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Current Concepts

The Multiple-Ligament Injured Knee: Evaluation, Treatment,and Results

Gregory C. Fanelli, M.D., Daniel R. Orcutt, M.D., M.S., and Craig J. Edson, M.S., P.T., A.T.C.

Abstract: The multiple-ligament injured knee is a complex problem in orthopaedic surgery. Mostdislocated knees involve tears of the anterior and posterior cruciate ligaments (ACL/PCL) and at least1 collateral ligament complex. Careful assessment of the extremity vascular status is essentialbecause of the possibility of arterial and/or venous compromise. These complex injuries require asystematic approach to evaluation and treatment. Physical examination and imaging studies enablethe surgeon to make a correct diagnosis and to formulate a treatment plan. Arthroscopically assistedcombined ACL/PCL reconstruction is a reproducible procedure. Knee stability is improved postop-eratively when evaluated using knee ligament rating scales, arthrometer testing, and stress radio-graphic analysis. Acute medial collateral ligament (MCL) tears, when combined with ACL/PCLtears, may in certain cases be treated with bracing. Posterolateral corner injuries combined withACL/PCL tears are best treated with primary repair as indicated, combined with reconstruction usinga post of strong autograft (split biceps tendon, biceps tendon, semitendinosus) or allograft (Achillestendon, bone–patellar tendon–bone) tissue. Surgical timing depends on the ligaments injured, thevascular status of the extremity, reduction stability, and the overall health of the patient. We preferto use allograft tissue for reconstruction in these cases because of the strength of these large graftsand the absence of donor site morbidity. Key Words: Dislocated knee—Combined ACL/PCLinjury—Allograft—Arthroscopic reconstruction.

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he dislocated knee is a severe injury resultingfrom violent trauma. It results in disruption of at

east 3 of the 4 major ligaments of the knee and leadso significant functional instability. Vascular anderve damage, as well as associated fractures, mayontribute to the challenge of caring for this injury.istorical treatment was primarily limited to immobi-

ization. However, with the advent of better surgicalnstrumentation and technique, the management ofombined anterior and posterior cruciate ligamentACL/PCL) tears associated with medial or lateral

From the Department of Orthopaedic Surgery, Geisinger Med-cal Center, Danville, Pennsylvania, U.S.A.

Address correspondence and reprint requests to Gregory C.anelli, M.D., Geisinger Medical Center, 100 North Academy Rd,anville, PA 17822-2130, U.S.A. E-mail: [email protected]© 2005 by the Arthroscopy Association of North America

k0749-8063/05/2104-4123$30.00/0doi:10.1016/j.arthro.2005.01.001

Arthroscopy: The Journal of Arthroscopic and Related S

ollateral ligament (MCL/LCL) disruption has be-ome primarily surgical. This article presents the basicnee anatomy, mechanisms and classifications of in-ury, evaluation, treatment, postoperative rehabilita-ion, and our experience with treating the dislocatednee.

ANATOMY

The stability of the knee is attributable to severalnatomic structures. The articulation of the femo-otibial joint is maintained in part by the bony anat-my of the femoral condyles and the tibial plateau.he menisci serve to increase the contact area between

emur and tibia and thus increase stability of the joint.he 4 major ligaments (ACL, PCL, MCL, LCL) and

he posterior medial and posterior lateral corners arehe most significant ligamentous stabilizers of the
nee. In addition to these static anatomic structures,
471urgery, Vol 21, No 4 (April), 2005: pp 471-486

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472 G. C. FANELLI ET AL.

ynamic anatomic structures, such as the musculaturehat crosses the knee joint, also play a role in stabili-ation. In any knee injury, examination must includevaluation of all these anatomic structures.

When evaluating a dislocated knee, it is imperativeo evaluate the structural integrity of any remainingigamentous structure; consequently, the functions ofhese structures must be well understood. The ACLrimarily prevents anterior translation of the tibia rel-tive to the femur, and accounts for about 86% of theotal resistance to anterior tibial translation.1 It is alsonvolved in limiting internal and external rotation ofhe tibia relative to the femur when the knee is inxtension.2 The ACL will also limit varus and valgustress in the face of either an LCL or an MCL injury.

The PCL may be considered the primary statictabilizer of the knee, given its location near the centerf rotation of the knee and its relative strength.3 TheCL has been shown to provide 95% of the totalestraint to posterior tibial displacement forces actingn the tibia.1 The PCL works in concert with struc-ures of the posterior lateral corner, and injury to bothtructures is required to significantly increase poste-ior translation.4

The MCL and LCL act alone to resist valgus andarus stresses, respectively, at 30° of knee flexion.ogether, they act in a secondary fashion to limitnterior and posterior translation, and rotation of theibia on the femur. The anatomy of the posteriorateral corner of the knee is complex; its major struc-ures consists of (1) the LCL, (2) the arcurate com-lex, (3) the popliteal tendon, and (4) the popliteal-bular ligament.5 The posterolateral corner primarilyesists posterior lateral rotation of the tibia relative tohe femur, but also contributes to resisting posterioribial translation. The posteromedial corner of thenee consists primarily of the posterior oblique por-ion of the MCL and associated joint capsule. Thesetructures provide resistance to valgus stress and pos-erior medial tibial translation. Evaluation of traumaticnee dislocation must include these anatomic struc-ures; typically, 3 or more areas are injured in kneeislocation. Failure to recognize and treat capsular andigamentous injury, aside from the obvious ACL/PCLnjury, will result in less than optimal results.6-8

Neurovascular structures are also at risk of injury.he popliteal fossa is defined by the tendons of the pesnserinus and semimembranous medially and the bi-eps tendon laterally. The space is closed distally byhe medial and lateral heads of the gastrocnemius androximally by the hamstrings. Within this space, the
opliteal artery and vein and the tibial and peroneal q
ranches of the sciatic nerve are located. The poplitealrtery may be most at risk to injury in knee disloca-ions. The popliteal artery is tethered proximally at thedductor hiatus as it exits from Hunter’s canal, andistally as it passes under the soleus arch, making itulnerable to injury in these areas. This artery isonsidered to be an “end artery” of the lower limb; ift is injured, the surrounding geniculate arteries are notufficient to maintain collateral blood flow to theower extremity. The popliteal vein is in close asso-iation with the artery, but seems to be less at riskuring injury than the popliteal artery. From a surgicaltandpoint, the popliteal vessels are located directlyosterior to the posterior horns of the medial andateral meniscus, and dissection in this area may puthese structures at risk if not adequately protected. Theciatic nerve divides into its peroneal and tibial divi-ions within the popliteal space. These nerves are lessikely to be injured with knee dislocation, probablyecause they are not tethered as the popliteal artery is.he peroneal nerve is at higher risk because its courseround the fibular head functionally decreases its po-ential excursion, and violent varus injuries may resultn traction and/or avulsion injuries to this nerve. Itsocation must be identified during dissections to re-onstruct the posterolateral corner.

