Management of Complex Knee Ligament Injuries · Anterior Cruciate Ligament Reconstruction The principles of reconstruction in a knee with multiple ligament injuries include identiﬁcation

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2010;92:2235-2246. J Bone Joint Surg Am.Whelan, Joel L. Boyd and Bruce A. Levy Gregory C. Fanelli, James P. Stannard, Michael J. Stuart, Peter B. MacDonald, Robert G. Marx, Daniel B.

Management of Complex Knee Ligament Injuries

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Management of ComplexKnee Ligament Injuries

By Gregory C. Fanelli, MD, James P. Stannard, MD, Michael J. Stuart, MD, Peter B. MacDonald, MDRobert 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 andChronic Multiligament Knee InjuriesInitial evaluation of a knee with multipleligament injuries begins with a thoroughand complete neurovascular examina-tion, an assessment of the soft tissue,and determination of the instabilitypattern. Failure to recognize a vascularinjury can lead to catastrophic limbdysfunction and ultimately to amputa-tion. Injury to the tibial and/or peronealnerves can also have devastating conse-quences and is encountered in almost25% of dislocated knees1. The modifiedSchenck classification2, in which notonly ligamentous structures but alsoneurovascular injury and the presence ofperiarticular fracture are taken intoaccount, is widely used to describe theseinjuries.

Vascular AssessmentThere are several algorithms for theassessment of vascular injury of thelower limb. Vascular assessment mayinclude physical examination alone, useof the ankle-brachial index, arterialultrasound, and conventional and/orcomputed tomography angiography. A

palpable pulse may be present distal toa complete popliteal arterial occlusion,as a result of the presence of collateralflow (Fig. 1). When a patient presentswith ‘‘hard signs’’ of ischemia, whichinclude a cool, pulseless, obviouslydysvascular limb, immediate vascularsurgery consultation is warranted.When the level of the lesion (forexample, the popliteal artery in thesetting of a dislocated knee) is known,the vascular surgeon may opt forimmediate surgical exploration or pro-ceed with angiography. Typically, a sa-phenous vein bypass graft obtainedfrom the contralateral side is used toreestablish arterial flow, and concomi-tant prophylactic four-compartmentfasciotomies are done. When a patientpresents with ‘‘soft signs’’ of ischemia,including palpable but asymmetricpulses and asymmetric warmth and/orcolor of the limb, further assessment isneeded.

The ankle-brachial index is de-termined by obtaining the systolic bloodpressure of the affected limb at the levelof the ankle and comparing it with thesystolic blood pressure of the ipsilateral

arm at the level of the brachial artery(Fig. 2): ankle-brachial index = Dopplersystolic arterial pressure in injured limb(ankle)/Doppler systolic arterial pres-sure in uninjured limb (brachial).

Mills et al.3 showed that when theankle-brachial index is ‡0.9 there is norisk of a major arterial injury but,because delayed thrombus is a risk,serial pulse examination should be doneevery four to six hours for a period oftwenty-four hours. When the ankle-brachial index is <0.9, either arterialultrasound or computed tomographyangiography4 should be done. Duplexarterial ultrasound has excellent sensi-tivity and specificity; however, it istechnician-dependent and not all cen-ters have access to an ultrasoundtechnician around the clock. The ad-vantage of computed tomography angi-ography over conventional angiographyis that there is less than one-fourth thedose of radiation, access is obtainedthrough the antecubital fossa as opposedto the groin, and computed tomographyangiography is 100% sensitive andspecific5. Conventional angiography hasa 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 ofthe 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 oragreement to provide such benefits from commercial entities (Biomet and Arthrex).

J Bone Joint Surg Am. 2010;92:2235-46

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 92-A d NU M B E R 12 d S E P T E M B E R 15, 2010MA N AG E M E N T O F CO M P L E X KN E E LI G A M E N T IN J U R I E S

Neurologic AssessmentNiall et al.1 reported the risk of peronealnerve injury with dislocation of the kneeto be approximately 25%. In their series,<50% of the patients had nerve re-covery. Prompt placement of an ankle-foot orthosis in the early postinjuryperiod is important to prevent equinusdeformity from Achilles tendoncontracture.

Treatment of a peroneal nervepalsy can include sural nerve grafting,direct repair, neurolysis, and tibialtendon transfer, but the success oftreatment can vary widely. The directtransfer of tibial nerve motor branchesto the peroneal nerve has promise, but

the long-term results of this procedureare unknown.

