Multiple Ligament Injuries around the Knee Assessment and Management Mark Blyth Consultant Orthopaedic Surgeon Glasgow Royal Infirmary GOTC Teaching Knee Term 2011

Spectrum of injury Isolated single ligament injury Two ligament injury Liow 2003, Brautigan 2000, Taft 1994 Dislocatable knee Twaddle 2003 Bicruciate injury Schenck 1994, Wascher 1997, Harner 2004 Frank dislocation Richter 2002, Rios 2003 Serious injuries Assessment and management difficult Outcomes uncertain MULTIPLE LIGAMENT = DISLOCATION

Classification Directional Kennedy 1963 unhelpful Schenck 1994 KD-I Cruciates not involved KD-II Bicruciate injury only KD-III Bicruciate +PM or PL disruption KD-IV Bicruciate + PM and PL disruption KD-V Dislocation with fractures 4 Subdivisions

Knee ligaments ACL PCL MCL + Posteromedial LCL + Posterolateral ACL/PCL/PLC 28% ACL/PCL/MCL/PLC 9%

Assessment Aetiology Robertson 2006 RTA 57% Sports 32% Low Energy Bilateral 5% Evaluation Polytrauma (ISS>25 - 26% Richter 2002) Vascular injury Neural injury Ligament evaluation

Vascular injury Incidence 10-40% arterial injury Anterior dislocation intimal tears Posterior dislocation rupture Stannard 2004 136 knees Incidence 7% surgical repair Intimal tears <50% treated expectantly

Vascular injury Stannard 2004 Selective arteriography Serial physical examination (6,24 and 48 hrs) Decreased pulses (ABIs) Expanding haematoma History dysvascular foot 90% positive predictive value 100% negative predictive value Intimal tears <50% No flow limit Can be treated expectantly Selective arteriography

Neural injury Incidence 10-30% Majority peroneal nerve Majority in continuity Hyperextension, lateral thrust injuries (45% ) (bicruciate+posterolateral corner) Injury can be proximal to main zone of injury

Ligament evaluation Difficult in the acute phase +/- EUA Lachman (Jonsson 1982, Torg 1976) Beware PCL false positive Pivot shift may be negative ACL Acute swelling may underestimate degree of instability

PCL Posterior drawer test at 900 Grade 1 0-5mm (tibial condyles anterior) Grade 2 5-10mm (condyles in line) Grade 3 10+mm (tibial condyles posterior) Grade 3 suspect collateral injury

MCL/posteromedial corner Valgus stress at 300 Grade 1 0-5mm Grade 2 5-10mm Grade 3 10+mm Grade 3+ Valgus in extn Grade 3+ suspect posteromedial corner and cruciate injury

LCL/posterolateral corner Varus stress at 300 Grade 1 0-2mm Grade 2 5-10mm Grade 3 10+mm Dial test at 300 only Posterolateral corner at 300+900 PCL+posterolateral corner Reverse pivot shift test Hughstons hyperextension ext rotation test Grade 2+3 suspect posterolateral injury

Emergency management Prompt reduction in ED Re-evaluate neurovascular status Simple extension splint usually sufficient

Imaging Plain XR Avulsion fractures PCL,ACL from tibia and biceps Segond fractures Stress views

Imaging MRI 100% accurate for PCL (Gross 1992) Less accurate for PLC (Ross 1997, Laprade 2000) Useful for meniscal, osteochondral injury MR cannot assess degree of instability

Management controversies Conservative vs operative Timing of surgery Repair versus reconstruction Allograft versus autograft Partial versus total repair Immediate vs delayed mobilisation All ‘supported’ by at best Level 3 evidence

Conservative vs Operative Mitchell 1930, Conwell 1937, Taylor 1972 cast Dedmond 2001 meta-analysis 132 knees - surgery better ROM, Lysholm - no difference activity levels Richter 2002 retrospective cohort study 89 knees superior results surgical group Levy meta-analysis 2009 IKDC A+B 58% surgery vs 20% Return to work 72% surgery vs 52% Many favour cast/ ex fix following vascular repair

Summary of acute surgical options Difficult in acute phase Risk of compartment syndrome with capsular disruption Degree of instability Avulsion or midsubstance rupture Associated injuries Definite indications early surgery Bony avulsions ACL and PCL Distal avulsion dynamic stabilisers – popliteus and biceps

Summary of acute surgical options Relative indications early surgery -Everything else ACL - reconstruction (?? repair tibial avulsion) PCL - reconstruction (? repair femoral avulsion) Staged reconstruction cruciates (Fanelli 2003, Shelbourne 1991, Yeh 1999, Ohkoshi 2002)

Early vs Late reconstruction Early within 3 weeks Direct repair (Wascher 1999, Fanelli 1996) Correct all instabilities Arthrofibrosis Liow 2003, 22 knees, Harner 2004, 31 knees Slightly better results acute group No difference ROM Levy Arthroscopy 2009 5 studies now Lysholm 90 acute vs 82 IKDC A+B 47% acute vs 31%

Early vs Late reconstruction Mook and Miller JBJS-Am 2009 Systematic literature review of timing surgery and post-operative rehabilitation Acute vs staged vs chronic– less laxity and post-operative stiffness in the patients managed with staged surgery More ROM deficits with acute surgery

Allograft vs Autograft Good theoretical advantages Donor site morbidity Amount of tissue available Strength of graft for PCL reconstruction (Harner 2004, Liow 2003, Fanelli 1999,Noyes 1997) Disease transmission Irradiation weakens graft

Alignment Important to consider especially in chronic cases Need to overcome lateral thrust in varus knees and PLC repair Consider augmenting acute repair of PLC with graft in varus knee Risk of stretching of repair and failure Levy Arthroscopy 2009 Osteotomy too much for acute cases 37 vs 9% failure

Multiple ligament injuries outcomes Not good! Objective ROM, stability results improving not comparable with isolated ACL reconstn Subjective poor IKDC nearly normal 50% abnormal 40% severely abnormal 10% Lysholm 70-80 Tegener 3-4 50 % risk OA at long-term f.u. Werier 1998

Summary Complex problems Assessment for vascular and neurological injury Data lacking for definitive management protocols External fixator possibly following vascular repair Early repair collateral and reconstruction cruciates by subspecialist Role for staged repair collaterals followed by cruciate reconstruction

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