CLASSIFICATION

Classification of knee dislocation is primarily basedn the direction the tibia dislocates relative to theemur.9,10 This results in 5 different categories: ante-ior, posterior, lateral, medial, or rotatory. The ante-ior-medial and lateral, posterior-medial, and lateralislocations are classified as “rotatory” dislocation.ther factors to be considered include whether (1) the

njury is open or closed, (2) the injury was caused byhigh-energy” or “low-energy” trauma, (3) the knee isompletely dislocated or subluxated, and (4) there iseurovascular involvement. Furthermore, one shoulde acutely conscious of the fact that a complete dis-ocation may spontaneously reduce, and any triple-igament knee injury constitutes a frank disloca-ion.7,11,12

Reports vary, but anterior and/or posterior disloca-ion appear to be the most common direction of dis-ocation. Frassica et al.13 found a 70% incidence ratef posterior, 25% anterior, and 5% rotatory disloca-ions in their series. Green and Allen14 reported a 31%nterior, 25% posterior, and 3% rotatory dislocation inheir series. Rotatory dislocations occur less fre-
uently, but the posterolateral dislocation seems to be

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473THE MULTIPLE-LIGAMENT INJURED KNEE

he most common combination. This particular patternay be irreducible as a result of the medial femoral

ondyle becoming “button-holed” through the antero-edial joint capsule. In addition, the MCL invaginates

nto the joint space, blocking reduction. This “button-oling” results in a “skin furrow” along the medialoint line as the subcutaneous tissue attachments to theoint capsule drag the skin into the joint.15 Attempts ateduction in this scenario make the skin furrow moreronounced.The actual incidence of different directional dislo-

ation is not as important as correctly diagnosing theirection of injury, and how it relates to potentialeurovascular injury. Hyperextension injuries (or pos-erior dislocations), because of the tethered poplitealrtery and vein, may have the highest incidence ofssociated vascular injury; however, any dislocation,f initial displacement is severe enough, will result innjury to the popliteal artery. The common peronealerve is less at risk because it has a greater excursionhan the popliteal vessels, but it is still susceptiblehen a varus force is applied to the knee. Posterolat-

ral dislocation is associated with a high incidence ofnjury to the common peroneal nerve.16,17

Open knee dislocations are not uncommon; the re-orted incidence is between 19% and 35% of allislocations.17,18 An open knee dislocation, in general,aries a worse prognosis because of the severe injuryo the soft-tissue envelope. Furthermore, an open in-ury may require an open ligament reconstruction, ortaged reconstruction, as arthroscopically assistedechniques cannot be performed in the acute settingith these open injuries.Distinguishing between low- and high-energy inju-

ies is important. Low-energy or low-velocity injuries,sually associated with sports injuries, have a de-reased incidence of associated vascular injury. High-nergy or velocity injuries, associated with motor ve-icle accidents or falls from a height, tend to have anncreased incidence of vascular compromise. Withecreased pulses in an injured limb and the history ofhigh-energy injury, one should obtain vascular stud-

es urgently.

MECHANISM OF INJURY

The mechanism of injury for the 2 most commonnee dislocation patterns, anterior and posterior, areeasonably well described. Kennedy16 was able toeproduce anterior dislocation by a hyperextensionorce acting on the knee; at 30° of hyperextension, he
ound that the posterior capsule failed. When extended r
urther, to about 50°, the ACL, PCL, and poplitealrtery fail. There is some question as to whether theCL or the PCL fails first with hyperextension,16,19

ut in our clinical experience,7 both the anterior andosterior cruciate ligaments fail with dislocation. Oth-rs have reported both ACL and PCL tears with com-lete knee dislocation.13,20,21

A posterior-directed force applied to the proximalibia when the knee is flexed to 90° is thought toroduce a posterior dislocation, the so-called “dash-oard” injury.20 Medial and lateral dislocations resultrom varus/valgus stresses applied to the knee. Aombination of varus/valgus stress with hyperexten-ion/blow to proximal tibia will likely produce one ofhe rotatory dislocations.

ASSOCIATED INJURIES

Several anatomic structures are at risk in the dislo-ated knee. The 4 major ligaments of the knee as wells the posterior medial and lateral corners can beompromised. Vascular and nerve injuries are com-on. There may also be associated bony lesions:

vulsion fractures of the ACL or PCL, frank tibiallateau or distal femur condylar fractures, or ipsilat-ral tibial or femoral shaft fractures.

There is evidence in the literature that a frank dis-ocation may not result in complete rupture of 3 of the

major ligaments16,17,22; however, this seems to behe exception rather than the rule. Several investiga-ors have found that a frank dislocation of the kneenvariably results in rupture of at least 3 of the 4 majorigaments. Sisto and Warren21 found that all knees inheir series had 3 or more ligaments compromised. Intudy of Frassica et al.,13 all 13 patients treated oper-tively were found to have ACL, PCL, and MCLisruptions. In the study by Fanelli et al.,7 19 of 20ere found to have a third component (posterior lat-

ral corner or MCL) in addition to complete ACL andCL disruption. With a frank dislocation of the knee,areful ligament examination is necessary to fullyiagnose the extent of the injury.The incidence of vascular compromise in knee dis-

ocations has been estimated to be about 32%.14 Whenimited to anterior or posterior dislocation, the inci-ence may be as high as 50%.23 Recent studies con-rm the significant incidence of arterial in-

ury,13,21,24,25 reaffirming the need for careful vascularvaluation. The popliteal artery is an “end-artery” tohe leg, with minimal collateral circulation through theenicular arteries. Furthermore, the popliteal vein is
esponsible for the majority of venous outflow from