Diagnostic ImagingA substantial number of dislocatedknees spontaneously reduce, and ra-diographic findings may be subtle, butstandard anteroposterior and lateralradiographs of the knee are necessaryfollowing this injury. Joint asymmetry,mild tibiofemoral subluxation, avul-sion fractures, and rim fractures areclues to the extent of the injury. In thenonacute setting, bilateral comparisonstress radiography (varus, valgus, andposterior) can help to determine theextent of ligamentous instability.

LaPrade et al.6 reported that demon-stration of a side-to-side difference of2.7 mm on comparison of varus stressanteroposterior radiographs indicatesa fibular collateral ligament injury,whereas a side-to-side difference of>4.0 mm indicates a fibular collateralligament and posterolateral cornerinjury. In the acute setting, fluoroscopicstress examination with the patientunder anesthesia helps to confirmclinical and/or magnetic resonanceimaging findings.

Magnetic resonance imaging isthe diagnostic imaging modality ofchoice after radiographs have beenobtained. Magnetic resonance imagingidentifies the ligament injury andits specific location and extent, bothof which are critical for surgicalplanning.

Indications for EmergencySurgical TreatmentThe indications for emergency surgicaltreatment include an open knee dislo-cation, an irreducible knee dislocation,and a compartment syndrome. Openknee dislocations require aggressiveirrigation and debridement and place-ment of antibiotic bead pouches and/ora wound vacuum-assisted closure device(VAC; Kinetic Concepts, San Antonio,Texas), and may warrant plastic surgeryfor soft-tissue coverage. The irreducibleknee dislocation is typically a postero-lateral dislocation in which the medialfemoral condyle buttonholes throughthe medial aspect of the capsule and/orthe medial collateral ligament, causinga classic puckering of the medial skin.Prompt reduction is imperative to avoidskin necrosis and typically requires anopen arthrotomy. In emergency casessuch as these, definitive ligament repairor reconstruction is usually performedin a staged fashion, once all debridementand/or wound considerations have beenaddressed and the soft tissues havehealed satisfactorily to allow additionalsurgery. Indications for the immediateplacement of joint-spanning externalfixation include vascular injury requir-ing repair, an open knee dislocation, andthe inability to maintain tibiofemoraljoint reduction by other means7,8.

Fig. 1

Conventional arteriogram demonstrating collateral

flow to the distal part of the lower extremity despite

complete popliteal artery occlusion.

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Combined Posterior Cruciate andAnterior Cruciate LigamentReconstructionThe principles of reconstruction ina knee with multiple ligament injuriesinclude identification and treatment ofall torn ligaments with accurate tunnelplacement, anatomic graft insertionsites, utilization of strong graft material,secure graft fixation, and an extensivepostoperative rehabilitation program8-24.

An Achilles tendon allograft is ourpreferred graft for single-bundle poste-rior cruciate ligament reconstructions,and we prefer Achilles tendon and tibialisanterior allografts for double-bundleposterior cruciate ligament reconstruc-tions. We prefer either a tibialis anterioror a patellar tendon allograft for anteriorcruciate ligament reconstructions. Theallograft tissue is prepared, and arthro-scopic instruments are placed with theinflow in the superolateral portal, thearthroscope in the inferolateral patellarportal, and instruments in the infero-medial patellar portal. An accessoryextracapsular extra-articular posterome-dial safety incision is used to protect theneurovascular structures and to confirmthe accuracy of tibial tunnel placement.

Notch preparation is performedfirst and consists of anterior cruciate andposterior cruciate ligament stump de-bridement, bone removal, and contour-ing of the medial and lateral walls androof of the intercondylar notch. Speciallydesigned 90� curets and rasps placed

through the notch to the posterior aspectof the tibia are used to elevate the capsuleand clearly identify the tibial footprint ofthe posterior cruciate ligament.

The arm of the PCL ACL guide isinserted through the inferomedial patel-lar portal to begin creation of the tibialtunnel for the posterior cruciate ligamentgraft. The tip of the guide is positioned atthe inferolateral aspect of the anatomicinsertion site of the posterior cruciateligament. The bullet portion of the guidecontacts the anteromedial surface ofthe proximal part of the tibia at a pointmidway between the posteromedial bor-der of the tibia and the anterior aspectof the tibial crest approximately 1 cmbelow the tibial tubercle. This will providean angle of graft orientation such that thegraft will turn two very smooth 45� angleson the posterior aspect of the tibia andwill not have an acute 90�-angle turn,which may cause pressure necrosis of thegraft. The tip of the guide in the posterioraspect of the tibia is confirmed with thesurgeon’s finger through the extracapsu-lar extra-articular posteromedial safetyincision. Intraoperative anteroposteriorand lateral radiographs may also be used.The surgeon’s finger confirms the posi-tion of the guidewire through the pos-teromedial safety incision, providinga double safety check. The appropriatelysized standard cannulated reamer is usedto create the tibial tunnel. The surgeon’sfinger through the extracapsular extra-articular posteromedial incision monitors

the position of the guidewire. The drillis advanced until it comes to the pos-terior cortex of the tibia. The chuck isdisengaged from the drill, and the tibialtunnel is completed by hand, whichprovides an additional margin of safetyfor completion of the tibial tunnel.

