It has been a blessing to be in a position that allowed me to expand my surgical techniques and research interest in the evaluation and treatment of the multi-ligament injured knee. The final chapter, 35, presents seven case studies in the management of the multiple ligament-injured knee.
Editor’s Experience
Anatomy and Biomechanics
Diagnosis and Evaluation of the Multiple Ligament Injured
Non-Surgical Treatment
Surgical Treatment of the Multiple Ligament Injured Knee
Surgical Treatment of the ACL-Based Multiple Ligament Injured Knee
Surgical Treatment of the PCL-Based Multiple Ligament Injured Knee
Other Considerations
Outcomes Data
Clinical Case Studies
- Introduction
- Respect the Anatomy
- Vascular Assessment
- Correct Diagnosis
- External Fixation
- Surgical Treatment
- Surgical Timing
- The Chronic Multiple Ligament Injured Knee
- Repair or Reconstruction
- Graft Preparation
- Arthroscopic or Open Surgical Procedure
- Surgical Technique
- Posteromedial Safety Incision
- PCL Tibial Tunnel Creation
- PCL Femoral Tunnel Creation
- ACL Reconstruction
- Mechanical Graft Tensioning and Fixation
- Posterolateral Reconstruction
- Posteromedial Reconstruction
- Postoperative Rehabilitation
- Multiple Ligament Knee Injuries in Children
- Outcomes and Results of Treatment
- Summary
External fixation is a useful tool in the treatment of a multi-ligament knee. Large bone avulsions of the tibial cruciate ligament are treated with reduction and fixation of the bony fragment.
Introduction
Surgeons performing reconstructions in patients with these injuries must have a complete understanding of the normal anatomy and biomechanics of the knee to optimize surgical timing, surgical approach, tunnel preparation, and anatomic placement of grafts. This chapter outlines the anatomy and biomechanics of the cruciate ligaments and their surgical implications.
Anatomy of the Cruciates
- Anterior Cruciate Ligament Anatomy
Multiligament knee injuries, although rare, are serious injuries that often result in the loss of the passive and active knee stabilizers and are often associated with involvement of neurovascular structures. The structure and shape of the anterior and posterior cruciate ligaments, patterns of injury, structural properties of the cruciate ligaments and graft substitutes, functional biomechanics and interplay between the cruciate ligaments, and the surgical implications related to anatomic reconstruction of the anterior and posterior cruciate ligaments are all comprehensively reviewed.
Anatomy and Biomechanics of the Cruciate Ligaments and Their Surgical Implications
- Posterior Cruciate Ligament Anatomy
- Vasculature of the Knee
- Injury Patterns of the Cruciate Ligaments
- Biomechanics of the Cruciates
- Biomechanics and Kinematics of the Knee Joint
- Passive Motion of the Knee
- The Functional Biomechanics of the Cruciate Ligaments
- Biomechanics of the ACL
- Biomechanics of the PCL
- The Interplay of the Cruciate Ligaments
- Surgical Implications of Cruciate Anatomy and Biomechanics .1 The Biomechanics of Ligament Reconstruction
- Structural Properties of Ligaments and Commonly Used Grafts
- Graft Tensioning
- Tunnel Placement for Cruciate Reconstruction
- Conclusion
- Introduction
- Anatomy
- Lateral and Posterolateral Knee
The effects of graft tension on laxity and kinematics in the anterior cruciate ligament reconstructed knee. Anatomy and biomechanics of the lateral and medial aspects of the knee and the surgical implications.
Anatomy and Biomechanics of the Lateral and Medial Sides of the Knee and the Surgical Implications
- Popliteus Tendon
- Popliteo fi bular Ligament
- Medial and Posteromedial Knee
- Super fi cial Medial Collateral Ligament
- Deep Medial Collateral Ligament
- Posterior Oblique Ligament
- Biomechanics
- Lateral and Posterolateral Knee
- Medial and Posteromedial Knee
- Injury Assessment: Examination and Imaging
- Treatment/Surgery
- Lateral and Posterolateral Knee
- Medial and Posteromedial Knee
- Immediate Postoperative Period
- Rehabilitation
Repair versus reconstruction of the fibular collateral ligament and posterolateral angle in the multiligament-injured knee. Nonoperative treatment of isolated complete tears of the medial collateral ligament of the knee.
Diagnosis and Evaluation of the Multiple Ligament Injured
Physical Examination
Open knee dislocations occur with an incidence between 19% and 35% and should be identified early in the physical examination [6. Assessment of neurological function in knee dislocation can be challenging because patient cooperation is unrestricted. seriously affected by head injury or drunkenness.