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he knee. If either structure is compromised to theoint of prolonged obstruction, ischemia and eventualmputation is often the result.26,27

Two mechanisms have been described for injury tohe popliteal artery: one is a “stretching” mechanism,een with hyperextension, until the vessel ruptures.his may occur secondary to the “tethered” nature of

he artery at the adductor hiatus and the entrancehrough the gastrocnemius-soleus complex. This typef injury should be suspected with an anterior dislo-ation. Posterior dislocations may cause direct contu-ion of the vessel by the posterior plateau, resulting inntimal damage. Under no circumstance should com-romised vascular status be attributed to arterialpasm; in this circumstance, there is often intimalamage and impending thrombosis formation. Cone28

oints out that initial examination may be normal;owever, thrombus formation can occur hours to daysater28-31 and recent studies have found delayed throm-us formation.13,21 Furthermore, bicruciate ligamentuptures presenting as a ‘reduced’ dislocated kneeay have as high an incidence of arterial injury as a

rank dislocation.12

Popliteal vein injury occurs much less frequently, ort least historically had not been reported. Despitehis, venous occlusion must also be recognized andppropriately treated. Historically, whether to repairenous injury seemed controversial. Ligating the pop-iteal vein, a common practice during the Vietnamonflict, led to severe edema, phlebitis, and chronicenous stasis changes. Venous repair was thought toead to thrombophlebitis and pulmonary embolism.urrently, if obstruction to outflow is recognized,

urgical repair of the popliteal vein is warranted.32

Injury to either the peroneal nerve or the tibial nerveas been documented,16,17,21-25,33 with an incidenceate of about 20% to 30%. The nervous structuresbout the knee are not as tightly anchored as theopliteal vessels; this probably accounts for the lowerncidence of injury compared with neighboring vas-ular structures. The mechanism of injury is usuallyne of stretch. The peroneal nerve seems to be morerequently involved than the tibial nerve, probablyecause of its anatomic location. With any varus load-ng of the knee, the peroneal nerve is placed underension. Shields et al. reported that posterior disloca-ion caused the majority of the nerve injuries.17

Given the fact that knee dislocation is usuallyaused by violent trauma, associated fractures areommon; the incidence rate may be as high as 60%.22

ibial plateau fractures and ligament avulsion frac-
ures from the proximal tibia or distal femur are com- l
on.13,18,21,22,33,34 Recognition of these injuries is alsomportant because additional bony involvement hasmplications on definitive treatment. Associated distalemur fractures and proximal tibial fractures treatedith intramedullary nailing make bone tunnel place-ent for ACL and PCL reconstruction difficult. With

iolent trauma, any fracture or avulsion conceivableay occur with a dislocated knee, but there is sugges-

ion that medial and lateral dislocations are associatedith some increased frequency of minor bony le-

ions.35

Fracture-dislocations represent a separate entity inhe spectrum of pure knee dislocation to tibial plateauractures. Pure knee dislocation requires only softissue reconstruction to gain stability; tibial plateauractures require purely bony stabilization. Fracture-islocations of the knee often involve both bony andigamentous repair or reconstruction, adding an ele-ent of complexity to their treatment.10,36 Long-term

utcome of fracture-dislocation injuries to the kneeoint falls somewhere between tibial plateau fracturesnd pure dislocations, with tibial plateau fracturesoing the best and dislocations the worst.36

INITIAL EVALUATION ANDMANAGEMENT

eneral Considerations

Obvious deformity may be present on initial exam-nation. However, in a polytrauma patient who isntubated and sedated, the injury may escape initialvaluation. Abrasions or contusions about the knee,ross crepitus, or laxity may allude to injury in antherwise normal appearing knee. This importance ofmmediate recognition of knee dislocation or fractureislocation lay not with the treatment of instability,ut the recognition of potential vascular injury andossible vascular compromise.12 Neurovascular statusust be assessed on both lower extremities. Neuro-

ogic examination may be difficult in the polytraumaatient, and is not as important initially as is serialeurologic examination. Vascular examination isore pressing because ischemia lasting more than 8

ours usually results in amputation.14 In the reducednee, a white, cool limb that is obvious on physicalxamination and denotes arterial damage, requires anmmediate arteriogram. However, normal pulses,oppler signals, and capillary refill do not rule out an

rterial injury.28 Thrombosis may occur hours to days
ater, necessitating serial examination. If there is any

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uestion of perfusion of the limb, an arteriogram isarranted.

maging Studies

Before any manipulation, anteroposterior and lat-ral radiographs of the affected extremity are com-leted. This is important to confirm the direction ofislocation and any associated fractures, and aids inlanning the reduction maneuver. In the presence ofyanosis, pallor, weak capillary refill, and decreasederipheral temperature following reduction, arteriog-aphy must be considered. Venography may be re-uired if the clinical picture indicates adequate limberfusion but obstruction of outflow. After the acutereatment of the dislocated knee, magnetic resonancemaging may be performed subacutely to confirm andid in planning the reconstruction of compromisedigamentous structures.

eduction

An unreduced dislocated knee constitutes an ortho-aedic emergency, and reduction should be under-aken as soon as possible, preferably in the emergencyepartment. Before manipulation, adequate anteropos-erior and lateral radiographic evaluation is per-ormed. This allows for determination of the directionf the dislocation, any associated fractures, and assistsn planning the reduction maneuver. In the isolatednee dislocation, intravenous morphine or consciousedation is usually required. Slow, gradual longitudi-al traction is applied to the leg from the ankle, andhe proximal tibia is manipulated in the appropriateirection to effect a reduction. Once reduced, radio-raphic evaluation to confirm tibiofemoral congru-ncy is performed, as well as repeated neurovascularxamination. The limb is than placed in either a longeg splint or extension knee immobilizer. It is imper-tive to perform radiographic evaluation after place-ent in the splint or brace, as posterior subluxation of

he tibia on femur is common. A “bump” consisting oftowel or pad behind the gastrocnemius-soleus com-

lex may aid in maintaining reduction.The “dimple sign” indicates a posterolateral dislo-

ation, and closed reduction may not be successful.he medial femoral condyle penetrates the medial

oint capsule, causing interposition of soft tissue in theoint, warranting open reduction.10,15

hysical Examination

Physical examination features of the ACL/PCL/
LC injured knee include abnormal anterior and pos- o
erior translation at both 25° and 90° of knee flexion,hich is usually greater than 15 mm. At 90° of kneeexion, the tibial step-off is absent, and the posteriorrawer test is 2� or greater, indicating greater than 10m of pathologic posterior tibial displacement. Theachman test and pivot-shift phenomenon are posi-

ive, indicating ACL disruption, and there may beyperextension of the knee. We have identified andescribed 3 types of posterolateral instability: A, B,nd C.

