1. Complex Ligament Injuries of The Knee
H.Makhmalbaf MD
Consultant Knee Surgeon
Assistant Professor Orthopaedics
Mashad University of Medical sciences

2. Surgical Management of Knee dislocations
JBJS supp Anikar Chhabra MD & Christopher Harner MD , University of Pittsburgh Medical Center Pittsburgh Pennsylvania

3. Evaluation & Management
Characterize the pattern of injury
Determine the surgical approach
By ligament examination
After, survival of the limb is assured
And, the patient is stabilized

4. Investigations : Plain radiographs AP& LAT
Avulsion fx:
Fibular head, PCL, Segond’s sign
Depression
CTscan, for fractures & avulsions
MRI
Ligament injuries
Other soft tissue injuries
Bony injuries

5. Imaging

6. Postermedial repair

7. PM inj.& Subluxation

8. PCL MCL ACL injury

9. After repair

10. Final outcome: Stable ,pain free, good ROM Stiff knee
Unstable & pain free
Unstable & painful

11. Type of instability One plain Rotational Posteromedial Posterolateral
Convert multidirectional to:
One plain instability

13. Anatomic classification of knee dislocation
KDI ,single cruciate torn+ one corner
KDII ,ACL/PCL torn ,collaterals intact
KDIIIM ,ACL/PCL/MCL
KDIIIL ,ACL/PCL/LCL/PLC torn
KDIV ,ACL/PCL/MCL/LCL-PLC torn
KDV knee fracture dislocation

14. Knee dislocation management
Reduce
Splint & observe then operate
External fixation
Transfix pins
Vascular repair
Soft tissue condition?

15. Planning Surgical & non surgical issues Timing of surgery Repair
Graft selection for reconstruction
Surgical techniques
Risks & benefits
Complications discussed with the patient

16. EUA & Positioning Position the patient EUA Determine ligaments injured
Arthroscopic assessment
Gravity inflow irrigation
Avoid extravasation & compartment syn.

17. Graft selection for multiple ligament injuries
Graft choice is based on the:
Extent of the injury
Timing of the surgery
Experience of the surgeon
Autograft
Better graft incorporation &
Remodeling
Allograft

18. ACL& PCL reconstruction
BPB allograft for ACL
Achilles tendon allograft for PCL
Or Hamstring tendon autograft
Tunnel preparation
Achilles tendon allograft or BPB for LCL
Pass PCL graft first then ACL
Fix in the femoral tunnel ,tibial at the end

19. Lateral side injury Repair if fresh, or reconstruct
After fixation of ACL & PCL reconstructs
Lateral incision
Expose proneal nerve
LCL,Popliteofemoral lig. ,popliteus tendon
Joint capsule
Avulsion of biceps femoris & ITB

20. KDIIIL

21. Lateral side reconstruction

22. KDIIIM

23. Critical concepts: The majority of the knees are treated surgically
The goal of anatomic repair & reconst.
Approach with in 1st three weeks
Emergency surgery in: open, irreducible
Or with vascular injury or compartment syn

24. Order of fixation of ligaments in repair or Reconstruction
1st FIX PCL in 90 flexion
Then ACL in extention
Then LCL in 30 FLEXION
Finally MCL in 30 flexion

25. Critical concepts In open knee dislocations : Wound management
Adequate soft tissue coverage
Dictate :
The timing of ligament reconstruction
Never be performed acutely

26. Irreducible Dislocations
Uncommon but needs prompt,
Surgical reduction
To avoid NV damage
Delay definitive reconstruction
Allow complete knee imaging
Planning & stabilization of the patient
Emergent vascular repair

27. Critical concepts Management & treatment of compartment syndrome
Simple primary repair of injured soft tissue
Avoid additional incisions
Delay definitive ligament reconstructions
In vascular repair give enough time

28. Contraindications: Advanced age or sedentary lifestyle
An active infection
Intra-articular or periarticular fractures
Osteoarthritis
Debilitating or posttraumatic comorbidities

29. Pitfalls: Well planned skin incisions
MIS, use of Allograft & arthroscopy
Open technique for medial & lateral
Low intra-articular fluid pressure
To avoid compartment syndrome
Re check to make sure the compartments are soft

30. Causes of failure in PLC inj
Frank R Noyes et al. Am J Sport Med PLC operative procedures
Untreated varus malalignment (10)
Failure to reconstruct all ruptured ligaments , including cruciates (27)
Nonanatomical graft reconstruction (23 )

31. F. Noyes recommendations AJSM 2006
Anatomical graft reconstruction of one or more P Lateral ligaments
Restoration of all cruciate ligaments
& correction of varus malalignment

32. Chronic inj.of the PLC of the knee (Covey DC.JBJS 2001)
More complex problem than acute
Scarring, secondary changes to other st.
Possible limb malalignment
The goals of operative treatment are:
Restoration of knee stability & kinematics
Return to preinjury activity level
Reduce chance OA ,

33. THANK YOU Tehran 2007