Initial Assessment in the Acute and Chronic Multiple-Ligament-Injured Knee
- Imaging Studies
- Surgical Timing
- External Fixation
- Arthroscopic Versus Open Cruciate Surgery
- Transtibial Tunnel or Tibial Inlay Surgery
- Single- or Double-Bundle Cruciate Reconstructions
- Introduction
- Initial Evaluation
- Position Classi fi cation System
- Energy of Injury Classi fi cation System
- The Anatomic Classi fi cation
- Conclusion
- Introduction
- Indications and Reasons for Instrumented Measurement
- Diagnosis
Magnetic resonance imaging is extremely important in the treatment of multiligamentous knee injuries. They consist of (1) anterior cruciate ligament (ACL), (2) posterior cruciate ligament (PCL), (3) medial structures, and (4) posterolateral structures.
Instrumented Measurement of the Multiple-Ligament-Injured Knee
Among the many important challenges are the accurate clinical diagnosis and classification of ligament and soft tissue injuries. History (ie, mechanism) and clinical examination are the most important elements in the evaluation of the knee.
Arthrometry, Stress Radiography, Rotationometry, and Computer Navigation
Post-Op
By comparing instrumented measures before and after surgery, the clinical effect of surgical intervention can be quantified. A direct comparison with the same measuring tool using the same technique can allow the surgeon immediate postoperative information on the effect of the repair or reconstruction.
Follow-up/Rehab
- Posterior Stress
Hamstring Contraction
Axial View
Posterior Sag/Gravity View
Kneeling Stress View
Valgus Stress
- Advantages
- Disadvantages
- Instrumented Stress Radiography Telos Stress Radiography
The Telos stress device (Austin and Associates Inc. Fallson MD) is a commercially available system that allows reproducible and consistent stress forces through the knee while taking a radiograph (Fig. 6.3. Depending on the patient's position and device orientation , it can be used to stress the tibiofemoral joint anteriorly, posteriorly, medially, or laterally.
Posterior Stress
- Anterior Stress
- Advantages
- Disadvantages
- Arthrometer KT-1000/2000
The KT-1000 and KT-2000 (the KT-2000 is essentially the same arthrometer, but with an added graphical interface) are arthrometers that measure anterior-posterior tibiofemoral translation (ie, translation in the sagittal plane).
Anterior
Posterior
- Advantages
- Disadvantages
- Knee Laxity Tester
The message is that the KT measurement is smaller than that measured by X-ray stress and that this difference is more pronounced when the displacement is greater than 10 mm. This study confirms that posterior displacement measurement is more accurate with stress radiation, especially in those cases that are greater than 10 mm.
Anterior
In 1995, we presented a study to the PCL study group comparing the KT value with the stress radiograph. 18 ] compared a novice and an experienced user of the KT-1000 device and found the device to be a reasonably reliable tool for evaluating PCL laxity.
Posterior
- Advantages
- Disadvantages
- Rotationometer/Laxiometer
- Advantages
- Disadvantages
- Computer-Assisted Navigation
- Advantages
- Disadvantages
In recent years, great progress has been made in the field of computer-assisted surgery (CAS). A recent study comparing computerized navigation with KT-1000 in the ACL-deficient knee showed comparable results [14.
Future Directions
Conclusion
Intratester and intertester reliability of the KT-1000 arthrometer in the assessment of posterior knee laxity. Instrumented examination of anterior cruciate ligament injuries: minimizing the shortcomings of manual clinical examination.
Introduction
- Image Quality
Central Stabilizers: Normal Anatomy and Injury
In (a) there is increased signal at the femoral attachment of the ACL and the attachment itself is not visible (circle). In (a) the ACL is thickened with bright T2 stripes, but the slope is normal, there is no focal discontinuity, and the femoral attachment is intact b) Shows an intact ACL with ACL ganglion (arrow.
Cruciate Grafts: Normal Appearance and Injury
Secondary findings supporting graft rupture include bone contusions with pivot displacement or signs of graft impingement, the latter often due to poor tunnel placement [18-20. Graft impingement manifests on MRI as focal anterior signal changes in the graft and/or bending of the graft as it contacts the intercondylar roof.
Medial and Lateral Stabilizers
In daily practice as well as in the surgical and radiological literature, these structures are often collectively called the medial collateral ligament (MCL) and lateral collateral ligament (LCL), respectively. Recent improved understanding of the intricate anatomy and function of these stabilizers suggests that injuries to these structures should be differentiated rather than grouped together.