The femoral tunnels for single-bundle or double-bundle reconstructionof the posterior cruciate ligament canbe made from inside out. Inserting theappropriately sized double-bundleaimer through a low anterolateral pa-tellar arthroscopic portal creates thefemoral tunnel for the anterolateralbundle of the posterior cruciate liga-ment graft. The double-bundle aimer ispositioned directly on the femoralfootprint of the insertion site of theanterolateral bundle of the posteriorcruciate ligament graft. The appropri-ately sized guidewire is drilled throughthe aimer, through the bone, and outa small skin incision. The double-bundle aimer is removed, and an acornreamer is used to drill endoscopicallyfrom inside out the femoral tunnelfor the anterolateral bundle of the pos-terior cruciate ligament graft. Whenthe surgeon chooses to perform a double-bundle double-femoral-tunnel recon-struction of the posterior cruciateligament, the same process is repeatedfor the posteromedial bundle of theposterior cruciate ligament graft. Thereshould be at least 5 mm of bone betweenthe two drill holes.

The tunnels for anterior cruciateligament reconstruction are created withuse of the single-incision technique. Thetibial tunnel begins externally at a point1 cm proximal to the tibial tubercle onthe anteromedial surface of the proximalpart of the tibia to emerge through thecenter of the stump of the anteriorcruciate ligament tibial footprint. Thefemoral tunnel is positioned next to theover-the-top position on the medial wallof the lateral femoral condyle near theanatomic insertion site of the anteriorcruciate ligament. The anterior cruciateligament graft is positioned and isanchored on the femoral side; this isfollowed by tensioning and tibial fixa-tion of the anterior cruciate ligamentgraft25 (Figs. 3, 4, and 5).

Fig. 2

Measurement of the ankle-brachial index.

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Lateral-Sided ReconstructionThe lateral side of the knee is commonlyinjured as part of a multiligament kneedislocation complex. The modifiedSchenck2,26 classification of knee dislo-cations includes KD IIIL (injuries in-volving the anterior and posteriorcruciate ligaments as well as the lateralcomplex). KD IV is less common andmore severe, as this injury involves boththe medial and lateral sides as well asboth cruciate ligaments. The mechan-ism of this injury includes a strong varusand external rotation force that is high-energy26. The lateral side of the knee iscomplex anatomically and thereforedifficult to replicate with reconstructivetechniques.

The lateral side consists of staticand dynamic stabilizers. The staticstabilizers include the fibular collateralligament and the popliteofibular liga-ment as well as the posterolateral aspectof the capsule. The popliteus muscle andtendon act as both a static and a dy-namic stabilizer to control posterolateralrotation of the knee. The fibular col-lateral ligament acts as a primary re-straint to varus stress and a secondaryrestraint to posterolateral rotation ofthe tibia on the femur. The popliteo-fibular ligament acts as a primary re-straint to external rotation of the tibiaon the femur at 30� of flexion, as does

the popliteus muscle and tendon. Theposterolateral aspect of the capsule actsin a secondary supportive role to resistexternal rotation, hyperextension, andvarus moments27-29.

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 allografttissue. An alternative is to simplify the re-pair by performing a fibular and femoral-based reconstruction alone14,21,30-32 (Figs.6-A and 6-B). There are few studiescomparing types of reconstructions inthe literature, but, with other kneereconstructions, the more anatomicrestorations tend to produce the bestresults. A reconstruction described byLaPrade et al.33 is often mentioned asthe closest reproduction of normalanatomy and will be described later inthis paper.

The timing of surgery has been oneof the most controversial aspects of kneedislocation management. Recent studieshave indicated that earlier reconstructionmay be better34, but the evidence is notstrong. The benefits of early surgery mustbe balanced against the risks of arthro-fibrosis and the risks of infection whereopen 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

Drawingdepictingfixation, tunnel, andgraft positioning inacombined reconstructionof theposterior and

anterior cruciate ligaments. Note the primary aperture-opening fixation combined with cortical sus-

pensory back-upfixation. (Reprinted,withpermission, from: Fanelli GC.Rationaleandsurgical technique

for PCL and multiple knee ligament reconstruction. Warsaw, IN: Biomet Sports Medicine; 2008.)

