthopaedic Proceedings, 85-B(supp), 13–13.\u003c/li\u003e\u003cli\u003eReith, G., Lefering, R., Wafaisade, A., Hensel, K. O., Paffrath, T., Bouillon, B., \u0026amp; Probst, C. (2015). Injury pattern, outcome and characteristics of severely injured pedestrian. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 23(1). doi: 10.1186/s13049–015–0137–8\u003c/li\u003e\u003cli\u003eMcElroy, L. M., Juern, J. J., Bertleson, A., Xiang, Q., Szabo, A., \u0026amp; Weigelt, J. (2013). A single urban center experience with adult pedestrians struck by motor vehicles. WMJ, 112(3), 117–122.\u003c/li\u003e\u003cli\u003eGeorgiadis, A. G., Mohammad, F. H., Mizerik, K. T., Nypaver, T. J., \u0026amp; Shepard, A.D. (2012). Changing Presentation of Knee Dislocation and Vascular Injury: From High-Energy Trauma to Low-Energy Falls in the Morbidly Obese. Journal of Vascular Surgery, 56(4), 1189. doi: 10.1016/j.jvs.2012.08.018\u003c/li\u003e\u003cli\u003eWoodmass, J. M., Johnson, N. R., Mohan, R., Krych, A. J., Levy, B. A., \u0026amp; Stuart, M. J. (2017). Poly-traumatic multi-ligament knee injuries: is the knee the limiting factor? Knee Surgery, Sports Traumatology, Arthroscopy, 26(9), 2865–2871. doi: 10.1007/s00167–017–4784–3\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"Due to technical limitations, Tables 1 - 5 are only available for download from the Supplementary Files section."}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-16953/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-16953/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose:\u0026nbsp;\u0026nbsp;The purpose of this study was to determine the prevalence and characteristics of ligamentous knee injuries and to compare patient demographics, associated injuries and hospital stay to pedestrians who did not sustain a ligamentous knee injury.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\u003cp\u003eMethods:\u0026nbsp;\u0026nbsp;A retrospective review of all adult patients presenting as pedestrians struck by a motor vehicle to a level 1 trauma center over a three-year period was performed.\u0026nbsp;Demographics, length of stay, orthopedic and non-orthopedic traumatic injuries were recorded.\u0026nbsp;Magnetic resonance imaging was reviewed for ligamentous, bony and chondral injuries.\u0026nbsp;\u003c/p\u003e\u003cp\u003eResults:\u0026nbsp;\u0026nbsp;539 patients were included.\u0026nbsp;\u0026nbsp;67 (12.4%) patients sustained a ligamentous knee injury and the majority of these were multi-ligamentous in nature.\u0026nbsp;\u0026nbsp;Patients with ligamentous knee injury were more likely to sustain traumatic brain injury, solid organ injury, cervical and lumbar spine injury, pelvic ring injuries, distal femur fractures, patella fractures, knee dislocations, tibial plateau fractures, tibial pilon fractures, and deep vein thrombosis when compared to patients who did not sustain ligamentous knee injury.\u0026nbsp;\u0026nbsp;Patients who sustained ligamentous knee injury were more likely to require hospital and intensive care admission and had a longer overall hospital stay.\u0026nbsp;\u003c/p\u003e\u003cp\u003eConclusion:\u0026nbsp;Given the high prevalence of ligamentous knee injuries in this patient population, these patients should be thoroughly evaluated for a ligamentous knee injury.\u0026nbsp;\u0026nbsp;If ligamentous knee injury is suspected, MRI should be considered as a majority of these injuries involved multiple structures.\u0026nbsp;\u0026nbsp;Patients with ligamentous knee injuries often had multi-system injuries with resulting longer hospital stay when compared to those without ligamentous knee injuries.\u0026nbsp;\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Prevalence of Ligamentous Knee Injuries in Pedestrian Versus Motor Vehicle Accidents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-03-12 15:10:18","doi":"10.21203/rs.3.rs-16953/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-04-30T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nBMC Musculoskeletal Disorders\n\nPrevalence of Ligamentous Knee Injuries in Pedestrian Versus Motor Vehicle Accidents\n\nOverview\nThis article is a retrospective study aiming to describe ligamentous knee injury prevalence among pedestrian struck by motor vehicles and to compare epidemiological and clinical data between patients who sustained ligamentous injury and patients who did not.\nThe authors conducted a retrospective analysis including all the patients admitted at their center (level 1 trauma hospital) between 2013 and 2017 involved in a pedestrian versus motor vehicle accident who did not died within 24 hours from the accident. Demographics, associated lesions as well as hospital stay and insurance data were recorded and compared between patients with and without ligamentous injuries.\nThe topic treated can be considered of interest and the scarcity of available literature makes this manuscript a valuable work.\nThe article is well structured and can be considered eligible with minor changes.\n\n\nAbstract\n8) MRI was reviewed when available (how many cases?)\n10) When starting a period with a number, write it as a word\n11) ..the majority was multiligamentous in nature (how many? percentage).\n12) change \"sustain\" with \"be affected also by\"\n\nIntroduction\nToo short. Add some epidemiology of pedestrian versus motor vehicle accidents if available in the literature. What are the most common injuries sustained, what is the percentage of knee involvement, how long is the hospital stay on average. Also introduce knee multiligament injuries and possible consequences on joint natural history.