Posterolateral instability in the multiple-ligamentnjured knee includes at least 10° of increased tibialxternal rotation compared with the normal knee at0° and 90° of knee flexion (positive dial test, andxternal rotation thigh-foot angle test), and variableegrees of varus instability depending on the in-ured anatomic structures. Posterolateral instabilityPLI) type A has increased external rotation only,orresponding to injury to the popliteofibular liga-ent, and popliteus tendon only. PLI type B pre-

ents with increased external rotation, and mildarus of approximately 5 mm increased lateral jointine opening to varus stress at 30° knee flexion. Thisccurs with damage to the popliteofibular ligament,opliteus tendon, and attenuation of the fibular col-ateral ligament. PLI type C presents with increasedibial external rotation, and varus instability of 10m greater than the normal knee tested at 30° of

nee flexion with varus stress. This occurs withnjury to the popliteofibular ligament, popliteus ten-on, fibular collateral ligament, and lateral capsularvulsion, in addition to cruciate ligament disruption.

The MCL is tested with valgus stress at 0° and 30°f knee flexion to assess the superficial MCL, theosterior oblique ligament, and the posterior medialapsule. Extensor mechanism stability is assessed byedial and lateral patellar glide to assess the integrity

f the lateral and medial patellar retinaculum.

ascular Injuries

A full spectrum of vascular injuries may be encoun-ered. The overall clinical picture may vary from anncomplicated, bicruciate ligament injury with possi-le intimal damage with a normal physical examina-ion to a polytrauma patient, with a closed head injury,ntra-abdominal bleeding, and dislocated knee withascular compromise. Life-threatening injuries are ad-ressed first. The orthopaedic surgeon needs to beware of the total limb ischemia time. If there is anyuspicion of arterial damage, a vascular consult is
btained immediately. Reduction is performed to see

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f this restores blood flow to the limb. When the totalschemia time approaches 6 hours,14 there is an ur-ency to restore flow to the lower extremity. Anntraoperative angiogram during vascular explorationnd shunting may be required at the expense of aigh-quality preoperative angiogram.10 Mechanism ofnjury should also be noted. A high-energy injurye.g., motor vehicle accident or a fall from a height)ay be more suspicious for vascular injury, and oneay elect to obtain arteriograms despite a normal

ascular examination.12

When an isolated dislocated knee with suspectedrterial injury occurs (asymmetric pulses, Doppler, ornkle-brachial index), arteriography is performed ashe simple presence of pulses does not rule out vas-ular damage.28 Any suspicion warrants a vascularurgery consultation. When the limb is well perfused,nd all indices are normal, one may elect to forego aormal arteriogram if there are frequent neurovascularhecks to the lower extremity. Despite the historicalreference to obtain an arteriogram in the presence ofknee dislocation as a screening tool, it has been

hown that arteriography following significant bluntrauma to the lower extremity with a normal vascularxamination has a low yield rate for detecting surgicalascular lesions.12,37,38 Popliteal vein injury is alsoossible. When the clinical picture warrants, aenogram may be useful.

bsolute Surgical Indications

A state of irreducibility and vascular injury war-ants immediate surgical intervention. Four-com-artment fasciotomy of the limb is considered whenschemia time is greater than 2.5 hours. The inabil-ty to maintain reduction also mandates externalkeletal fixation or early ligamentous reconstructiono stabilize the knee to avoid potential recurrentascular compromise. Open dislocations and openracture-dislocations require immediate surgical de-ridement to decontaminate the wound. An externalxator may be a reasonable option in the case of anpen dislocation with a large soft-tissue defect, orn open fracture dislocation. In this circumstance,ccess to soft tissue would be maintained for sur-ical debridement.

DEFINITIVE SURGICAL MANAGEMENT

istorical Management

Knee dislocations were initially managed conserva-
ively with a cylinder cast for several months.39,40 b
arly reports by Kennedy16 and Meyers and Harvey18

eported reasonable outcomes for nonoperativelyreated knee dislocations. However, there was theuggestion that a surgically stabilized dislocated kneeould fare better in the long term. A recent report bylmekinders and Logan24 compared surgically stabi-

ized knees with conservative treatment and concludedhat conservative treatment was comparable to surgi-al treatment. Despite similar outcomes, the conser-atively treated knees were grossly unstable comparedith surgically stabilized knees. Their study was ret-

ospective from 1963 to 1988 and the typical surgicalreatment during this period was in most cases openirect repair of the ligaments. Sisto and Warren21

ound similar results comparing 4 conservativelyreated knees with 16 direct suture repairs of tornigaments. Frassica et al.13 also evaluated early (within

days of injury) direct repair (with or without aug-entation) of torn ligamentous structures in 13 of 17

atients. They concluded that better results wherebtained with early versus later direct repair of tornigaments. This study supports surgical treatment ofhe dislocated knee, and introduces the concept ofenefit from a ligamentously stable knee.Within the last decade, the technique of arthroscopi-

ally assisted ACL/PCL reconstruction has becomeopular. Several advancements have made these tech-iques possible: (1) better procurement, sterilization,nd storage of allograft tissue, (2) improved arthro-copic surgical instrumentation, (3) better graft fixa-ion methods, (4) improved surgical technique, and (5)mproved understanding of the ligamentous anatomynd biomechanics of the knee. Few reports of com-ined ACL/PCL reconstruction are available in theiterature, but surgical reconstruction appears to affordt least the same results, if not better, than direct repairf the ligaments. Shapiro and Freedman25 recon-tructed 7 ACL/PCL injuries with primarily allograftchilles tendon or bone–patellar tendon–bone. They

ound that 3 patients had excellent results, 3 goodesults, and 1 fair result. Furthermore, the averageT-1000 was �3.3 mm side-to-side difference, withery little varus/valgus instability or significant pos-erior drawer. All 7 of their patients were able to returno school or the workplace.