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fixation pin sites or wounds from soft-tissue injury (Fig. 7). The decision whento operate needs to be individualized.

Another controversial issue iswhether to repair or reconstruct theposterolateral corner. Recent work byboth Stannard et al.34 and Levy et al.35

indicates that reconstruction is probablybetter than repair. When surgery isperformed within the first three weeksafter the injury, a combination of repairand reconstruction can be done andshould provide the best chance of pro-ducing a stable posterolateral corner.Stannard et al. recently reported a trialof repair versus reconstruction of theposterolateral corner in fifty-sevenknees34. Forty-four (77%) of the patientshad sustained multiple ligament injuriesof 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 rateof 9%. Reconstruction was found tohave a significant advantage over re-pair in terms of stability on clinicalexamination.

In the study by Levy et al.35,patients with multiligament knee in-juries treated by a single surgeon wereidentified in a prospective database.Between February 2004 and May 2005,patients underwent repair of medial andlateral-sided injuries, followed by de-layed cruciate ligament reconstructions.Between May 2005 and February 2007,patients underwent single-stage multi-ligament knee reconstruction. Forty-fiveknees (forty-two patients) with a mini-mum of two years of follow-up were

identified. Four of ten repairs of thefibular collateral ligament and postero-lateral corner and one of eighteenreconstructions of the fibular collateralligament and posterolateral corner failed(p = 0.04). Although neither of thesestudies34,35 was randomized, the findingsof the two were quite similar, with bothshowing the rate of failure of repairs ofthe fibular collateral ligament and pos-terolateral corner to be significantlyhigher than the rate of failure of re-constructions of those structures.

Numerous surgical techniques totreat posterolateral corner injury havebeen described, with varying clinicaloutcomes14,36-38. Stannard et al. useda modified two-tailed technique thatreconstructs the popliteofibular liga-ment and fibular collateral ligamentthrough transtibial and transfibularbone tunnels and around a single screwon the lateral femoral condyle36. Twenty-two knees were followed for a minimumof two years, and the mean range ofmotion at the time of follow-up was133�. The mean Lysholm knee score was90 points for the entire group, 92 pointsfor the knees with multiligament in-juries, and 88 points for those with anisolated posterolateral corner recon-struction. There were two failures (13%)in the group with multiligament kneeinjuries, compared with no failures inthe group with an isolated posterolateralcorner reconstruction.

Strobel et al. evaluated the clinicaloutcomes after single-stage anteriorcruciate ligament, posterior cruciateligament, and posterolateral corner re-construction in seventeen patients withchronic knee injuries and a minimumduration of follow-up of twenty-fourmonths37. The posterolateral cornerwas reconstructed with a graft passedthrough the proximal part of the fibula,with both graft limbs inserting at anisometric point on the femur. At thefinal evaluation, performed with theInternational Knee DocumentationCommittee (IKDC) score, the result wasgraded as nearly normal for five of theseventeen patients, as abnormal for ten,and as grossly abnormal for two. Themean postoperative subjective IKDCscore 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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The LaPrade technique33 has beenpopularized as a stable and anatomicallycomplete reconstruction utilizing a two-tailed graft (usually an Achilles tendonallograft) and reconstructing the fibularcollateral ligament, the popliteofibularligament, and the popliteus tendon. Thistechnique requires four tunnels: twoin the femur (for the insertion of thefibular collateral ligament and the pop-liteus tendon), one in the fibula, and onein the proximal part of the tibia. TheAchilles tendon can be split into twoseparate grafts and bone blocks. Bothbone blocks are inset into the femoraltunnels and secured with interferencescrews, replicating the insertions of thefibular collateral ligament and popliteustendon, respectively. The fibular col-lateral ligament graft then runs fromanterior to posterior through the tun-nel in the fibula and subsequently into

the tibia. The popliteus portion thenruns from the femur into the tibialtunnel to join the other graft. A largebioabsorbable screw is then placedfrom anterior to posterior with the twograft limbs under tension at 30� offlexion and slight internal rotation.Excessive internal rotation force canconstrain the knee excessively. Al-though the procedure is technicallychallenging, the results of this recon-struction appear to be good.

When the posterolateral corner istorn, there are usually other knee ligamentinjuries. Therefore, when the posterolat-eral corner is being repaired the lateralcollateral ligament and the popliteofibularligament complexes should be repaired aswell. Allograft tissue is recommended forposterolateral corner reconstruction sothat autogenous grafts can be used torepair the other ligaments and donor site

morbidity is kept to a minimum. Nu-merous surgical techniques are available,but varus and posterolateral rotatorystability is best restored by the techniquewith which the surgeon is most familiar.

