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Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
KENNETH A. EGOL
EDITOR,VOL. 60
COMMITTEE
KENNETH A. EGOL
CHAIR
FREDERICK M. AZAR
MARY I. O’CONNOR
MARK PAGNANO
PAUL TORNETTA III
EX-OFFICIO
DEMPSEY S. SPRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES
Printed with permission of the American Academy of
Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
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or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
2234
Management of Complex
Knee Ligament Injuries
By Gregory C. Fanelli, MD, James P. Stannard, MD, Michael J. Stuart, MD, Peter B. MacDonald, MD
Robert G. Marx, MD, MSc, FRCSC, Daniel B. Whelan, MD, Joel L. Boyd, MD, and Bruce A. Levy, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Initial Evaluation of Acute and
Chronic Multiligament Knee Injuries
Initial evaluation of a knee with multiple
ligament injuries begins with a thorough
and complete neurovascular examina-
tion, an assessment of the soft tissue,
and determination of the instability
pattern. Failure to recognize a vascular
injury can lead to catastrophic limb
dysfunction and ultimately to amputa-
tion. Injury to the tibial and/or peroneal
nerves can also have devastating conse-
quences and is encountered in almost
25% of dislocated knees
1
. The modified
Schenck classification
2
, in which not
only ligamentous structures but also
neurovascular injury and the presence of
periarticular fracture are taken into
account, is widely used to describe these
injuries.
Vascular Assessment
There are several algorithms for the
assessment of vascular injury of the
lower limb. Vascular assessment may
include physical examination alone, use
of the ankle-brachial index, arterial
ultrasound, and conventional and/or
computed tomography angiography. A
palpable pulse may be present distal to
a complete popliteal arterial occlusion,
as a result of the presence of collateral
flow (Fig. 1). When a patient presents
with ‘‘hard signs’’ of ischemia, which
include a cool, pulseless, obviously
dysvascular limb, immediate vascular
surgery consultation is warranted.
When the level of the lesion (for
example, the popliteal artery in the
setting of a dislocated knee) is known,
the vascular surgeon may opt for
immediate surgical exploration or pro-
ceed with angiography. Typically, a sa-
phenous vein bypass graft obtained
from the contralateral side is used to
reestablish arterial flow, and concomi-
tant prophylactic four-compartment
fasciotomies are done. When a patient
presents with ‘‘soft signs’’ of ischemia,
including palpable but asymmetric
pulses and asymmetric warmth and/or
color of the limb, further assessment is
needed.
The ankle-brachial index is de-
termined by obtaining the systolic blood
pressure of the affected limb at the level
of the ankle and comparing it with the
systolic blood pressure of the ipsilateral
arm at the level of the brachial artery
(Fig. 2): ankle-brachial index =Doppler
systolic arterial pressure in injured limb
(ankle)/Doppler systolic arterial pres-
sure in uninjured limb (brachial).
Mills et al.
3
showed that when the
ankle-brachial index is 0.9 there is no
risk of a major arterial injury but,
because delayed thrombus is a risk,
serial pulse examination should be done
every four to six hours for a period of
twenty-four hours. When the ankle-
brachial index is <0.9, either arterial
ultrasound or computed tomography
angiography
4
should be done. Duplex
arterial ultrasound has excellent sensi-
tivity and specificity; however, it is
technician-dependent and not all cen-
ters have access to an ultrasound
technician around the clock. The ad-
vantage of computed tomography angi-
ography over conventional angiography
is that there is less than one-fourth the
dose of radiation, access is obtained
through the antecubital fossa as opposed
to the groin, and computed tomography
angiography is 100% sensitive and
specific
5
. Conventional angiography has
a 5% to 7% false-positive rate.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. In addition, one or more of
the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or
agreement to provide such benefits from commercial entities (Biomet and Arthrex).
J Bone Joint Surg Am. 2010;92:2235-46
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
Neurologic Assessment
Niall et al.
1
reported the risk of peroneal
nerve injury with dislocation of the knee
to be approximately 25%. In their series,
<50% of the patients had nerve re-
covery. Prompt placement of an ankle-
foot orthosis in the early postinjury
period is important to prevent equinus
deformity from Achilles tendon
contracture.
Treatment of a peroneal nerve
palsy can include sural nerve grafting,
direct repair, neurolysis, and tibial
tendon transfer, but the success of
treatment can vary widely. The direct
transfer of tibial nerve motor branches
to the peroneal nerve has promise, but
the long-term results of this procedure
are unknown.
Diagnostic Imaging
A substantial number of dislocated
knees spontaneously reduce, and ra-
diographic findings may be subtle, but
standard anteroposterior and lateral
radiographs of the knee are necessary
following this injury. Joint asymmetry,
mild tibiofemoral subluxation, avul-
sion fractures, and rim fractures are
clues to the extent of the injury. In the
nonacute setting, bilateral comparison
stress radiography (varus, valgus, and
posterior) can help to determine the
extent of ligamentous instability.
LaPrade et al.
6
reported that demon-
stration of a side-to-side difference of
2.7 mm on comparison of varus stress
anteroposterior radiographs indicates
a fibular collateral ligament injury,
whereas a side-to-side difference of
>4.0 mm indicates a fibular collateral
ligament and posterolateral corner
injury. In the acute setting, fluoroscopic
stress examination with the patient
under anesthesia helps to confirm
clinical and/or magnetic resonance
imaging findings.
Magnetic resonance imaging is
the diagnostic imaging modality of
choice after radiographs have been
obtained. Magnetic resonance imaging
identifies the ligament injury and
its specific location and extent, both
of which are critical for surgical
planning.
Indications for Emergency
Surgical Treatment
The indications for emergency surgical
treatment include an open knee dislo-
cation, an irreducible knee dislocation,
and a compartment syndrome. Open
knee dislocations require aggressive
irrigation and debridement and place-
ment of antibiotic bead pouches and/or
a wound vacuum-assisted closure device
(VAC; Kinetic Concepts, San Antonio,
Texas), and may warrant plastic surgery
for soft-tissue coverage. The irreducible
knee dislocation is typically a postero-
lateral dislocation in which the medial
femoral condyle buttonholes through
the medial aspect of the capsule and/or
the medial collateral ligament, causing
a classic puckering of the medial skin.
Prompt reduction is imperative to avoid
skin necrosis and typically requires an
open arthrotomy. In emergency cases
such as these, definitive ligament repair
or reconstruction is usually performed
in a staged fashion, once all debridement
and/or wound considerations have been
addressed and the soft tissues have
healed satisfactorily to allow additional
surgery. Indications for the immediate
placement of joint-spanning external
fixation include vascular injury requir-
ing repair, an open knee dislocation, and
the inability to maintain tibiofemoral
joint reduction by other means
7,8
.
Fig. 1
Conventional arteriogram demonstrating collateral
flow to the distal part of the lower extremity despite
complete popliteal artery occlusion.
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
Combined Posterior Cruciate and
Anterior Cruciate Ligament
Reconstruction
The principles of reconstruction in
a knee with multiple ligament injuries
include identification and treatment of
all torn ligaments with accurate tunnel
placement, anatomic graft insertion
sites, utilization of strong graft material,
secure graft fixation, and an extensive
postoperative rehabilitation program
8-24
.
