Multiple Ligament Injuries of the Knee Dr. Andrew de Vlieg Gateway Private Hospital Prime Human Performance Institute Umhlanga/ Durban South Africa

Definition Tear of at least 2 of: - ACL - PCL - PMC (Posteromedial Corner) - PLC (Posterolateral Corner) Not necessarily a knee dislocation

Classification by Schenck Explaining Schenck’s knee dislocation classification Additional caps of "C" and "N" are utilized for associated injuries. "C" indicates an arterial injury. "N" indicates a neural injury, such as the tibial or, more commonly, the peroneal nerve. ACL, anterior cruciate ligament; FCL, fibular collateral ligament; KD, Knee Dislocation Classification I–V; MCL, media collateral ligament. Classification by Schenck KD I Injury to single cruciate + collaterals KD II Injury to ACL and PCL with intact collaterals KD III M Injury to ACL, PCL, MCL KD III L Injury to ACL, PCL, FCL KD IV Injury to ACL, PCL, MCL, FCL KD V Dislocation + fracture

Classification High Energy Injuries- commonly motor vehicle accidents or fall from a great height Low Energy Injuries- sporting injuries Ultra-low Energy Injuries- obese patients (usually female) who trip and sustain severe knee disruption

Evaluation Maintain a high level of suspicion- not uncommon Pay attention to neurovascular status of the leg (LaPrade has shown a 4x increased incidence in vascular injuries if there is neurology) X-Rays – Plain views, Stress views, Alignment view (chronic cases) MRI Angiography (Ankle-Brachial Index < 0.9)

Ankle-Brachial Index Systolic Pressure at the ankle Systolic Pressure in the Upper Arm Measured with a Doppler device If < 0.9 then do a formal angiogram Vascular injuries occur in 25% of knee dislocations

Neurological Assessment Common peroneal nerve injuries occur in 14- 40% of knee dislocations More common in Ultra-low Energy injuries Only around 25% recover

Controversies in Management Operative vs. Non-operative Timing- Acute vs. Chronic Repair vs. Reconstruction Graft Selection Rehabilitation

Surgical vs. Non-surgical Treatment Surgical outcomes are better than non-surgical (Dedmond et al. Am.J.Knee Surg 2001) (Richter et al. Am.J.Sports Med 2002) (Peskun,Whelan.Sports Med Arthrosc 2011) Literature favours surgical management followed by functional rehabilitation

Timing of Surgery Acute - Generally favoured in the literature - 3 weeks (before scarring/ necrosis occurs and bony avulsions (Engebretsen, Mariani, Fanelli, Harner papers) - 6 weeks regarded as acute by Levy, La Prade papers Chronic – Not recommended unless forced delay (eg. Vascular injury)

Repair vs. Reconstruction Mariani (Am.J Knee Surg. 1999) compared repair vs. reconstruction - ↑ flexion deficit - ↑ instability - ↑ re-operation rate IN REPAIR GROUP - ↑ failures - ↓ return to pre-injury activities La Prade (JBJS Am. 2011) biomechanically validated reconstructions achieve better outcomes. New techniques of repair may improve outcomes Bony avulsions are suitable for repair Levy (AJSM 2010), Stannard (AJSM 2005) – higher failure rate with repair

Surgical Principles Planning - Tunnel positions to avoid convergence (sockets) - Graft selection - Equipment/ Instrumentation - Expertise

Graft Selection Hamstrings Quadriceps Tendon Patella Tendon Peroneus Longus Allograft

Surgical Principles Lateral Reconstruction Medial Reconstruction

Modified Larson Lateral Reconstruction

Surgical Principles Sequence of reconstruction- - generally start with the periphery - repair bony avulsions then do reconstructions Tensioning sequence (my preference)- - PCL 1st at 60° flexion (restores tibial step-off) - LCL at 30° - PLC at 60° (neutral rotation) - ACL at 20° - MCL/PMC at 30°

Rehabilitation PCL Brace for 6 weeks Early ROM with Physio assistance to achieve full extension and 90° flexion by 2 weeks Crutches for 4-6 weeks (varies with different reconstructions)

My Preferences Surgery in the 1st 3-6 weeks Repair/Augmentation of PLC &/or PMC (Hamstrings/ Internal Brace) PCL repair with Internal Brace Augmentation ACL reconstruction using Quadriceps tendon autograft (All-Inside) Attend to any meniscal pathology PCL Brace for 6 weeks Crutches for 4-6 weeks depending on specific pathology