Medial Stabilizers: Normal Anatomy
Posteromedial Corner: Normal Anatomy
The second component of the posteromedial angle, the semimembranous tendon, emerges and attaches to the tibia posteromedially. The two main arms of the semimembranosus, the anterior and direct arms, are well seen on MRI and rarely appear injured.
Medial and Posteromedial Structures: Injury and Pitfalls
The anterior arm is inserted to the medial aspect of the tibia at the level of the joint line, and the direct arm is inserted to the posteromedial tibia just below the joint line. The femoral attachments of the superficial MCL (large white arrows) and meniscofemoral ligaments (small white arrow) are thickened but intact.
Posterolateral Corner
- Lateral and PLC: Anatomy and Injury
It inserts medial to the attachments of the fabellofibular ligament and the arcuate ligament far posteriorly to the fibular styloid. Note how the edema highlights a portion of the intact arcuate ligament (small black arrow), which is located between the popliteal fibular ligament and the conjoined tendon.
Conclusion
The supporting structures and layers on the medial side of the knee: an anatomical analysis. MR imaging, MR arthrography and specimen correlation of the posterolateral angle of the knee: an anatomical study.
Introduction
Associated Injuries
In later wars, Korea and Vietnam, when vascular repair was a more common practice, amputation rates after popliteal artery injury increased to. This reinforces the need for accurate and rapid diagnosis and treatment of vascular injuries for successful outcomes after knee dislocation.
Nonoperative Treatment
As the resolution of MRI continues to improve, it has become the gold standard for imaging in acute knee dislocation. The following is a historical review of where the treatment of knee dislocations began, the results of nonsurgical treatment, and the evidence that has prompted current knee surgeons to advance the field of knee ligament reconstruction in multiligamentous knee injuries.
Old Results
As the century progressed, surgeons began to realize that the patient's range of motion was limited after prolonged immobilization. In 1967, Myles evaluated 7 knee dislocations and found that the patients' final range of motion was inversely proportional to their duration of immobilization [29.
De fi nition of Good
In 1743 Heister's stated that some loss of motion must be sacrificed for stability. This led many surgeons for years to use prolonged immobilization in the hope that intimidation would lead to a more stable knee.
New Studies
Fracture dislocations are associated with significant joint instability and require extensive ligamentous reconstruction and stable fracture fixation. Current improvements in arthroscopic techniques and safer ligament fixation methods have allowed for more aggressive physical therapy programs.
Natural Course
Animal studies have shown that a weak ACL knee leads to arthritic changes in the knee [46. This reduced risk of degeneration is attributed to early and improved surgical treatment creating better stability and allowing faster mobilization.
Who Should Be Operated on: What Is New?
Recent studies show that knee dislocations treated non-operatively tend to develop more severe degenerative changes than operative patients [33, 34. Plancher showed that 88% of non-operative patients had grade II or greater chondromalacia, compared with 47.4% of operative patients at an average 8.3-year follow-up [34.
Conclusion
Traumatic dislocation of the knee: a report of forty-three cases with special reference to conservative treatment. Timing of anterior cruciate ligament reconstruction in athletes and incidence of secondary pathology within the knee.
Surgical Treatment of the Multiple Ligament Injured Knee
- Introduction
- Patient Factors
- Graft Factors
- Availability of Graft
- Autograft
- Allograft
- Risk of Infectious Disease Transmission
- Delayed Incorporation of Allograft
- Procurement of Allograft Donor Tissue
- Sterilization of Allografts
- Storage of Allograft
- Authors’ Recommendation
- Biomechanical Strength of Graft
- Graft Choice for Speci fi c Ligament Reconstructions
- Surgical Technique
- Patellar Tendon
- Hamstrings
- Quadriceps Tendon Harvest
Arthroscopically assisted anterior cruciate ligament reconstruction using autogenous patellar ligament grafts. Late patellar tendon rupture after central third removal for anterior cruciate ligament reconstruction.
Surgical Treatment of the ACL-Based Multiple Ligament Injured Knee
Introduction
The treatment algorithm is usually dictated based on the severity of the medial knee injury, as well as injuries to associated structures such as the medial meniscus, medial retinaculum, or medial patellofemoral ligament (MPFL). Treatment of this combined injury pattern requires a thorough understanding of the complex anatomy of the medial aspect of the knee, as well as the key biomechanical principles involved in evaluating isolated and combined knee injury patterns, which will include the collateral ligament superficial medial (sMCL), posterior oblique ligament (POL), semimembranosus tendon (SM) and cruciate ligaments (ACL and/or PCL).