An Achilles tendon allograft is our
preferred graft for single-bundle poste-
rior cruciate ligament reconstructions,
and we prefer Achilles tendon and tibialis
anterior allografts for double-bundle
posterior cruciate ligament reconstruc-
tions. We prefer either a tibialis anterior
or a patellar tendon allograft for anterior
cruciate ligament reconstructions. The
allograft tissue is prepared, and arthro-
scopic instruments are placed with the
inflow in the superolateral portal, the
arthroscope in the inferolateral patellar
portal, and instruments in the infero-
medial patellar portal. An accessory
extracapsular extra-articular posterome-
dial safety incision is used to protect the
neurovascular structures and to confirm
the accuracy of tibial tunnel placement.
Notch preparation is performed
first and consists of anterior cruciate and
posterior cruciate ligament stump de-
bridement, bone removal, and contour-
ing of the medial and lateral walls and
roof of the intercondylar notch. Specially
designed 90°curets and rasps placed
through the notch to the posterior aspect
of the tibia are used to elevate the capsule
and clearly identify the tibial footprint of
the posterior cruciate ligament.
The arm of the PCL ACL guide is
inserted through the inferomedial patel-
lar portal to begin creation of the tibial
tunnel for the posterior cruciate ligament
graft. The tip of the guide is positioned at
the inferolateral aspect of the anatomic
insertion site of the posterior cruciate
ligament. The bullet portion of the guide
contacts the anteromedial surface of
the proximal part of the tibia at a point
midway between the posteromedial bor-
der of the tibia and the anterior aspect
of the tibial crest approximately 1 cm
below the tibial tubercle. This will provide
an angle of graft orientation such that the
graft will turn two very smooth 45°angles
on the posterior aspect of the tibia and
willnothaveanacute90°-angle turn,
which may cause pressure necrosis of the
graft. The tip of the guide in the posterior
aspect of the tibia is confirmed with the
surgeon’s finger through the extracapsu-
lar extra-articular posteromedial safety
incision. Intraoperative anteroposterior
and lateral radiographs may also be used.
The surgeon’s finger confirms the posi-
tion of the guidewire through the pos-
teromedial safety incision, providing
a double safety check. The appropriately
sized standard cannulated reamer is used
to create the tibial tunnel. The surgeon’s
finger through the extracapsular extra-
articular posteromedial incision monitors
the position of the guidewire. The drill
is advanced until it comes to the pos-
terior cortex of the tibia. The chuck is
disengaged from the drill, and the tibial
tunnel is completed by hand, which
provides an additional margin of safety
for completion of the tibial tunnel.
The femoral tunnels for single-
bundle or double-bundle reconstruction
of the posterior cruciate ligament can
be made from inside out. Inserting the
appropriately sized double-bundle
aimer through a low anterolateral pa-
tellar arthroscopic portal creates the
femoral tunnel for the anterolateral
bundle of the posterior cruciate liga-
ment graft. The double-bundle aimer is
positioned directly on the femoral
footprint of the insertion site of the
anterolateral bundle of the posterior
cruciate ligament graft. The appropri-
ately sized guidewire is drilled through
the aimer, through the bone, and out
a small skin incision. The double-
bundle aimer is removed, and an acorn
reamer is used to drill endoscopically
from inside out the femoral tunnel
for the anterolateral bundle of the pos-
terior cruciate ligament graft. When
the surgeon chooses to perform a double-
bundle double-femoral-tunnel recon-
struction of the posterior cruciate
ligament, the same process is repeated
for the posteromedial bundle of the
posterior cruciate ligament graft. There
should be at least 5 mm of bone between
the two drill holes.
The tunnels for anterior cruciate
ligament reconstruction are created with
use of the single-incision technique. The
tibial tunnel begins externally at a point
1 cm proximal to the tibial tubercle on
the anteromedial surface of the proximal
part of the tibia to emerge through the
center of the stump of the anterior
cruciate ligament tibial footprint. The
femoral tunnel is positioned next to the
over-the-top position on the medial wall
of the lateral femoral condyle near the
anatomic insertion site of the anterior
cruciate ligament. The anterior cruciate
ligament graft is positioned and is
anchored on the femoral side; this is
followed by tensioning and tibial fixa-
tion of the anterior cruciate ligament
graft
25
(Figs. 3, 4, and 5).
Fig. 2
Measurement of the ankle-brachial index.
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
Lateral-Sided Reconstruction
The lateral side of the knee is commonly
injured as part of a multiligament knee
dislocation complex. The modified
Schenck
2,26
classification of knee dislo-
cations includes KD IIIL (injuries in-
volving the anterior and posterior
cruciate ligaments as well as the lateral
complex). KD IV is less common and
more severe, as this injury involves both
the medial and lateral sides as well as
both cruciate ligaments. The mechan-
ism of this injury includes a strong varus
and external rotation force that is high-
energy
26
. The lateral side of the knee is
complex anatomically and therefore
difficult to replicate with reconstructive
techniques.
The lateral side consists of static
and dynamic stabilizers. The static
stabilizers include the fibular collateral
ligament and the popliteofibular liga-
ment as well as the posterolateral aspect
of the capsule. The popliteus muscle and
tendon act as both a static and a dy-
namic stabilizer to control posterolateral
rotation of the knee. The fibular col-
lateral ligament acts as a primary re-
straint to varus stress and a secondary
restraint to posterolateral rotation of
thetibiaonthefemur.Thepopliteo-
fibular ligament acts as a primary re-
straint to external rotation of the tibia
on the femur at 30°of flexion, as does
the popliteus muscle and tendon. The
posterolateral aspect of the capsule acts
in a secondary supportive role to resist
external rotation, hyperextension, and
varus moments
27-29
.
The challenge of anatomic re-
constructions is to recreate the postero-
lateral anatomy as closely as possible,
usually with a combination of femoral,
tibial, and fibular drill holes and allograft
tissue. An alternative is to simplify the re-
pair by performing a fibular and femoral-
based reconstruction alone
14,21,30-32
(Figs.
6-A and 6-B). There are few studies
comparing types of reconstructions in
the literature, but, with other knee
reconstructions, the more anatomic
restorations tend to produce the best
results. A reconstruction described by
LaPrade et al.
33
is often mentioned as
the closest reproduction of normal
anatomy and will be described later in
this paper.
The timing of surgery has been one
of the most controversial aspects of knee
dislocation management. Recent studies
have indicated that earlier reconstruction
may be better
34
, but the evidence is not
strong. The benefits of early surgery must
be balanced against the risks of arthro-
fibrosis and the risks of infection where
open wounds persist from either external
Fig. 3
Double-bundle posterior cruciate ligament reconstruction with use of an Achilles tendon allograft
(anterolateral bundle) and a tibialis anterior allograft (posteromedial bundle) as well as anterior
cruciate ligament reconstruction with use of an Achilles tendon allograft.
Fig. 4
Drawing depicting fixation, tunnel, and graft positioning in a combined reconstruction of the posterior and
anterior cruciate ligaments. Note the primary aperture-opening fixation combined with cortical sus-
pensory back-up fixation. (Reprinted, with permission, from: Fanelli GC. Rationale and surgical technique
for PCL and multiple knee ligament reconstruction. Warsaw, IN: Biomet Sports Medicine; 2008.)
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
fixation pin sites or wounds from soft-
tissue injury (Fig. 7). The decision when
to operate needs to be individualized.
Another controversial issue is
whether to repair or reconstruct the
posterolateral corner. Recent work by
both Stannard et al.