Reconstruction of the MedialCollateral Ligament andPosteromedial CornerCombined injuries of the anterior cruciateligament, posterior cruciate ligament, andmedial collateral ligament/posteromedialcorner are classified as Type III accordingto the modified Schenck anatomic classi-fication scheme. The anatomic structureson the medial side are arranged in threedistinct layers: Layer 1 is the sartorius andsartorius fascia; Layer 2 is the superficialmedial collateral ligament, posterior ob-lique ligament, and semimembranosus;and Layer 3 is the deep medial collateralligament (the meniscofemoral and me-niscotibial ligaments) and the poster-omedial aspect of the capsule. The gracilisand semitendinosus tendons are foundbetween Layers 1 and 2. These layers arenot always separate since Layers 1 and 2blend anteriorly, whereas Layers 2 and 3blend posteriorly.

LaPrade et al.39 described theclinically relevant medial knee anatomy.There are three osseous prominences onthe medial aspect of the distal part of thefemur: the medial epicondyle, the ad-ductor tubercle, and the gastrocnemiustubercle. The femoral origin of thesuperficial medial collateral ligamentis approximately 3 mm proximal and5 mm posterior to the epicondyle, whilethe tibial insertion is approximately6 cm distal to the joint line. The deepmedial collateral ligament inserts alongthe tibial plateau margin, just distal tothe articular cartilage. The femoralorigin of the posterior oblique ligamentis approximately 8 mm distal and 6 mmposterior to the adductor tubercle.These anatomic sites correspond to theradiographic landmarks described byWijdicks et al.40. The combination ofrecognition of osseous prominences andradiographic identification helps toguide the surgeon to the proper liga-ment origin and insertion sites duringrepair or reconstruction. In a study ofcadaver knees, Stannard et al.41 found

Fig. 6-A

Fig. 6-A and 6-B Pictorial representations of fibular and femoral-based reconstructions of the fibular

collateral ligament (FCL) and posterolateral corner. PFL = popliteofibular ligament. (Copyrighted and

used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)

2240



that use of radiographic landmarks,rather than palpating the osseous pro-minences, led to better reproduction ofthe isometry of the superficial medialcollateral ligament.

More than 10 mm of medial jointopening with the knee in full extensionis the hallmark finding in a knee witha combined injury involving the medialside and both cruciate ligaments. Stressexamination, with the patient underanesthesia, with the use of fluoroscopyor radiography to compare joint spaceopening of the injured knee with that ofthe contralateral knee helps the surgeonto understand the extent of pathologicligament laxity. Magnetic resonanceimaging is a sensitive tool for identifyinginjured structures.

Once the soft tissues are satisfac-tory, acute surgery (performed one tothree weeks after the injury) is indicatedwhen there is extensive medial disruption,a displaced meniscal tear, or a so-calledStener lesion of the knee in which the

distal medial collateral ligament is flippedover the pes anserinus tendons. Delayedsurgical intervention (at more than threeweeks after the injury) may be necessaryto allow the swelling to resolve and kneemotion to return. When the only medialdamage is a femoral medial collateralligament avulsion, healing may occur andonly the cruciate ligaments need to berepaired. When the anterior cruciateligament, posterior cruciate ligament, andmedial side need to be repaired, a single-stage procedure with anterior and poste-rior cruciate ligament reconstructionsalong with repair or reconstruction of themedial collateral ligament and poster-omedial corner, as indicated, is best.

In the acute setting, a femoral ortibial-sided avulsion of the medialcollateral ligament with good ligamentsubstance can be repaired to the ana-tomic origin with a suture post andligament washer. Figure 8 shows anexample of a tibial-sided disruption ofthe medial collateral ligament. The in-

tact ligament with excellent tissue sub-stance allows a secure repair without theneed for augmentation or reconstruc-tion. The deep meniscotibial ligamentcan be reattached with suture anchors.The repair should be tensioned with theknee at 30� of flexion, a varus stress, andslight tibial external rotation. Injuries ofthe posterior oblique ligament and theposteromedial aspect of the capsule arealso repaired anatomically with sutureanchors and tensioning near full exten-sion. It is important to avoid overten-sioning in flexion, as this may preventfull knee extension.

Numerous reconstruction tech-niques for treatment in the chronicsetting have been described23,42-44. Ourpreferred technique is to use an Achillestendon allograft with the bone plugfixed in a femoral socket with an in-terference screw and the tendon securedto the tibia with a suture post/ligamentwasher construct. Figure 9 shows theAchilles tendon allograft after fixation

Fig. 6-B

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of the femoral attachment. The pos-terior oblique ligament and postero-medial aspect of the capsule are repairedif necessary.