\n36) do not use we/our senteces\n\nMaterials and Methods\n53) use \"MRI\" abbreviation\n55) study\n58) change \"includes\" with \"was considered to include\"\n\nResults \u0026 Figures\n74) When starting a period with a number, write it as a word.\nAdd percentages when describing results.\n84) better describe the location of bone bruises and meniscal injuries\n88) Put table references after introducing the topic of interest, considering them as a additional information to sum up lot of data.\nTable 2) Improve graphic representation of the table\nTable 5) Was the average hospital stay identical (5 days) between with and without ligament injury? Also add range and/or standard deviation.\nHow were the injuries treated?\n\nDiscussion\nStart discussion with \"The main finding of this study is\"\nOverall, discussion in well written, but need to be implemented with some other references related to ligamentous injuries in pedestrian-car injuries and to the consequences of the injuries. Moreover, the clinical relevance of this study has to be better defined.\nIs there a suggestion about the better timing to perform MRI? During the hospital stay? And what about the treatment of this injuries?\n156) Longer overall hospital stay (cite your own data when comparing).\n160) need to be mentioned\n\nConclusion\nOk\n\nReferences\nAdd some other relevant references\nSuggested articles:\nEpidemiology of Pedestrian-Motor Vehicle Fatalities and Injuries, 2006-2015.\nChong SL, Chiang LW, Allen JC Jr, Fleegler EW, Lee LK.\nAm J Prev Med. 2018 Jul;55(1):98-105. doi: 10.1016/j.amepre.2018.04.005. Epub 2018 Jun 18.\n\n\n\nPedestrian fatality risk as a function of car impact speed.\nRosén E, Sander U.\nAccid Anal Prev. 2009 May;41(3):536-42. doi: 10.1016/j.aap.2009.02.002. Epub 2009 Feb 24.\n\n\nSimultaneous bilateral multiligamentous knee injuries are associated with more severe multisystem trauma compared to unilateral injuries.\nBurrus MT, Werner BC, Cancienne JM, Miller MD.\nKnee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):3038-43. doi: 10.1007/s00167-015-3720-7. Epub 2015 Jul 28.\n\nEpidemiology and outcomes of traumatic knee dislocations: isolated vs multi-trauma injuries\nG. Darcy, E. Edwards, R. Hau\nInjury., 49 (2018), pp. 1183-1187\n\nDecision making in the multiligament-injured knee: an evidence-based systematic review\nB.A. Levy, K.A. Dajani, D.B. Whelan, et al.\nArthroscopy., 25 (4) (2009), pp. 430-438\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **Nothing to disclose**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"decision","content":"Minor revision","date":"2020-04-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-04-24T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nI enjoyed reading your paper as it describes some novel data. However, I would like to see some changes in the paper.\n1) I would like to see 95% confidence intervals when describing prevalence.\n2) In the Statistical Analysis on line 66-67 you state that the incidence of identified injuries were calculated along with a 95% CI, but, I don't see any 95% CI listed anywhere in the paper.\n3) In the Material and Methods section on line 51-52 you talk about the diagnosis of ligamentous knee injuries. I would like to see a short discourse on the reliability and validity of the diagnosis with both physical exam and MRI. It is important that any diagnosis in the data be made with a reliable and valid method.\n4) On line 88, you describe Tables 3 and 4 where it shows associated non-orthopedic and orthopedic injuries. I would like to see the strength of these associations described with odd ratios and 95% CI. The same can be done with any association you are looking at in Table 1.\n\nI feel these changes would strengthen your paper and make it more acceptible for publication in this journal. I look forward to seeing these updates in your manuscript.\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **No to the above**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: ** I agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-04-08T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-04-06T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-03-18T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-03-06T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-03-05T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-03-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-03-05T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4743a3d7-454a-4bb5-afdf-854d0463fa46","owner":[],"postedDate":"March 12th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":69150,"name":"Orthopedics"}],"tags":[],"updatedAt":"2021-09-27T18:28:14+00:00","versionOfRecord":{"articleIdentity":"rs-16953","link":"https://doi.org/10.1186/s12891-020-03397-w","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2020-06-10 18:21:27","publishedOnDateReadable":"June 10th, 2020"},"versionCreatedAt":"2020-03-12 15:10:18","video":"","vorDoi":"10.1186/s12891-020-03397-w","vorDoiUrl":"https://doi.org/10.1186/s12891-020-03397-w","workflowStages":[]},"version":"v1","identity":"rs-16953","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-16953","identity":"rs-16953","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}