34
and Levy et al.
35
indicates that reconstruction is probably
better than repair. When surgery is
performed within the first three weeks
after the injury, a combination of repair
and reconstruction can be done and
should provide the best chance of pro-
ducing a stable posterolateral corner.
Stannard et al. recently reported a trial
of repair versus reconstruction of the
posterolateral corner in fifty-seven
knees
34
. Forty-four (77%) of the patients
had sustained multiple ligament injuries
of the knee, and the minimum duration
of follow-up was twenty-four months.
The repair failure rate was 37%, com-
pared with a reconstruction failure rate
of 9%. Reconstruction was found to
have a significant advantage over re-
pair in terms of stability on clinical
examination.
In the study by Levy et al.
35
,
patients with multiligament knee in-
juries treated by a single surgeon were
identified in a prospective database.
Between February 2004 and May 2005,
patients underwent repair of medial and
lateral-sided injuries, followed by de-
layed cruciate ligament reconstructions.
Between May 2005 and February 2007,
patients underwent single-stage multi-
ligament knee reconstruction. Forty-five
knees (forty-two patients) with a mini-
mum of two years of follow-up were
identified. Four of ten repairs of the
fibular collateral ligament and postero-
lateral corner and one of eighteen
reconstructions of the fibular collateral
ligament and posterolateral corner failed
(p =0.04). Although neither of these
studies
34,35
was randomized, the findings
of the two were quite similar, with both
showing the rate of failure of repairs of
the fibular collateral ligament and pos-
terolateral corner to be significantly
higher than the rate of failure of re-
constructions of those structures.
Numerous surgical techniques to
treat posterolateral corner injury have
been described, with varying clinical
outcomes
14,36-38
. Stannard et al. used
a modified two-tailed technique that
reconstructs the popliteofibular liga-
ment and fibular collateral ligament
through transtibial and transfibular
bone tunnels and around a single screw
on the lateral femoral condyle
36
. Twenty-
two knees were followed for a minimum
of two years, and the mean range of
motion at the time of follow-up was
133°. The mean Lysholm knee score was
90 points for the entire group, 92 points
for the knees with multiligament in-
juries, and 88 points for those with an
isolated posterolateral corner recon-
struction. There were two failures (13%)
in the group with multiligament knee
injuries, compared with no failures in
the group with an isolated posterolateral
corner reconstruction.
Strobel et al. evaluated the clinical
outcomes after single-stage anterior
cruciate ligament, posterior cruciate
ligament, and posterolateral corner re-
construction in seventeen patients with
chronic knee injuries and a minimum
duration of follow-up of twenty-four
months
37
. The posterolateral corner
was reconstructed with a graft passed
through the proximal part of the fibula,
with both graft limbs inserting at an
isometric point on the femur. At the
final evaluation, performed with the
International Knee Documentation
Committee (IKDC) score, the result was
graded as nearly normal for five of the
seventeen patients, as abnormal for ten,
and as grossly abnormal for two. The
mean postoperative subjective IKDC
score was 71.8 ±19.3 points.
Fig. 5
Postoperative radiograph made after reconstruction of the anterior cru-
ciate ligament, posterior cruciate ligament, and posterolateral corner.
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
The LaPrade technique
33
has been
popularized as a stable and anatomically
complete reconstruction utilizing a two-
tailed graft (usually an Achilles tendon
allograft) and reconstructing the fibular
collateral ligament, the popliteofibular
ligament, and the popliteus tendon. This
technique requires four tunnels: two
in the femur (for the insertion of the
fibular collateral ligament and the pop-
liteus tendon), one in the fibula, and one
in the proximal part of the tibia. The
Achilles tendon can be split into two
separate grafts and bone blocks. Both
bone blocks are inset into the femoral
tunnels and secured with interference
screws, replicating the insertions of the
fibular collateral ligament and popliteus
tendon, respectively. The fibular col-
lateral ligament graft then runs from
anterior to posterior through the tun-
nel in the fibula and subsequently into
the tibia. The popliteus portion then
runs from the femur into the tibial
tunnel to join the other graft. A large
bioabsorbable screw is then placed
from anterior to posterior with the two
graft limbs under tension at 30°of
flexion and slight internal rotation.
Excessive internal rotation force can
constrain the knee excessively. Al-
though the procedure is technically
challenging, the results of this recon-
struction appear to be good.
When the posterolateral corner is
torn, there are usually other knee ligament
injuries. Therefore, when the posterolat-
eral corner is being repaired the lateral
collateral ligament and the popliteofibular
ligament complexes should be repaired as
well. Allograft tissue is recommended for
posterolateral corner reconstruction so
that autogenous grafts can be used to
repair the other ligaments and donor site
morbidity is kept to a minimum. Nu-
merous surgical techniques are available,
but varus and posterolateral rotatory
stability is best restored by the technique
with which the surgeon is most familiar.
Reconstruction of the Medial
Collateral Ligament and
Posteromedial Corner
Combined injuries of the anterior cruciate
ligament, posterior cruciate ligament, and
medial collateral ligament/posteromedial
corner are classified as Type III according
to the modified Schenck anatomic classi-
fication scheme. The anatomic structures
on the medial side are arranged in three
distinct layers: Layer 1 is the sartorius and
sartorius fascia; Layer 2 is the superficial
medial collateral ligament, posterior ob-
lique ligament, and semimembranosus;
and Layer 3 is the deep medial collateral
ligament (the meniscofemoral and me-
niscotibial ligaments) and the poster-
omedial aspect of the capsule. The gracilis
and semitendinosus tendons are found
between Layers 1 and 2. These layers are
not always separate since Layers 1 and 2
blend anteriorly, whereas Layers 2 and 3
blend posteriorly.
LaPrade et al.
39
described the
clinically relevant medial knee anatomy.
There are three osseous prominences on
the medial aspect of the distal part of the
femur: the medial epicondyle, the ad-
ductor tubercle, and the gastrocnemius
tubercle. The femoral origin of the
superficial medial collateral ligament
is approximately 3 mm proximal and
5 mm posterior to the epicondyle, while
the tibial insertion is approximately
6 cm distal to the joint line. The deep
medial collateral ligament inserts along
the tibial plateau margin, just distal to
the articular cartilage. The femoral
origin of the posterior oblique ligament
is approximately 8 mm distal and 6 mm
posterior to the adductor tubercle.
These anatomic sites correspond to the
radiographic landmarks described by
Wijdicks et al.
40
. The combination of
recognition of osseous prominences and
radiographic identification helps to
guide the surgeon to the proper liga-
ment origin and insertion sites during
repair or reconstruction. In a study of
cadaver knees, Stannard et al.
41
found
Fig. 6-A
Fig. 6-A and 6-B Pictorial represen tations of fibular and femoral-based reconstruct ions of the fibular
collateral ligament (F CL) and posterolateral corner. PFL =popl iteofibular ligament. (Copyrighted a nd
used with permission of Mayo Found ation for Medical Education and Research, all rights reserved .)
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that use of radiographic landmarks,
rather than palpating the osseous pro-
minences, led to better reproduction of
the isometry of the superficial medial
collateral ligament.