Fanelli et al.6 reported on 20 ACL/PCL arthroscopi-ally assisted ligament reconstructions. In their studyroup, there was 1 ACL/PCL tear, 10 ACL/PCL/osterior lateral corner tears, 7 ACL/PCL/MCL tears,nd 2 ACL/PCL/MCL/posterior lateral corner tears.chilles tendon allografts and bone–patellar tendon–
one autografts were used in PCL reconstructions, and

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utograft and allograft bone–patellar tendon–boneas used in ACL reconstruction. An additional com-onent, not previously mentioned with any consis-ency in the literature, was the addressing of the as-ociated MCL or posterior lateral corner injury. It ismperative to address these injuries as well, or theesults of ACL/PCL reconstruction alone will be lesshan optimal.

Postoperatively, significant improvement was foundccording to the Lysholm, Tegner, and Hospital forpecial Surgery (HSS) knee ligament rating scales, asell as the KT-1000 arthrometer. Overall postopera-

ively, 75% of patients had a normal Lachman testesult, 85% no longer displayed a pivot-shift, 45%estored a normal posterior drawer test, and 55% dis-layed grade I posterior laxity. All 20 knees wereeemed functionally stable and all patients returned toesired levels of activity. The authors concluded thatesults of reconstruction are reproducible and thatppropriate reconstruction will produce a stable knee.

Noyes and Barber-Westin41 evaluated surgically re-onstructed ACL/PCL tears (all had additional MCLr LCL/PCL reconstruction) at an average of 4.8ears. Seven of these knees were acute knee disloca-ions and 4 were chronically unstable knees secondaryo knee dislocations. At follow-up, 5 of the 7 acutelynjured knees had returned to preinjury level of activ-ty. Three of the 4 chronic knee injuries were asymp-omatic with activities of daily living. Arthrometriceasurements at 20° showed less than 3 mm of side-

o-side difference with anterior to posterior translationn 10 of the 11 knees; at 70°, there were 9 knees thatad less than 3 mm side-to-side difference in antero-osterior translation. These authors concluded thatimultaneous bicruciate ligament reconstruction isarranted to restore function to the knee.

anelli Sports Injury Clinic Experience

Our practice is located in a tertiary-care regionalrauma center. There is a 38% incidence of PCL tearsn acute knee injuries, with 45% of these PCL injurednees being combined ACL/PCL tears.42,43 Carefulssessment, evaluation, and treatment of vascular in-uries is essential in these acute multiple-ligamentnjured knees. There is an 11% incidence of vascularnjury associated with these acute multiple-ligamentnjured knees at our center.

Our preferred approach to combined ACL/PCL in-uries is an arthroscopic ACL/PCL reconstruction us-ng the transtibial technique, with collateral/capsular
igament surgery as indicated. Not all cases are ame- p
able to the arthroscopic approach and the operatingurgeon must assess each case individually.

urgical Timing

Surgical timing is dependent on vascular status,eduction stability, skin condition, systemic injuries,pen versus closed knee injury, meniscus and articularurface injuries, other orthopaedic injuries, and theollateral/capsular ligaments involved. Certain ACL/CL/MCL injuries can be treated with bracing of theCL followed by arthroscopic combined ACL/PCL

econstruction in 4 to 6 weeks after healing of theCL. Other cases may require repair or reconstruc-

ion of the medial structures and must be assessed onn individual basis.

Combined ACL/PCL/posterolateral injuries are ad-ressed as early as safely possible. ACL/PCL/postero-ateral repair-reconstruction performed between 2 andweeks after injury allows sealing of capsular tissues

o permit an arthroscopic approach, and still permitsrimary repair of injured posterolateral structures.Open multiple-ligament knee injuries/dislocationsay require staged procedures. The collateral/capsu-

ar structures are repaired after thorough irrigation andebridement, and the combined ACL/PCL reconstruc-ion is performed at a later date after wound healingas occurred. Care must be taken in all cases ofelayed reconstruction to confirm that the tibiofemoraloint is reduced by serial anteroposterior and lateraladiographs.

The surgical timing guidelines outlined abovehould be considered in the context of the individualatient. Many patients with multiple-ligament injuriesf the knee are severely injured multiple-trauma pa-ients with multisystem injuries. Modifiers to the idealiming protocols outlined earlier include the vasculartatus of the involved extremity, reduction stability,kin condition, open or closed injury, and other ortho-aedic and systemic injuries. These additional consid-rations may cause the knee ligament surgery to beerformed earlier or later than desired. We have pre-iously reported excellent results with delayed recon-truction in the multiple-ligament injured knee6,7 (Ta-le 1).

raft Selection

The ideal graft material is strong, provides securexation, is easy to pass, readily available, and has lowonor-site morbidity. The available options in thenited States are autograft and allograft sources. Our
referred graft for the PCL is the Achilles tendon

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llograft because of its large cross-sectional area andtrength, absence of donor-site morbidity, and easyassage with secure fixation. We prefer Achilles ten-on allograft or bone–patellar tendon–bone allograftor ACL reconstruction. The preferred graft materialor the posterolateral corner is a split biceps tendonransfer, or free autograft (semitendinosus) or allograftissue when the biceps tendon is not available.44 Casesequiring MCL and posteromedial corner surgery mayave primary repair, reconstruction, or a combinationf both. Our preferred method for MCL and postero-edial reconstructions is a posteromedial capsular

hift with autograft or allograft supplementation aseeded.

urgical Approach

Our surgical approach is a single-stage arthroscopicombined ACL/PCL reconstruction using the trans-ibial technique with collateral/capsular ligament sur-ery as indicated. The posterolateral corner is repairednd then augmented with a split biceps tendon trans-er, biceps tendon transfer, semitendinosus free graft,r allograft tissue. Acute medial injuries not amenableo brace treatment undergo primary repair, and pos-eromedial capsular shift, and/or allograft reconstruc-ion as indicated. The operating surgeon must be pre-ared to convert to a dry arthroscopic procedure or anpen procedure if fluid extravasation becomes a prob-