A detailed search of the literaturefrom 1978 through 2008 identified allstudies with outcome data on repair orreconstruction of the medial collateralligament in the setting of combinedligament injuries8. Only eight studiesmet the inclusion criteria: five were onmedial collateral ligament repair, andthree were on medial collateral ligamentreconstruction. No prospective studiesdirectly compared medial collateral lig-ament repair or reconstruction withnonoperative treatment or comparedmedial collateral ligament reconstruc-tion with repair. The collective resultssuggest that either repair or reconstruc-tion in the knee with multiple ligamentinjuries yields satisfactory outcomes.Owens et al.45 reported on eleven kneeswith injuries to the anterior cruciateligament, posterior cruciate ligament,and medial collateral ligament, with themedial collateral ligament repaired onlyif it was avulsed, and all were stable tovalgus stress at the time of final follow-up. One of us (G.C.F.) and colleagues22

reported on nine knees with injuries tothe anterior cruciate ligament, posteriorcruciate ligament, and medial collateralligament, and all were stable to valgus

stress, including seven that were treatedsurgically. In a study by Hayashi et al.46

in which seven reconstructions of theanterior cruciate ligament, posteriorcruciate ligament, and medial collateral

ligament were performed with use ofa semitendinosus autograft, the averageLysholm score was 95.1 points. Stannardet 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.

2242



injuries. Forty-eight underwent auto-graft or allograft reconstruction of themedial collateral ligament, and twenty-four had a medial collateral ligamentrepair. On the basis of a 20% failure ratein 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 multipleligament injuries.

It is important to make an accu-rate, anatomic diagnosis with the use ofphysical examination, imaging studies,and bilateral comparison stress radio-graphs. The surgeon needs to determinethe safe and appropriate timing ofsurgery and then proceed with recon-struction of the anterior and posteriorcruciate ligaments along with repair orreconstruction of the medial collateralligament, posterior oblique ligament,and posteromedial aspect of the capsule.

Postoperative RehabilitationThe knee should be kept in full ex-tension for a minimum of three weeks,and the patient should remain non-weight-bearing for six weeks47. Pro-gressive range-of-motion exercises startthree weeks after the operation. Thebrace should be unlocked at the end ofthe third week, and use of the crutchesis discontinued once the patient canbear full weight. Progressive closed-kinetic-chain strength training andcontinued motion exercises are per-formed. Use of the brace should be

discontinued after the tenth week. Thepatient can return to sports and stren-uous labor after the ninth postoperativemonth as long as sufficient strength,proprioceptive skills, and motion havereturned11,48. A loss of 10� to 15� ofterminal flexion might be expectedafter these complex knee ligamentreconstructions.

Fracture-DislocationsFracture-dislocations of the knee aresevere injuries that have frequently beenassociated with poor outcomes49-54. Themost common fracture around the kneeassociated with a multiligament kneeinjury is a tibial plateau fracture. It isdifficult to treat patients who haveinstability of both the bone (a fracture)and ligaments of the knee. Recon-structing ligaments is a challenge whenone is trying to anchor a reconstructionin fractured bone. The risk of failure ofearly reconstruction of the posterolat-eral corner with use of the modifiedtwo-tailed technique is higher in pa-tients with a tibial plateau fracture thanit is in patients who do not have afracture34,36.

Knee fracture-dislocations occurmore frequently than generally thoughtand are particularly challenging to di-agnose. It is difficult to determine thestability of the knee in a patient witha tibial plateau fracture. These patientsalso frequently have multiple injuriesthat divert the attention of treatingteams away from the knee injury. As

identified with magnetic resonance im-aging, the prevalence of concomitantligament injuries with tibial plateaufractures has been reported to be as lowas 33% and as high as 90%55-58. Whilemany of these injuries do not representfracture-dislocations, in Stannard’s se-ries of 103 consecutive tibial plateaufractures, more than half of the patientshad multiple ligament injuries and26% had a fracture-dislocation55.Magnetic resonance imaging is animportant adjunct to an examinationunder anesthesia for the successfuldiagnosis of fracture-dislocations ofthe knee.

There are very few publishedstudies dedicated to the topic of fracture-dislocation of the knee. The publishedresults show a high prevalence of pooroutcomes, with pain, instability, andarthrofibrosis being the most commoncomplications49-54. Conservative treat-ment is associated with poor results,and most authors have recommendedsurgical treatment for patients withfracture-dislocation. Delamarter et al.reported that 40% of their patients witha fracture-dislocation had a poor out-come after nonoperative treatment com-pared with a 16% rate of poor resultsin those who had had an operation59.Stannard et al. developed a staged treat-ment protocol for fracture-dislocations,in which the treatment of the fracture isseparated from that for the dislocation,and it has yielded good functional out-comes in most patients60. Outcome scoresafter use of this staged protocol have beenencouraging in patients with these com-plex injuries.