More than 10 mm of medial joint
opening with the knee in full extension
is the hallmark finding in a knee with
a combined injury involving the medial
side and both cruciate ligaments. Stress
examination, with the patient under
anesthesia, with the use of fluoroscopy
or radiography to compare joint space
opening of the injured knee with that of
the contralateral knee helps the surgeon
to understand the extent of pathologic
ligament laxity. Magnetic resonance
imaging is a sensitive tool for identifying
injured structures.
Oncethesofttissuesaresatisfac-
tory, acute surgery (performed one to
three weeks after the injury) is indicated
when there is extensive medial disruption,
a displaced meniscal tear, or a so-called
Stener lesion of the knee in which the
distal medial collateral ligament is flipped
over the pes anserinus tendons. Delayed
surgical intervention (at more than three
weeks after the injury) may be necessary
to allow the swelling to resolve and knee
motion to return. When the only medial
damage is a femoral medial collateral
ligament avulsion, healing may occur and
only the cruciate ligaments need to be
repaired. When the anterior cruciate
ligament, posterior cruciate ligament, and
medial side need to be repaired, a single-
stage procedure with anterior and poste-
rior cruciate ligament reconstructions
along with repair or reconstruction of the
medial collateral ligament and poster-
omedial corner, as indicated, is best.
In the acute setting, a femoral or
tibial-sided avulsion of the medial
collateral ligament with good ligament
substance can be repaired to the ana-
tomic origin with a suture post and
ligament washer. Figure 8 shows an
example of a tibial-sided disruption of
the medial collateral ligament. The in-
tact ligament with excellent tissue sub-
stance allows a secure repair without the
need for augmentation or reconstruc-
tion. The deep meniscotibial ligament
can be reattached with suture anchors.
The repair should be tensioned with the
knee at 30°of flexion, a varus stress, and
slight tibial external rotation. Injuries of
the posterior oblique ligament and the
posteromedial aspect of the capsule are
also repaired anatomically with suture
anchors and tensioning near full exten-
sion. It is important to avoid overten-
sioning in flexion, as this may prevent
full knee extension.
Numerous reconstruction tech-
niques for treatment in the chronic
setting have been described
23,42-44
.Our
preferred technique is to use an Achilles
tendon allograft with the bone plug
fixed in a femoral socket with an in-
terference screw and the tendon secured
to the tibia with a suture post/ligament
washer construct. Figure 9 shows the
Achillestendonallograftafterfixation
Fig. 6-B
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
of the femoral attachment. The pos-
terior oblique ligament and postero-
medial aspect of the capsule are repaired
if necessary.
A detailed search of the literature
from 1978 through 2008 identified all
studies with outcome data on repair or
reconstruction of the medial collateral
ligament in the setting of combined
ligament injuries
8
. Only eight studies
met the inclusion criteria: five were on
medial collateral ligament repair, and
three were on medial collateral ligament
reconstruction. No prospective studies
directly compared medial collateral lig-
ament repair or reconstruction with
nonoperative treatment or compared
medial collateral ligament reconstruc-
tion with repair. The collective results
suggest that either repair or reconstruc-
tion in the knee with multiple ligament
injuries yields satisfactory outcomes.
Owens et al.
45
reported on eleven knees
with injuries to the anterior cruciate
ligament, posterior cruciate ligament,
and medial collateral ligament, with the
medial collateral ligament repaired only
if it was avulsed, and all were stable to
valgus stress at the time of final follow-
up. One of us (G.C.F.) and colleagues
22
reported on nine knees with injuries to
the anterior cruciate ligament, posterior
cruciate ligament, and medial collateral
ligament, and all were stable to valgus
stress, including seven that were treated
surgically. In a study by Hayashi et al.
46
in which seven reconstructions of the
anterior cruciate ligament, posterior
cruciate ligament, and medial collateral
ligament were performed with use of
a semitendinosus autograft, the average
Lysholm score was 95.1 points. Stannard
et al.
41
reported on seventy-three dis-
located knees with posteromedial corner
Fig. 7
Clinical photograph of a knee dislocation requiring spanning external fixation with substantial soft-tissue injury.
Fig. 8
A tibial-sided disruption of the medial collateral ligament
with excellent tissue substance that is amenable to direct
repair.
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
injuries. Forty-eight underwent auto-
graft or allograft reconstruction of the
medial collateral ligament, and twenty-
four had a medial collateral ligament
repair. On the basis of a 20% failure rate
in the repair group compared with a 4%
failure rate in the reconstruction group,
Stannard concluded that medial collat-
eral ligament repair is inferior to re-
construction in a knee with multiple
ligament injuries.
It is important to make an accu-
rate, anatomic diagnosis with the use of
physical examination, imaging studies,
and bilateral comparison stress radio-
graphs. The surgeon needs to determine
the safe and appropriate timing of
surgery and then proceed with recon-
struction of the anterior and posterior
cruciate ligaments along with repair or
reconstruction of the medial collateral
ligament, posterior oblique ligament,
and posteromedial aspect of the capsule.
Postoperative Rehabilitation
The knee should be kept in full ex-
tension for a minimum of three weeks,
and the patient should remain non-
weight-bearing for six weeks
47
. Pro-
gressive range-of-motion exercises start
three weeks after the operation. The
braceshouldbeunlockedattheendof
the third week, and use of the crutches
is discontinued once the patient can
bear full weight. Progressive closed-
kinetic-chain strength training and
continued motion exercises are per-
formed. Use of the brace should be
discontinued after the tenth week. The
patient can return to sports and stren-
uous labor after the ninth postoperative
month as long as sufficient strength,
proprioceptive skills, and motion have
returned
11,48
.Alossof10°to 15°of
terminal flexion might be expected
after these complex knee ligament
reconstructions.
Fracture-Dislocations
Fracture-dislocations of the knee are
severe injuries that have frequently been
associated with poor outcomes
49-54
. The
most common fracture around the knee
associated with a multiligament knee
injury is a tibial plateau fracture. It is
difficult to treat patients who have
instability of both the bone (a fracture)
and ligaments of the knee. Recon-
structing ligaments is a challenge when
one is trying to anchor a reconstruction
in fractured bone. The risk of failure of
early reconstruction of the posterolat-
eral corner with use of the modified
two-tailed technique is higher in pa-
tients with a tibial plateau fracture than
it is in patients who do not have a
fracture
34,36
.
Knee fracture-dislocations occur
more frequently than generally thought
and are particularly challenging to di-
agnose. It is difficult to determine the
stability of the knee in a patient with
a tibial plateau fracture. These patients
also frequently have multiple injuries
that divert the attention of treating
teams away from the knee injury. As
identified with magnetic resonance im-
aging, the prevalence of concomitant
ligament injuries with tibial plateau
fractures has been reported to be as low
as 33% and as high as 90%
55-58
.While
many of these injuries do not represent
fracture-dislocations, in Stannard’s se-
ries of 103 consecutive tibial plateau
fractures, more than half of the patients
had multiple ligament injuries and
26% had a fracture-dislocation
55
.
Magnetic resonance imaging is an
important adjunct to an examination
under anesthesia for the successful
diagnosis of fracture-dislocations of
the knee.
There are very few published
studies dedicated to the topic of fracture-
dislocation of the knee. The published
results show a high prevalence of poor
outcomes, with pain, instability, and
arthrofibrosis being the most common
complications
49-54
. Conservative treat-
ment is associated with poor results,
and most authors have recommended
surgical treatment for patients with
fracture-dislocation. Delamarter et al.
reported that 40% of their patients with
a fracture-dislocation had a poor out-
come after nonoperative treatment com-
pared with a 16% rate of poor results
in those who had had an operation
59
.