TABLE 1. Surgical Timing Algorithm for Acute ACL/PCL Injuries

ACL/PCL lateral-side injuriesSurgery within 2-3 weeks after injuryArthroscopic ACL/PCL reconstruction plus lateral

side reconstruction (type A and B PLRI)Lateral-posterolateral augmented primary repairStage type C lateral-side injuries

Lateral-posterolateral augmented primary repair(within first 10 days)

Arthroscopic ACL/PCL reconstruction (4–6weeks later)

ACL/PCL medial-side injuriesSurgical timing depends on degree of medial-side

damageLow-grade MCL injury: brace treatment 4–6

weeks followed by arthroscopic ACL-PCLreconstruction

High-grade MCL injuryMCL augmented primary repair (within first 10

days)Arthroscopic ACL/PCL reconstruction (4–6

weeks later)

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urgical Technique

The principles of reconstruction in the multiple-igament injured knee are to identify and treat allathology, accurately place tunnels, create anatomicraft insertion sites, utilize strong graft material, pro-ide secure graft fixation, and provide the appropriateostoperative rehabilitation program. The patient isositioned supine on the operating room table. Theurgical leg hangs over the side of the operating tablend the well leg is supported by the fully extendedperating table. A lateral post is used for control of theurgical leg. A leg holder is not used. The surgery isone under tourniquet control unless previous arterialr venous repair contraindicates the use of a tourni-uet. Fluid inflow is by gravity; we do not use anrthroscopic fluid pump.

Allograft tissue is prepared before bringing the pa-ient into the operating room. Arthroscopic instru-ents are placed with the inflow in the superior lateral

ortal, the arthroscope in the inferior lateral patellarortal, and instruments in the inferior medial patellarortal. An accessory extracapsular extra-articular pos-eromedial safety incision is used to protect the neu-ovascular structures, and to confirm the accuracy ofibial tunnel placement (Fig 1).

The notchplasty is performed first and consists ofCL and PCL stump debridement, bone removal, and

ontouring of the medial wall of the lateral femoralondyle and the intercondylar roof. This allows visu-lization of the over-the-top position and preventsCL graft impingement throughout the full range ofotion. Specially curved PCL instruments are used to

IGURE 1. A 1- to 2-cm extra capsular posterior medial safetyncision allows the surgeon’s finger to protect the neurovascular
tructures and confirm the position of instruments on the posteriorspect of the proximal tibia. (Reprinted with permission.8)

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levate the capsule from the posterior aspect of theibia (Fig 2; Arthrotek, Warsaw, IN).

The PCL tibial and femoral tunnels are created withhe help of the PCL/ACL drill guide (Fig 3, Ar-hrotek). The transtibial PCL tunnel courses from thenteromedial aspect of the proximal tibial one cmelow the tibial tubercle to exit in the inferior lateralspect of the PCL anatomic insertion site. The PCLemoral tunnel originates externally between the me-ial femoral epicondyle and the medial femoral con-ylar articular surface to emerge through the center ofhe stump of the anterolateral bundle of the posteriorruciate ligament. The PCL graft is positioned andnchored on the femoral or tibial side, and left free onhe opposite side.

The ACL tunnels are created using the single-inci-ion technique. The tibial tunnel begins externally at aoint 1 cm proximal to the tibial tubercle on thenteromedial surface of the proximal tibia to emergehrough the center of the stump of the ACL tibialootprint. The femoral tunnel is positioned next to thever-the-top position on the medial wall of the lateralemoral condyle near the ACL anatomic insertion site.he tunnel is created to leave a 1- to 2-mm posteriorortical wall so interference fixation can be used. TheCL graft is positioned and anchored on the femoral

ide, with the tibial side left free (Fig 4). Attention ishen turned to the posterior lateral corner.

One surgical technique for posterolateral recon-truction is the split biceps tendon transfer to the

IGURE 2. Specially curved PCL reconstruction instruments usedo elevate the capsule from the posterior aspect of the tibial ridgeuring PCL reconstruction. Posterior capsular elevation is criticaln transtibial PCL reconstruction because it facilitates accurateCL tibial tunnel placement, and subsequent graft passage. (Cour-

esy of Arthrotek, Inc, Warsaw, IN.)

ateral femoral epicondyle. The requirements for thisgi

rocedure include an intact proximal tibiofibularoint—the posterolateral capsular attachments to theommon biceps tendon should be intact, and the bi-eps femoris tendon insertion into the fibular headust be intact. This technique creates a new poplit-

ofibular ligament and LCL, tightens the posterolat-ral capsule, and provides a post of strong autogenousissue to reinforce the posterolateral corner.

A lateral hockey-stick incision is made. The pero-eal nerve is dissected free and protected throughouthe procedure. The long head and common bicepsemoris tendon is isolated, and the anterior two thirdss separated from the short head muscle. The tendon isetached proximal and left attached distally to itsnatomic insertion site on the fibular head. The strip oficeps tendon should be 12 to 14 cm long. The ili-tibial band is incised in line with its fibers and thebular collateral ligament and popliteus tendons arexposed. A drill hole is made 1 cm anterior to thebular collateral ligament femoral insertion. A longi-

IGURE 3. The Fanelli PCL/ACL drill guide system is used torecisely create both the PCL femoral and tibial tunnels, and theCL single-incision technique and double-incision technique tun-els. The drill guide is positioned for the PCL tibial tunnel so thatguidewire enters the anteromedial aspect of the proximal tibia

pproximately 1 cm below the tibial tubercle, at a point midwayetween the posteromedial border of the tibia, and the tibial crestnteriorly. The guidewire exits in the inferior lateral aspect of theCL tibial anatomic insertion site. The guide is positioned for theCL femoral tunnel so the guidewire enters the medial aspect of

he medial femoral condyle midway between the medial femoralondyle articular margin and the medial epicondyle, 2 cm proximalo the medial femoral condyle distal articular surface (joint line).he guidewire exits through the center of the stump of the antero-

ateral bundle of the PCL. The drill guide is positioned for theingle-incision endoscopic ACL technique so that the guidewirenters the anteromedial surface of the proximal tibia approximatelycm proximal to the tibial tubercle at a point midway between the

osteromedial border of the tibia and the tibial crest anteriorly. The
uidewire exits through the center of the stump of the tibial ACLnsertion. (Courtesy of Arthrotek, Inc, Warsaw, IN.)