The initial phase of treatmentfor a patient with a fracture-dislocationof the knee is on the day of injury. Themechanism of injury, radiographicfindings, and examination of the skin leadto a suspicion of a fracture-dislocation.The fracture is gently reduced withtraction, and a careful vascular exami-nation is performed. If the knee remainsreduced, the extremity should be immo-bilized with a splint or knee-immobilizerand magnetic resonance imaging shouldbe performed. In most cases, the skinand soft-tissue injury are so severe thatsurgical 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.

2243



at least three to seven days. Once thecondition of the soft tissues around theknee is satisfactory, the second phase oftreatment can begin.

Phase two is surgical stabiliza-tion of the fracture and any avulsionsof major ligaments. Locked plates arefrequently necessary to stabilize the com-plex fractures associated with fracture-dislocations. Preoperative planning iscritical, both for successful treatment ofthe fracture and to ensure that the im-plants do not block future tunnels thatwill be necessary for reconstruction of theinjured ligament. A knee-immobilizershould be applied after stabilization ofthe fracture, and one must be certain thatthe knee stays reduced.

Phase three is the early recon-structive phase of the protocol. If thecondition of the patient and the softtissues allow it, we advance to this phaseduring week three or four following theinjury. Allograft ligament reconstruc-tion is the mainstay of this phase. Thereare no definitive data in the literatureregarding the timing or staging ofligament reconstructions in patientsfollowing knee dislocations. On thebasis of the findings in the seriesevaluated by Stannard et al.34,36, recon-struction of the anterior cruciate liga-ment and posterolateral corner shouldbe delayed for approximately fourmonths to allow early healing of thetibial plateau before tunnels are drilledthrough the tibia. Those authors re-ported a failure rate of >30% whenposterolateral corner reconstructionshad been performed during phase threecompared with a failure rate of 8% whenthe same posterolateral corner recon-struction technique had been performedin patients without a tibial plateaufracture34,36. A hinged external fixator isplaced at the end of the surgery in phasethree, providing a stable environmentfor early ligament healing. Gentle mo-tion is initiated on postoperative dayone if the condition of the soft tissueallows it.

Phase four is the late reconstruc-tive phase. The patient should have atleast 80� of knee flexion before startingphase four. The hinged external fixatoris removed, and the anterior cruciate

ligament and posterolateral corner arereconstructed if the knee remains un-stable. Again, allograft tissue is normallyused for the reconstructions. Earlymotion after surgery is used to minimizearthrofibrosis.

In series evaluated by Stannardet al.60, good functional outcomes wereachieved in patients in whom a fracture-dislocation had been treated with thisstaged protocol. In a series of fiftypatients with a total of fifty-four fracture-dislocations, the final Lysholm kneescore averaged 86 points (range, 50 to100 points). According to the final ob-jective IKDC scores, there were thirty-two normal or nearly normal knees andseventeen abnormal knees. However,while good function was achieved,patients required an average of foursurgical procedures to complete theirtreatment.

ComplicationsComplications are frequent after kneedislocations and fracture-dislocations.Complications include a wide variety ofconditions including wound-healing,vascular, and neurologic problems. Themost common complications remainpain, arthrofibrosis, and ligament in-stability despite reconstruction. Pain isa difficult complication to quantify ob-jectively, but many patients have prob-lems with chronic pain following theseinjuries. The prevalence of chronicpain has ranged from 25% to 68%61.Arthrofibrosis remains a substantialsource of pain and disability followingknee dislocations. The prevalence hasranged from 5% to 71% in the publishedliterature, with a mean of 29% of patientshaving arthrofibrosis requiring surgicaltreatment61. The prevalence of persistentinstability was 100% after nonoperativetreatment, and it ranged from 18% to100% after surgical treatment, with a meanof 42% of patients having instability inat least one plane61.

Results of Treatment of KneeDislocationsOutcomes after knee dislocation aredifficult to quantify in large part becausethe injuries are heterogeneous62. A kneedislocation can range from a three-

ligament noncontact injury that reducedspontaneously to one sustained in ahigh-speed motor-vehicle accident andis associated with severe neurologic andvascular injuries. Nevertheless, the dataon the outcomes of these injuries aresummarized below.

Levy et al.8 performed a systematicreview of 413 articles on this topic. Theyevaluated studies that compared surgicaltreatment with nonoperative treat-ment63-66, studies that compared repairwith reconstruction34,67, and studiesthat compared early and late surgicaltreatment21,68-71.