Stannard et al. developed a staged treat-
ment protocol for fracture-dislocations,
in which the treatment of the fracture is
separated from that for the dislocation,
and it has yielded good functional out-
comes in most patients
60
. Outcome scores
after use of this staged protocol have been
encouraging in patients with these com-
plex injuries.
The initial phase of treatment
for a patient with a fracture-dislocation
of the knee is on the day of injury. The
mechanism of injury, radiographic
findings, and examination of the skin lead
to a suspicion of a fracture-dislocation.
The fracture is gently reduced with
traction, and a careful vascular exami-
nation is performed. If the knee remains
reduced, the extremity should be immo-
bilized with a splint or knee-immobilizer
and magnetic resonance imaging should
be performed. In most cases, the skin
and soft-tissue injury are so severe that
surgical treatment should be delayed for
Fig. 9
A reconstruction of the medial collateral ligament with an Achilles
tendon allograft after fixation of the bone block in the femoral socket.
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
atleastthreetosevendays.Oncethe
condition of the soft tissues around the
knee is satisfactory, the second phase of
treatment can begin.
Phase two is surgical stabiliza-
tion of the fracture and any avulsions
of major ligaments. Locked plates are
frequently necessary to stabilize the com-
plex fractures associated with fracture-
dislocations. Preoperative planning is
critical, both for successful treatment of
the fracture and to ensure that the im-
plants do not block future tunnels that
will be necessary for reconstruction of the
injured ligament. A knee-immobilizer
should be applied after stabilization of
the fracture, and one must be certain that
the knee stays reduced.
Phase three is the early recon-
structive phase of the protocol. If the
condition of the patient and the soft
tissues allow it, we advance to this phase
during week three or four following the
injury. Allograft ligament reconstruc-
tion is the mainstay of this phase. There
are no definitive data in the literature
regarding the timing or staging of
ligament reconstructions in patients
following knee dislocations. On the
basis of the findings in the series
evaluated by Stannard et al.
34,36
, recon-
struction of the anterior cruciate liga-
ment and posterolateral corner should
be delayed for approximately four
months to allow early healing of the
tibial plateau before tunnels are drilled
through the tibia. Those authors re-
ported a failure rate of >30% when
posterolateral corner reconstructions
had been performed during phase three
compared with a failure rate of 8% when
the same posterolateral corner recon-
struction technique had been performed
in patients without a tibial plateau
fracture
34,36
. A hinged external fixator is
placed at the end of the surgery in phase
three, providing a stable environment
for early ligament healing. Gentle mo-
tion is initiated on postoperative day
one if the condition of the soft tissue
allows it.
Phase four is the late reconstruc-
tive phase. The patient should have at
least 80°of knee flexion before starting
phase four. The hinged external fixator
is removed, and the anterior cruciate
ligament and posterolateral corner are
reconstructed if the knee remains un-
stable. Again, allograft tissue is normally
used for the reconstructions. Early
motion after surgery is used to minimize
arthrofibrosis.
In series evaluated by Stannard
et al.
60
, good functional outcomes were
achieved in patients in whom a fracture-
dislocation had been treated with this
staged protocol. In a series of fifty
patients with a total of fifty-four fracture-
dislocations, the final Lysholm knee
score averaged 86 points (range, 50 to
100 points). According to the final ob-
jective IKDC scores, there were thirty-
two normal or nearly normal knees and
seventeen abnormal knees. However,
while good function was achieved,
patients required an average of four
surgical procedures to complete their
treatment.
Complications
Complications are frequent after knee
dislocations and fracture-dislocations.
Complications include a wide variety of
conditions including wound-healing,
vascular, and neurologic problems. The
most common complications remain
pain, arthrofibrosis, and ligament in-
stability despite reconstruction. Pain is
a difficult complication to quantify ob-
jectively, but many patients have prob-
lems with chronic pain following these
injuries. The prevalence of chronic
pain has ranged from 25% to 68%
61
.
Arthrofibrosis remains a substantial
source of pain and disability following
knee dislocations. The prevalence has
ranged from 5% to 71% in the published
literature, with a mean of 29% of patients
having arthrofibrosis requiring surgical
treatment
61
. The prevalence of persistent
instability was 100% after nonoperative
treatment, and it ranged from 18% to
100% after surgical treatment, with a mean
of 42% of patients having instability in
at least one plane
61
.
Results of Treatment of Knee
Dislocations
Outcomes after knee dislocation are
difficult to quantify in large part because
the injuries are heterogeneous
62
. A knee
dislocation can range from a three-
ligament noncontact injury that reduced
spontaneously to one sustained in a
high-speed motor-vehicle accident and
is associated with severe neurologic and
vascular injuries. Nevertheless, the data
on the outcomes of these injuries are
summarized below.
Levy et al.
8
performed a systematic
review of 413 articles on this topic. They
evaluated studies that compared surgical
treatment with nonoperative treat-
ment
63-66
, studies that compared repair
with reconstruction
34,67
, and studies
that compared early and late surgical
treatment
21,68-71
.
Of the four studies that com-
pared operative and nonoperative
treatment
63-66
, one was a meta-analysis of
investigations published prior to 2000
63
.
In three studies in which the Lysholm
score was used to record postoperative
outcomes, surgical treatment resulted in
higher mean scores
63-65
, with one of the
differences being significant
64
.Thesurgical
group also had higher IKDC scores
64,66
.
Return to work and to sports activities
were also better overall in the surgically
treated group.
Two studies that compared surgi-
cal repair with reconstruction were
identified
34,67
. Direct repair of cruciate
ligaments resulted in inferior motion,
a higher rate of positive posterior sag
signs, and a lower rate of return to the
preinjury activity level
67
. The rate of
failure after repair of the posterolateral
corner was also found to be higher than
that after reconstruction
34
.
In general, three weeks was the
most consistent time point up to which
surgery was described as ‘‘early.’’ Overall,
the patients who had had early surgery
had improved outcomes for several
parameters
21,68-71
. However, there is po-
tential for substantial bias with respect
to the timing of surgery because the
reason for early or late surgery may be
related to prognosis (such as other
injuries or the status of the soft tissues
around the knee).
An excellent prospective cohort
study with a minimum of two years of
follow-up after reconstruction for treat-
ment of knee dislocations was carried out
by Engebretsen et al.
72
. Inclusion criteria
were injury to both the anterior and
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MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
the posterior cruciate ligament as well as
an injury to the medial and/or lateral
side. Patients were treated with surgical
reconstruction within two weeks after the
injury, when that was not contraindi-
cated by other injuries. The authors used
both autograft and allograft tissue, with
a trend toward using autograft later in
the study enrollment period. Of 121
patients who were initially eligible,
eighty-five patients had sufficient follow-
up. Approximately half of the patients
in this cohort sustained what was
considered high-energy knee disloca-
tions. The median Lysholm score for
the patients who were followed was 83
points, and the median Tegner score
was 5 points. The authors found that
injuries resulting from high-energy
trauma and those involving all four
major ligaments resulted in worse out-
comes than did those resulting from
low-energy trauma and those involving
three ligaments.
Despite some excellent case series
as well as comparative studies and the
prospective cohort study by Engebretsen
et al.