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udinal incision is made in the lateral capsule justosterior to the fibular collateral ligament. The spliticeps tendon is passed medial to the iliotibial bandnd secured to the lateral femoral epicondylar regionith a screw and spiked ligament washer at the afore-entioned point. The residual tail of the transferred

plit biceps tendon is passed medial to the iliotibialand and secured to the fibular head. The posterolat-ral capsule that had been previously incised is thenhifted and sewn into the strut of transferred bicepsendon to eliminate posterolateral capsular redun-ancy. In cases where the proximal tibiofibular jointas been disrupted, a 2-tailed allograft reconstructions used to control the tibia and fibula independently.

Posterolateral reconstruction with the free graft fig-re-of-8 technique uses semitendinosus autograft orllograft, Achilles tendon allograft, or other soft-tissuellograft material. A curvilinear incision is made inhe lateral aspect of the knee, extending from theateral femoral epicondyle to the interval betweenerdy’s tubercle and the fibular head. The fibular head

s exposed and a tunnel is created in an anterior toosterior direction at the area of maximal fibular di-meter. The tunnel is created by passing a guide pinollowed by a cannulated drill, usually 7 mm in diam-ter. The peroneal nerve is protected during tunnelreation and throughout the procedure. The free ten-on graft is then passed through the fibular head drillole. An incision is then made in the iliotibial band inine with the fibers directly overlying the lateral fem-ral epicondyle. The graft material is passed medial tohe iliotibial band and the limbs of the graft arerossed to form a figure-of-8. A drill hole is made 1m anterior to the fibular collateral ligament femoralnsertion. A longitudinal incision is made in the lateralapsule just posterior to the fibular collateral ligament.he graft material is passed medial to the iliotibialand, and secured to the lateral femoral epicondylaregion with a screw and spiked ligament washer at thebove-mentioned point. The posterolateral capsulehat had been previously incised is then shifted andewn into the strut of figure-of-8 graft tissue materialo eliminate posterolateral capsular redundancy. Thenterior and posterior limbs of the figure-of-8 graftaterial are sewn to each other to reinforce and

ighten the construct. The iliotibial band incision ishen closed. The procedures described are intended toliminate posterolateral and varus rotational instabilityFig 5).

Posteromedial and medial reconstructions are per-ormed through a medial hockey-stick incision. Care

IGURE 4. (A) Anatomic drawing of the ACL and PCL tibial andemoral tunnel positions in combined ACL/PCL reconstructionurgery. It is important to be aware of the 2 tibial tunnel directions,nd to have a 1-cm bone bridge between the PCL and ACL tibialunnels. This will reduce the possibility of fracture. (Courtesy ofrthrotek, Inc, Warsaw, IN.) (B) Combined arthroscopic ACL/CL reconstruction using Achilles tendon allograft. The tunnelsre precisely created to reproduce the anatomic insertion sites ofhe anterolateral bundle of the PCL and the anatomic insertion sitesf the ACL. Correct and accurate tunnel placement is essential foruccessful combined ACL/PCL reconstructions. The Achilles ten-

s taken to maintain adequate skin bridges between

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ncisions. The superficial MCL is exposed and a lon-itudinal incision is made just posterior to the poste-ior border of the MCL. Care is taken not to damagehe medial meniscus during the capsular incision. Thenterval between the posteromedial capsule and me-ial meniscus is developed. The posteromedial cap-

IGURE 5. Surgical technique for posterolateral and lateral recon-truction are the (A) split biceps tendon transfer or (B) the allograftr autograft figure-of-8 reconstruction combined with posterolat-ral capsular shift, and primary repair of injured structures asndicated. These complex surgical procedures reproduce the func-ion of the popliteofibular ligament and the LCL, and eliminateosterolateral capsular redundancy. The split biceps tendon trans-er uses anatomic insertion sites and preserves the dynamic func-ion of the long head and common biceps femoris tendon.

ule is shifted anterosuperiorly. The medial meniscusti

s repaired to the new capsular position and the shiftedapsule is sewn into the MCL. When superficial MCLeconstruction is indicated, it is performed using allo-raft tissue or semitendinosus autograft. This graftaterial is attached at the anatomic insertion sites of

he superficial MCL on the femur and tibia. Theosteromedial capsular advancement is performed andewn into the newly reconstructed MCL (Fig 6).

raft Tensioning and Fixation

The PCL is reconstructed first followed by theCL, followed by the posterolateral complex andedial ligament complex. Tension is placed on theCL graft distally using the Arthrotek knee ligament

ensioning device with the tension set for 20 lb (Fig 7).his restores the anatomic tibial step-off. The knee isycled through a full range of motion 25 times tollow pretensioning and settling of the graft. The knees placed in 70° of flexion, and fixation is achieved onhe tibial side of the PCL graft with a screw and spikedigament washer and bioabsorbable interferencecrew. The knee is then placed in 30° of flexion, theibial internally rotated, slight valgus force applied tohe knee, and final tensioning and fixation of theosterolateral corner is achieved. The Arthrotek kneeigament tensioning device is applied to the ACL

IGURE 6. Severe medial-side injuries are successfully treatedith primary repair using suture anchor technique combined withCL reconstruction using allograft tissue combined with postero-edial capsular shift procedure. The Achilles tendon allograft’s

road anatomy can anatomically reconstruct the superficial MCL.he Achilles tendon allograft is secured to the anatomic insertionites of the superficial MCL using screws and spiked ligamentashers. The posteromedial capsule can then be secured to the

llograft tissue to eliminate posteromedial capsular laxity. This
echnique will address all components of the medial-side instabil-ty.

