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

2. 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

3. 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

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

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

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

7. 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

8. 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

9. 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

10. PCL
Posterior drawer test at 900
Grade mm (tibial condyles anterior)
Grade mm (condyles in line)
Grade mm (tibial condyles posterior)
Grade 3 suspect collateral injury

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

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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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%

21. 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

22. 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

23. 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

24. 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

25. 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

26. Thank you 26