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

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

3. 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

4. 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

5. 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)

6. 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

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

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

9. 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

10. 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)

11. 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

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

13. Graft Selection Hamstrings Quadriceps Tendon Patella Tendon
Peroneus Longus
Allograft

14. Surgical Principles
Lateral Reconstruction Medial Reconstruction

15. Modified Larson Lateral Reconstruction

16. 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°

17. 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)

18. 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