72
, we are not aware of any random-
ized controlled trials to assist us with
outcome assessment after knee disloca-
tion. These injuries are complex and not
easily amenable to randomized trials
for many reasons
62
. Additional research
is needed to identify prognostic factors
and treatment algorithms to improve
outcomes after these rare and devastat-
ing injuries.
Overview
Recent advances in surgical techniques,
including anatomic reconstructions, for
management of knees with multiple
ligament injuries have led to improved
patient outcomes. Current recommen-
dations include measurement of the
ankle-brachial index in each patient,
early surgical management (earlier than
three weeks postinjury), the use of
autograft or allograft tissue, recon-
struction as opposed to repair alone of
the fibular collateral ligament and pos-
terolateral corner structures, recon-
struction of the anterior and posterior
cruciate ligaments, and repair and/or
reconstruction of the medial collateral
ligament and posteromedial corner,
depending on the injury pattern and
quality of tissue. Future research in-
cluding the establishment of multicenter
working groups and the collection of
prospective data may hold the key to
identifying optimal treatment protocols
for these complex injuries.
Gregory C. Fanelli, MD
Department of Orthopaedic Surgery, Geisinger
Medical Center, 115 Woodbine Lane, Danville,
PA 17822-5212
James P. Stannard, MD
Department of Orthopaedic Surgery, University
of Missouri, 1 Hospital Drive, Columbia,
MO 65212
Michael J. Stuart, MD
Bruce A. Levy, MD
Department of Orthopedic Surgery
(M.J.S. and B.A.L.) and Sports
Medicine Center (M.J.S.), Mayo Clinic,
200 First Avenue S.W.,
Rochester, MN 55906
Peter B. MacDonald, MD
Pan Am Clinic, 75 Poseidon Bay, Winnipeg,
MB R3M 3E4, Canada
Robert G. Marx, MD, MSc, FRCSC
Hospital for Special Surgery,
535 East 70th Street, New York, NY 10021
Daniel B. Whelan, MD
University of Toronto, 55 Queen Street East,
Suite 800, Toronto, ON M5C 1R6, Canada
Joel L. Boyd, MD
TRIA Orthopaedic Center,
8100 Northland Drive,
Minneapolis, MN 55431
Printed with permission of the American
Academy of Orthopaedic Surgeons. This
article, as well as other lectures presented at
the Academy’s Annual Meeting, will be
available in February 2011 in Instructional
Course Lectures, Volume 60. The complete
volume can be ordered online at www.aaos.
org, or by calling 800-626-6726 (8 A.M.-5 P. M . ,
Central time).
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THE JOURNAL OF BONE &JOI NT SURGERY dJBJS.ORG
VOLUME 92-A dNUMBER 12 dSEPTEMBER 15, 2010
MANAGEMENT OF COMPLEX KNEE LIGAMENT INJURIES
... Thus, knee dislocation should be assessed in every patient with a lesion in two or more knee ligaments. 2,3,[5][6][7][8][9][10] The most frequent injury mechanism is direct or indirect high-energy trauma to the knee, mostly caused by motor vehicle accidents. These lesions are also related to fall from height and sports traumas, usually football, skiing, soccer, and rugby. ...
... The severity of these vascular injuries is emphasized by the fact that, regardless of treatment, the incidence of amputations in these patients is of 12%. 3,6,8,9,12,14 Thus, demographics of patients with these knee injuries must be known to optimize their treatment and outline preventive strategies. As a result, the Brazilian literature was queried on multiligamental injuries and knee dislocation at databases (PubMed and SciELO) and journals (Revista Brasileira de Ortopedia [RBO]). ...
Article
Full-text available
Resumo Objetivo Descrever e associar as características das lesões multiligamentares de joelho com o perfil do paciente e mecanismo de trauma. Métodos Trata-se de um estudo transversal que avaliou 82 pacientes com lesões multiligamentares do joelho de setembro de 2016 até setembro de 2018. As variáveis coletadas foram idade, gênero, eixo mecânico, lateralidade, arco de movimento, mecanismo do trauma, lesões associadas, ligamentos afetados e afastamento do trabalho. Resultados A amostra incluiu pacientes de 16 a 58 anos, com média de 29,7 anos, e os homens foram os mais afetados, correspondendo a 92,7% dos casos. O mecanismo de trauma mais comum foi acidente motociclístico (45,1%). O ligamento mais lesado foi o ligamento cruzado anterior (80,5%), seguido do ligamento cruzado posterior (77,1%), do canto posterolateral (61,0%) e do ligamento colateral tibial (26,8%). O tipo de luxação mais frequente era o KD IIIL (30,4%). Apenas 1 paciente apresentou lesão vascular, e 13 (15,9%) apresentaram lesões neurológicas. A maioria das vítimas foi afastada do trabalho (52,4%). Conclusão Há grande diferença entre os pacientes que apresentam lesão multiligamentar no Brasil em relação ao encontrado nos estudos internacionais. Desta forma, convém realizar mais estudos específicos sobre o tema com a nossa população, de modo a aperfeiçoar o tratamento destes pacientes.
... • Post-reduction antero-posterior and lateral radiographs are mandatory to confirm joint reduction, identify avulsion fractures around the knee, and assess the need for associated fracture surgery • MRI is the imaging investigation of choice in knee dislocations and helps determine the extent of injury to soft tissues, ligaments, and muscle-tendon units. [6] MRI significantly aids in surgical planning and should be done early in the treatment process • A CT scan may be useful for detailed characterization of fracture dislocations • Stress radiography may be considered in select cases to document the extent of ligamentous laxity • Regular monitoring of the distal pulsations and ankle brachial index (ABI) should be done in the acute setting for at least 72 h [ Figure 2]. Although asymmetry of distal pulses, or fall of ABI below 0.9 is an absolute indication for angiography, many centers advocate routine vascular studies for any multiple ligament injured knee. ...
... However, angiography is an invasive procedure with its associated risks, and studies have shown that selective angiography is adequate, [14] and only patients with either asymmetric pulsations or ABI <0.9 need further vascular evaluation. CT angiography is 100% sensitive and specific [6] while being less invasive and involves lesser radiation than a conventional arteriogram. [15] MR angiography is also equally accurate [16] without the risks of radiation and can be performed in the same sitting as the knee MRI. ...
Article
Multiple ligament knee injuries involve tears of two or more of the four major knee ligament structures, and are commonly noted following knee dislocations. These devastating injuries are often associated with soft-tissue trauma, neurovascular deficit, and concomitant articular cartilage or meniscus tears. The complexity of presentation, and spectrum of treatment options, makes these injuries unique and extremely challenging to even the most experienced knee surgeons. A high level of suspicion, and a comprehensive clinical and radiological examination, is required to identify all injured structures. The current literature supports surgical management of these injuries, with cruciate reconstructions, and repair/augmented repair/ reconstruction of collateral ligaments. This review article analyses management principle of multiple ligament knee injuries, and formulates clinical practice guidelines with treatment algorithms essential to plan individualized management of these complex heterogeneous injuries.
... The common complications and sequalae of a treated knee joint dislocation include varying degree of persistent chronic pain (25%-68%), persistent instability in at least one plane (18%-100%) with a feeling of giving away or locking upon strenuous work, knee stiffness especially in those undergoing early reconstruction and repair, and [35] arthrobrosis (5%-71%), 29% of whom require adhesiolysis . Total internal derangement of knee is one of the consequences of conservative management of multiligament damage which in turn [36] leads to chronic pain, instability and restricted range of movement . ...