Of the four studies that com-pared operative and nonoperativetreatment63-66, one was a meta-analysis ofinvestigations published prior to 200063.In three studies in which the Lysholmscore was used to record postoperativeoutcomes, surgical treatment resulted inhigher mean scores63-65, with one of thedifferences being significant64. The surgicalgroup also had higher IKDC scores64,66.Return to work and to sports activitieswere also better overall in the surgicallytreated group.

Two studies that compared surgi-cal repair with reconstruction wereidentified34,67. Direct repair of cruciateligaments resulted in inferior motion,a higher rate of positive posterior sagsigns, and a lower rate of return to thepreinjury activity level67. The rate offailure after repair of the posterolateralcorner was also found to be higher thanthat after reconstruction34.

In general, three weeks was themost consistent time point up to whichsurgery was described as ‘‘early.’’ Overall,the patients who had had early surgeryhad improved outcomes for severalparameters21,68-71. However, there is po-tential for substantial bias with respectto the timing of surgery because thereason for early or late surgery may berelated to prognosis (such as otherinjuries or the status of the soft tissuesaround the knee).

An excellent prospective cohortstudy with a minimum of two years offollow-up after reconstruction for treat-ment of knee dislocations was carried outby Engebretsen et al.72. Inclusion criteriawere injury to both the anterior and

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the posterior cruciate ligament as well asan injury to the medial and/or lateralside. Patients were treated with surgicalreconstruction within two weeks after theinjury, when that was not contraindi-cated by other injuries. The authors usedboth autograft and allograft tissue, witha trend toward using autograft later inthe study enrollment period. Of 121patients who were initially eligible,eighty-five patients had sufficient follow-up. Approximately half of the patientsin this cohort sustained what wasconsidered high-energy knee disloca-tions. The median Lysholm score forthe patients who were followed was 83points, and the median Tegner scorewas 5 points. The authors found thatinjuries resulting from high-energytrauma and those involving all fourmajor ligaments resulted in worse out-comes than did those resulting fromlow-energy trauma and those involvingthree ligaments.

Despite some excellent case seriesas well as comparative studies and theprospective cohort study by Engebretsenet al.72, we are not aware of any random-ized controlled trials to assist us withoutcome assessment after knee disloca-tion. These injuries are complex and noteasily amenable to randomized trialsfor many reasons62. Additional researchis needed to identify prognostic factorsand treatment algorithms to improve

outcomes after these rare and devastat-ing injuries.

OverviewRecent advances in surgical techniques,including anatomic reconstructions, formanagement of knees with multipleligament injuries have led to improvedpatient outcomes. Current recommen-dations include measurement of theankle-brachial index in each patient,early surgical management (earlier thanthree weeks postinjury), the use ofautograft or allograft tissue, recon-struction as opposed to repair alone ofthe fibular collateral ligament and pos-terolateral corner structures, recon-struction of the anterior and posteriorcruciate ligaments, and repair and/orreconstruction of the medial collateralligament and posteromedial corner,depending on the injury pattern andquality of tissue. Future research in-cluding the establishment of multicenterworking groups and the collection ofprospective data may hold the key toidentifying optimal treatment protocolsfor these complex injuries.

Gregory C. Fanelli, MDDepartment of Orthopaedic Surgery, GeisingerMedical Center, 115 Woodbine Lane, Danville,PA 17822-5212

James P. Stannard, MDDepartment of Orthopaedic Surgery, Universityof Missouri, 1 Hospital Drive, Columbia,MO 65212

Michael J. Stuart, MDBruce A. Levy, MDDepartment of Orthopedic Surgery(M.J.S. and B.A.L.) and SportsMedicine Center (M.J.S.), Mayo Clinic,200 First Avenue S.W.,Rochester, MN 55906

Peter B. MacDonald, MDPan Am Clinic, 75 Poseidon Bay, Winnipeg,MB R3M 3E4, Canada

Robert G. Marx, MD, MSc, FRCSCHospital for Special Surgery,535 East 70th Street, New York, NY 10021

Daniel B. Whelan, MDUniversity of Toronto, 55 Queen Street East,Suite 800, Toronto, ON M5C 1R6, Canada

Joel L. Boyd, MDTRIA Orthopaedic Center,8100 Northland Drive,Minneapolis, MN 55431

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. Thisarticle, as well as other lectures presented atthe Academy’s Annual Meeting, will beavailable in February 2011 in InstructionalCourse Lectures, Volume 60. The completevolume 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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Documents

Management of Complex Knee Ligament Injuries · Anterior Cruciate Ligament Reconstruction The principles of reconstruction in a knee with multiple ligament injuries include identiﬁcation