Anatomy of the Medial Aspect of the Knee
This chapter will review the evaluation and treatment of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries. Although MCL injuries are the most commonly seen knee injuries and the typical ACL injury occurs through a non-contact mechanism, the less frequent combined ACL-MCL injury pattern occurs more commonly via a contact or collision mechanism, which involves valgus stress with combined tibial causing external rotation.
Deep Medial Collateral Ligament (Mid-third Capsular Ligament)
Surgical Treatment of Combined ACL and Medial-Sided Knee Injuries: Acute and Chronic
- Posterior Oblique Ligament
- Semimembranosus Tendon Tibial Attachments
- Medial Patellofemoral Ligament
- Clinical Evaluation
- Classi fi cation of Injury
- Clinical Biomechanics
- Valgus Stress and Medial Compartment Motion Limits
- Anterior Translation
- External Rotation Limits
- Internal Rotation Limits
- Diagnostic Imaging
- Treatment Algorithm
- Surgical Indications
- Operative Strategy for Acute Medial Ligamentous Repair
- Chronic Medial-Sided Ligamentous De fi ciency
- Conclusion
- Introduction
- Pathophysiology/Biomechanics
Biomechanical studies repositioning the medial collateral ligament to correct a chronic anteromedial instability of the knee joint. Proximal advancement of the medial collateral ligament for chronic medial instability of the knee joint.
Surgical Treatment of Combined ACL and Lateral Side Injuries
- Clinical Evaluation
- History and Physical Examination
- Imaging
- Diagnostic Arthroscopy
- Nonoperative Management
- Surgical Indications
- Surgical Management
- Acute Combined Injuries to the ACL and Lateral Knee
- Chronic Combined Injuries to the ACL and Lateral Knee
- Postoperative Rehabilitation
- Complications
- Conclusion
- Introduction
- Combined ACL/MCL/Posteromedial Corner Injuries
- Imaging
The role of the lateral extra-articular limitations in the anterior cruciate ligament-deficient knee. Treatment of combined anterior cruciate ligament/posterior cruciate ligament/posterolateral complex injuries of the knee.
Surgical Treatment of Combined ACL Medial and Lateral Side Injuries: Acute and Chronic
Nonoperative Treatment
A combined MCL and ACL injury represents a completely different entity than an isolated MCL injury. In these scenarios, treatment for active individuals consists of delayed surgical ACL reconstruction, usually 6 weeks after injury, to allow the MCL to heal.
Operative Management
They noted three osseous prominences on the medial aspect of the distal femur: the medial epicondyle, the adductor tubercle, and the gastrocnemius tubercle. The majority of the distal attachment is located within the pes anserine bursa, with the posterior aspect fusing with the distal aspect of the semimembranosus tendon, an average of 61.2 cm distal to the joint line.
- MCL/PMC Reconstruction
When a combined ACL/MCL is performed, we perform our diagnostic arthroscopy and drill the ACL femoral and tibial tunnels before drilling the MCL tunnels. If this starts to happen, the dilator will limit further drilling of the MCL tunnel and it can be rerouted as needed.
Postoperative Management
The authors concluded that this technique can tighten the MCL without compromising knee ROM [1]; however we have no experience with this technique. Studies have also observed changes in ROM after ACL reconstruction combined with MCL repair based on the location of the MCL tear.
Combined ACL/Lateral-Sided Injuries
Posteromedial corner (PMC) repair was performed in 25 patients; five (20%) failed and required revision. Both the anterior and posterior portions of the PFL originate from the proximal-lateral aspect of the musculoendinous junction of the popliteus.
Imaging
The insertion of the popliteus tendon is anterior and distal to the origin of the LCL on the femur, with an average distance of 18.5 mm between the two structures (see Figure 3.1b). The attachment of the anterior part of the PFL is, on average, 2.8 mm distal to the tip of the fibular styloid on the anteromedial downslope, while the posterior division is, on average, 1.6 mm distal to the tip of the fibular styloid on the posteromedial. downward slope is secured.
Nonoperative Treatment
As it runs proximally and laterally, the tendon becomes intra-articular and runs around the posterior aspect of the lateral femoral condyle. After excavating the posterolateral structures of the knee in ten cadavers, LaPrade et al.
Operative Management
Acutely (within 3 weeks of injury), this includes anatomic ACL reconstruction with allograft as described above, followed by direct repair of the injured posterolateral injuries. These are typically direct avulsions of the LCL, popliteus and/or biceps femoris tendons or fibular head fractures.
- Chronic
This provides visualization of the PFL insertion on the fibular styloid and posterior popliteal sulcus. The LCL attachment site on the fibula is identified by entering the bursa between the long head of the biceps and the LCL.