Article
Full-text available
Background: Dislocation of the knee joint is one of the most under-reported orthopaedic emergencies due to its ability to undergo spontaneous reduction. It carries a high risk of involving the popliteal artery and peroneal nerve both acutely, or in the long term. Due to this catastrophic potential of the condition, it has been well established that it warrants prompt diagnosis and management. It may be secondary to ultra-low, low or high velocity trauma which makes every dislocation case unique due to involvement of different joint structures, capsule or fractures of the articulating bones. A broad spectrum of treatment modalities (both conservative and surgical) has been documented for this condition, with the latter showing better results across most studies. In developing countries like India, the nancial chasm is relatively bigger with a major chunk of the population unable to bear the cost of complete surgical management. Objective: To assess the functional outcome in patients with frank knee dislocations with multiligamentous injuries and vascular decit treated by a middle path regimen of an extended period of external xator and immobilization. Method: A prospective study was undertaken from January 2018 to July 2020 involving 10 patients with knee joint dislocations with vascular decit and multiligamentous injury, treated by an extended period of external xator application and immobilization. Fasciotomy was done wherever needed, in association with split thickness skin grafting. The assessments were made using Lysholm knee scoring scale (LKSS), International Knee Documentation Committee Scores (IKDC), range of motion (ROM), antero- posterior tibial translation (AP translation) and overall patient satisfaction on every follow-up. Results: The mean LKSS score was 78.3±6.23, mean IKDC score was 68.17±5.34, mean ROM progressively increased to 135.8⁰ with a mean extension lag of 2.2⁰, while the mean AP tibial translation was noted to be 9.16 mm. No poor result or complication was reported. Conclusion: The middle path regimen provides an affordable alternative for providing a stable knee to patients who are ill-affording and are expected to have a sedentary lifestyle, without indulging into rigorous activities
Chapter
Malalignment around the knee may harbour cosmetic, biomechanical and joint longevity complications [1]. Current literature is inconclusive regarding the long-term implications of angular deformities of the lower limb [1–3]; however, long-bone nonunions have shown a reduction in quality of life that is greater than diabetes, stroke and HIV [4]. Fortunately, these complications, following fracture care, are seen less frequently as a result of a better understanding of fracture biomechanics and better orthopaedic implant design [5–15]. Despite this, malalignment rates as high as 60% have been reported following intramedullary nailing for proximal tibia fractures in particular [16].
Chapter
Fractures of the tibial head are usually complex fractures, which are frequently associated with extensive soft tissue damage due to a high-energy trauma. As a result, these often increase the degree of difficulty for the optimal operative treatment and thus are a major challenge for the surgeon. Therefore, a differentiated therapy concept is necessary in the sense of a “damage control surgery” to treat this injury. For this purpose, the operative treatment by means of temporal external stabilization of the fracture by means of an external fixator proved to be a good and rapid therapy option especially with polytraumatized patients. In addition to the classic fixateur externe or the ring fixator which has been in existence for some time, other possibilities have also been developed in the course of time for optimum supply, e.g., a hybrid fixator or a fixator with motion capacity.
Article
Purpose: Multi-ligament knee injuries are a serious consequence of knee dislocation with a poorly evaluated post-operative complication profile due to low incidence. The aim of this study is to assess the risk of adverse post-operative events associated with operative management of multi-ligament knee injuries. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing surgical procedures for multi-ligament knee injuries from 2006 to 2016 using Current Procedural Terminology codes. We evaluated data on patient demographics and used a propensity score algorithm to adjust for baseline differences in these patients and developed univariate and multivariate logistic regression models to assess effects on minor and severe 30-day post-operative complications. Results: We identified 444 patients in this database who underwent multi-ligament knee reconstructions between 2006 and 2016. After propensity matching, minor and major adverse post-operative events were more frequent in patients with multi-ligament knee injuries (1.4% vs 0.2%, p < 0.001 and 2.7% vs 1.1%, p = 0.002, respectively). Patients with multi-ligament knee injuries experienced a 55-fold increase risk of need for transfusion (p < 0.001) and a fivefold increased risk of pulmonary embolism (p = 0.025), with most occurring in bicruciate reconstructions (Schenck Classification KD-III and KD-IV injuries). Conclusion: The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse event over arthroscopic ACL reconstruction. These patients are most at risk for post-operative blood transfusion requirement, and pulmonary embolism, with patient's undergoing surgery for bicruciate ligament injuries at particularly high risk of complication. Level of evidence: IV.
Chapter
Acute ligament injuries are common in sports. Typically, a traumatic mechanism causes the ligament to stretch beyond its normal range, leading to injury. Injuries are typically graded by the degree of disruption to the ligament, ranging from grade 1 (sprains) to grade 3 (complete tears). Other associated injuries, such as fractures, can occur. Although ligament injuries can typically be diagnosed by performing a thorough history and physical exam, depending on the specific injury and patient, imaging modalities such as radiographs, ultrasonography, and MRI can be important adjuncts for confirming the diagnosis, guiding treatment options, and preoperative planning and determining prognosis for recovery. Healing occurs in several discrete phases, which can last weeks to years. In general, lower-grade injuries will recover with conservative care alone, while higher-grade injuries require surgical intervention for full return of function. However, ligaments vary in their ability to heal, and some ligaments can heal spontaneously following a high-grade injury. Nonoperative conservative care may include rest, physical therapy, and possible adjunctive regenerative therapies. Surgical care may include primary repair or reconstruction with grafting. Complications of ligament injuries include injuries to surrounding structures, joint instability, loss of time in sports, reduced athletic performance, and chronic pain. This chapter will discuss specific ligament injuries, their management, and return to sports recommendations.
Article
Full-text available
Aim: There is a shortage of high-level evidence regarding periarticular fractures affect outcomes after MLKIs. The purpose of this study was to determine whether concomitant periarticular fractures with mutliligament knee injuries (MLKIs) predict worse patient-reported outcomes (PROMs) when compared to MLKIs without concomitant periarticular fractures after surgical repair and/or reconstruction. Materials and methods: Medical records of patients who sustained MLKIs from January 1, 2009 to June 1, 2014 were retrospectively reviewed. All patients aged 18-65 years with grade III injuries of two or more knee ligaments and 1-year minimum follow-up were included. Patients with injuries or surgeries to either knee before their MLKIs were excluded. Radiographs and computed tomography imaging obtained at the time of injury were used to detect concomitant periarticular fractures. Patients with and without concomitant periarticular fractures were matched on a 1:2 basis, respectively. Multiple PROMs were collected, including the IKDC Subjective Knee Form (IKDC-SKF), and Knee Injury and Osteoarthritis Outcome Score (KOOS). The independent t-test was used to compare PROMs between patients with and without periarticular fractures. Results: Eighteen patients (10 males, 8 females) with a mean follow-up of 4.0 years (range 1.1-8.6 years) were included in the final analysis, with six patients having MLKIs and concomitant periarticular fractures. Compared to patients with isolated ligamentous MLKIs (n = 12), patients with concomitant periarticular fracture (n = 6) demonstrated significantly worse outcomes on the IKDC-SKF (54.2 ± 13.3 vs. 74.0 ± 19.6, p = 0.04) and KOOS-Sports and Recreation subscale (41.2 ± 32.4 vs. 70.8 ± 19.4, p = 0.03). Conclusion: The presence of a periarticular fracture predicted significantly worse clinical outcomes in the setting of MLKI. These findings may be useful in determining the prognosis of MLKI with concomitant periarticular fractures treated with surgical repair and/or reconstruction.
Article
Purpose: Posterolateral corner (PLC) injuries commonly occur in the setting of a dislocated knee and often require multiple procedures due to concomitant vascular, nerve, and soft tissue involvement. Debate persists regarding single vs staged surgery. The purpose of this study was to compare knee function after single and staged surgery for PLC injury. Methods: Patients who underwent surgery for a PLC injury (KD I, IIIL, IV) with minimum follow-up of 2 years were included. Patients treated with staged and single surgery were matched according to age, sex, and KD grade. Lysholm and International Knee Documentation Committee (IKDC) subjective scores were obtained. Risk factors for poor knee function were assessed, including age, nerve, vascular, meniscal and articular cartilage injuries. Results: Twenty single-surgery patients with a median age of 24 years (median follow-up 5.3 years, range 2-18.3) and 20 staged surgery patients with a median age of 26 years (median follow-up 4.3 years, range 2-19.8) were studied. The mean Lysholm score was 78.7 (± 20.3) in the single surgery and 84.2 (± 17.8) in the staged surgery cohort (n.s.). The mean IKDC score was 80.8 (± 21.1) in the single and 74.9 (± 18.9) in the staged surgery cohort (n.s.). Age at injury, peroneal, vascular, meniscal or cartilage injury were not associated with poor knee outcome. Conclusion: This study demonstrates similar knee function among patients with PLC injuries treated with single or staged surgical procedures. The need for staged surgery for the dislocated knee with PLC involvement should be individualized based on specific knee and patient-related factors. Level of evidence: III.
Article
Background: Knee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them. Objective: This article provides a review of the diagnosis and management of knee dislocation for the emergency provider. Discussion: Knee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission. Conclusion: Knee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
Article
The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, utilize strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, mechanical graft tensioning, secure graft fixation, and the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single- and double-bundle arthroscopic transtibial tunnel PCL reconstruction based upon stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements. The purpose of this manuscript is to describe the arthroscopic transtibial tunnel posterior cruciate ligament reconstruction surgical technique.
Book
The Multiple Ligament Injured Knee: A Practical Guide to Management presents the orthopedic surgeon with an unprecedented review of the most recent and advanced information available on the successful diagnosis and treatment of multiple ligament knee injuries. Gregory C. Fanelli, MD, handpicked internationally renowned contributors to ensure that the clearly written guide is valuable for orthopedic surgeons, trauma surgeons, sports medicine fellows, physical therapists, physician assistants, and all other health professionals who treat traumatic injuries of the knee. The comprehensive volume covers the basic anatomy and biomechanics of the knee as well as the assessment and classification of knee injuries. Although the chapters build upon each other, they can also stand alone as practical, quick references. The format is particularly useful given the extensive number of treatment techniques that are examined, including nonoperative, arthroscopic, and open surgical approaches. Vascular and nerve injuries are addressed in addition to various ACL/PCL/Medial/Lateral injuries. Chapters on postoperative rehabilitation, possible complications, and brace treatment provide additional insight. The definitive text is completed by select case studies that demonstrate how highlighted approaches are applied. Techniques are also reinforced by a wealth of line drawings and photographs.
Book
POSTERIOR CRUCIATE LIGAMENT INJUIRES: A PRACTICAL GUIDE TO MANAGEMENT, presents the orthopaedic surgeon an unprecedented review of the most recent and advanced knowledge needed to diagnosis and treat PCL injuries successfully. This comprehensive and practical volume covers everything from biomechanics and anatomy, non-operative treatment and rehabilitation to the latest surgical treatments of PCL injuries using arthroscopy, grafts and synthetic ligament substitutes. Each of this early written chapters is accompanied by a wealth of line drawings and photographs demonstrating both the surgical and non-surgical approaches to examination and treatment. For any orthopaedic surgeon confronted by knee injuries, this volume is fundamental reading.
Article
Fractures of the proximal tibia involving the articular surfaces vary greatly in type, severity, and prognosis, and a considerable percentage have significant associated ligamentous injuries. This report classifies and analyzes 132 particular fractures separated from over 1,000 patients with fractures of the proximal tibia. The remaining cases were considered to have tibial plateau fractures. Eighty-six fractures required operative treatment, and it was possible to divide them into five distinct types. The characteristic of these five types is marked joint instability with a high incidence of serious soft-tissue and/or neurovascular injury. Knee dislocation is a discrete entity. Plateau fracture is a discrete entity that requires definition (and which in large measure has little or no implication of significant soft-tissue injury). Fracture--dislocation of the knee is a much more serious injury than plateau fracture. For successful treatment of this injury, a radically different understanding of fractures of the proximal tibial condyles is needed.
Article
The goals leading to successful posterior cruciate ligament (PCL) reconstruction surgery include identification and treatment of associated pathology such as posterolateral instability, posteromedial instability, and lower extremity malalignment. The use of strong graft material, properly placed tunnels to approximate as closely as possible the PCL insertion sites, and minimization of graft bending also enhance the probability of PCL reconstruction success. In addition, mechanical graft tensioning, primary and backup PCL graft fixation, and the appropriate postoperative rehabilitation program are also necessary ingredients for PCL reconstruction success. Both single-bundle and double-bundle PCL reconstruction surgical techniques are successful when evaluated with stress radiography, KT-1000 arthrometer measurements, and knee ligament rating scales. Indications for double-bundle PCL reconstruction as of this writing include severe hyperextension of the knee and revision PCL reconstruction. In combined PCL, anterior cruciate ligament, medial- and lateral-side knee injuries (global laxity), 2-18-year postsurgical results revealed very successful posterior cruciate ligament reconstruction using the arthroscopic transtibial tunnel surgical technique. The purpose of this article is to describe the arthroscopic transtibial tunnel posterior cruciate ligament reconstruction surgical technique, and present the author's results with this surgical procedure.
Article
When designing rehabilitation programs following multiple ligament reconstruction, consideration should be given to graft protection, patient function, and functional outcomes. The programs outlined in this article are founded upon basic scientific principles as they relate to the effects of range of motion and strengthening exercises on graft healing and restoration of patient function. As with the surgical techniques, rehabilitation programs are ever evolving and are becoming less conservative with experience, improved fixation techniques, and additional research.
Article
The multiple ligament injured knee is a complex problem in orthopedic surgery. These injuries may present as acuteknee dislocations, and careful assessment of the extremity vascular status is essential because of the possibility of arterial and/or venous compromise. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Arthroscopically assisted combined anterior cruciate ligament/ posterior cruciate ligament (ACL/PCL) reconstruction is a reproducible procedure. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Posterolateral complex (PLC) injuries combined with ACL/PCL tears are best treated with primary repair as indicated combined with PCL reconstruction using a post of strong autograft (split biceps tendon, biceps tendon, semitendinosus), or allograft (Achilles tendon, bone-patellar tendon-bone) tissue. Surgical timing depends on the injured ligaments, vascular status of the extremity, reduction stability, and overall patient health. The use of allograft tissue is preferred because of the strength of these large grafts and the absence of donor site morbidity.