Postoperative Management
The remaining portion of the LCL graft is passed through the tibial tunnel from posterior to anterior, reconstructing the PFL. For additional fixation, a staple is placed over the free ends of the grafts on the anterior tibia.
Conclusion
Non-operative treatment of grade II and III sprains of the lateral ligament region of the knee. This usually occurs relatively early after primary ACL reconstruction due to the large non-physiological forces that the graft must absorb.
Posterolateral Corner Injuries
This study demonstrated that splitting the PLC increases forces in the ACL under both varus and internal tibial torque. They found that cutting the LCL increased forces in the ACL graft under both varus and combined varus and internal torque.
Posteromedial Corner Injuries
14], it was found that the mean load responses to external rotation in the LCL were significantly higher than in the popliteus tendon and PFL at 0 and 30° of flexion. Additional splitting of the PFL and PT further increased ACL graft forces under both loading conditions.
Revision ACL Reconstruction
In Hughston's series describing patients with AMRI, patients had injuries to the midportion of the superficial and deep MCLs or to the POL, often (but not always) with an associated ACL injury [24. In one cohort of patients with POL injuries, the semimembranosus was injured in 70% of cases and peripheral meniscus detachment occurred in 30% of cases.
Preoperative Planning
The effect of posterior tibial translation increases when the tibia internally rotates due to the orientation of the POL and capsule fibers [21. Almost all patients (22 of 23) in a series of surgically treated MCL and ACL injuries had POL tears, with 8 of 23 having tears of the entire PMC [25.
Physical Examination
Injury to multiple structures on the medial side of the knee helps explain the phenomenon of anteromedial rotator instability (AMRI), which is defined as anterior subluxation and external rotation of the medial tibial plateau relative to the femur. Another advantage of anatomic double-bundle reconstruction is its ability to eliminate rotational laxity that is often overlooked or underappreciated in in-office examinations.
Radiographic Evaluation
This is especially true in regards to performing an accurate pivot displacement examination and determining the amount of pathologic rotatory weakness that is present. The location of the previous incisions should also be marked and planned to avoid any soft tissue compromise.
Staging
Examination Under Anesthesia
Patient Setup
Graft Selection
However, important information can be obtained regarding the integrity of the graft and associated meniscal, chondral, and secondary stabilizer injuries such as the PMC/PLC, which should be addressed at the time of surgery.
Portal Placement and Arthroscopy
Tunnel Placement
As is usually the case on the tibial side, the primary ACL tunnel can be used to create the AM tunnel. Our experience is that this has had no influence on the placement of the grafts, the fixation or the tension patterns.
Graft Passage and Fixation
Creating the ideal tunnel can be accomplished by placing a guide pin by hand through the primary ACL tibial tunnel and securing the tip of the pin in the roof of the femoral notch. For the PL tunnel, the guide is set at 45° and the tunnel is started medial to the AM tunnel and just anterior to the MCL on the tibial metaphysis, using the downward slope of the medial tibial spine as a reference.
Addressing Posterolateral Corner Injuries
Sutures are placed at the top of the fibular head to reproduce the LCL. The other limb is placed in the tibial tunnel to reproduce the attachment of the popliteus to the posterior tibia.
Addressing Posteromedial Corner Injuries
One limb is inserted into a drill tunnel in the posterolateral tibia, which enters posteriorly at the approximate site of attachment of the popliteus muscle-tendon unit to the posterior tibia. The distal tibial insertion of the superficial MCL is next fixed with the knee in 30° of flexion and neutral rotation.
Postoperative Rehab
The third technique for MCL and POL reconstruction differs from the previously described techniques in that separate soft tissue grafts are used to reconstruct the superficial MCL and POL (Fig. All grafts are secured with bone tunnel/interference screw constructs at the anatomic femur and tibial insertion sites .
Summary
Management of chronic posterolateral rotatory instability of the knee: surgical technique for the posterolateral corner sling procedure. Simultaneous reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee.
Surgical Treatment of the PCL-Based Multiple Ligament Injured Knee
Introduction
Although historically acute repair was the mainstay of surgical treatment, recent literature does not support primary repair of the ACL, PCL, or collaterals. We feel that primary cruciate ligament repair plays a role in the armamentarium of the surgeon managing the MLIK patient.
Arthroscopic Primary Cruciate Repair in the Multiligament Injured Knee
Indications and Imaging
Appropriate and refined indications are critical in identifying patients most likely to benefit from primary ACL and/or PCL repair. Most importantly, the treating surgeon should be aware of the difficulty of performing an arthroscopic primary repair three weeks after the injury.