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raft, and set to 20 lb. The knee is placed in 70° ofexion, and final fixation is achieved of the ACL graftith a bioabsorbable interference screw and spiked

igament washer back-up fixation. Tensioning theCL graft at 70° of knee flexion enabled us to main-

ain the neutral position of the knee by monitoring theibial step-off at the time of final graft fixation. The

CL reconstruction is tensioned with the knee in 30°f flexion with the leg in a figure-of-4 position. Fullange of motion is confirmed on the operating table tossure the knee is not “captured” by the reconstruc-ion.

echnical Hints

The posteromedial safety incision protects the neu-ovascular structures, confirms accurate tibial tunnellacement, and allows more expeditious completionf the surgical procedure (Fig 1). The single-incisionCL reconstruction technique prevents lateral cortex

rowding and eliminates multiple through-and-hrough drill holes in the distal femur, which reduces

IGURE 7. The mechanical graft knee ligament tensioning devices used to precisely tension PCL and ACL grafts. During PCLeconstruction, the tensioning device is attached to the tibial end ofhe graft and the torque wrench ratchet is set to 20 lb. This restoreshe anatomic tibial step-off. The knee is cycled through 25 fullexion-extension cycles, and with the knee at 0° of flexion, finalCL tibial fixation is achieved with a Lactosorb resorbable inter-erence screw (Arthrotek), and screw and spiked ligament washeror back-up fixation. The tensioning device is applied to the ACLraft, set to 20 lb, and the graft is tensioned with the knee in 70°f flexion. Final ACL fixation is achieved with Lactosorb bioab-orbable interference screws, and spiked ligament washer back-upxation. The mechanical tensioning device assures consistent graft

ensioning and eliminates graft advancement during interferencecrew insertion. It also restores the anatomic tibial step-off duringCL graft tensioning, and applies a posterior drawer force duringCL graft tensioning. (Courtesy of Arthrotek, Inc, Warsaw, IN.)

he stress riser effect. It is important to be aware of the s

tibial tunnel directions, and to have a 1-cm boneridge between the PCL and ACL tibial tunnels. Thisill reduce the possibility of fracture. We have found

t useful to use primary and back-up fixation. Primaryxation is with resorbable interference screws, andack-up fixation is achieved with a screw and spikedigament washer. Secure fixation is critical to theuccess of this surgical procedure (Fig 8).10

The order of tensioning is the PCL first, the poste-ior lateral corner second, the ACL third, and the MCLast. Restoration of the normal tibial step-off at 70° ofexion has provided the most reproducible method ofstablishing the neutral point of the tibia-femoral re-ationship in our experience.

ostoperative Rehabilitation

The knee is maintained in full extension for 3 weekson–weight bearing. Progressive range of motion oc-urs during weeks 4 through 6. Progressive weightearing occurs at the end of 6 weeks. Progressivelosed-chain kinetic strength training and continuedotion exercises are performed. The brace is discon-

inued after the tenth week. Return to sports and heavyabor occurs after 9 months when sufficient strengthnd range of motion has returned.

omplications

Potential complications in treatment of the multiple-igament injured knee include failure to recognize andreat vascular injuries (both arterial and venous), iat-ogenic neurovascular injury at the time of reconstruc-ion, iatrogenic tibial plateau fractures at the time ofeconstruction, failure to recognize and treat all com-onents of the instability, postoperative medial femo-al condyle osteonecrosis, knee motion loss, and post-perative anterior knee pain.

PUBLISHED RESULTS

Recent published reports on the results of the treat-ent of the the multiple-injured knee provide insight

nto this complex problem. Wang et al.45 reviewed theesults of 25 combined arthroscopic single-bundleCL and posterolateral complex reconstructions. Theverage time from injury to surgery was 10 monthsith an average follow-up of 40 months. Restorationf ligamentous stability was obtained in only 44% ofatients, with 20% having 5 to 10 mm of residualaxity; 44% of the knees had degenerative changes athe time of surgery. Their study recommended early
urgical repair of the multiple-injured knee.

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Ohkoshi et al.46 studied a 2-stage reconstructionechnique with autograft tissue for knee dislocations.heir study group consisted of 9 knees undergoing a-stage reconstruction with autograft tissue. Stage 1onsisted of PCL reconstruction using semitendinosusnd gracilis hamstring autografts from the contralat-ral knee 2 weeks after injury. Stage 2 consisted ofCL reconstruction with or without MCL and/or pos-

erolateral reconstruction 3 months after injury. TheCL reconstruction was performed using ipsilateralamstring or bone–patellar tendon–bone autograft re-nforced by an artificial ligament. MCL reconstructionas performed with autogenous semitendinosus plus

rtificial ligament reinforcement. Posterolateral recon-truction was performed with biceps tendon transfer.ll knees in their study had negative Lachman test

esults, 66% had a negative posterior drawer test, and4% had a grade 1 posterior drawer. All knees weretable to varus and valgus stress. KT-1000 arthrometeride-to-side difference values were reported to be 2.3m � 1.9 mm, and passive range of motion of the

urgical knee being 0° to 139°.Mariani et al.47 have recently reported their results

f 1-stage arthroscopically assisted ACL and PCLeconstruction. Their study group consisted of 15nees. The ACL reconstructions were performed us-ng hamstring autografts and the PCL reconstructionsing bone–patellar tendon-–bone autografts.T-2000 arthrometer side-to-side difference measure-ents were 5.8 � 1.1 mm. Preoperative and postop-

rative HSS knee ligament rating scale scores were 32nd 89 points, respectively. Preoperative and postop-rative Lysholm knee ligament rating scale scoresere 65 and 95 points, respectively.Richter et al.48 compared surgical and nonsurgical

reatment in patients with traumatic knee dislocations.heir study group consisted of 89 patients; 63 patientsnderwent surgical repair and/or reconstruction withinweeks of injury and 26 patients had nonsurgical

reatment. The average follow-up was 8.2 years. Ly-holm knee ligament rating scale scores were 78.3 forhe surgical group, and 64.8 for the nonsurgicalroup—a statistically significant difference. Tegnernee ligament rating scale scores were 4.0 for theurgical group and 2.7 for the nonsurgical group—a

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™FIGURE 8. Anteroposterior and lateral radiographs after combinedACL/PCL reconstruction. Note the position of tibial tunnel on thelateral radiograph. The tibial tunnel guidewire exits at the apex of
the tibial ridge posteriorly, which places the graft at the anatomictibial insertion site after the tibial tunnel is drilled.

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tatistically significant difference. These authors rec-mmended early surgical treatment of traumatic kneeislocations.Harner et al.49 have reported excellent objective and

unctional results after surgical reconstruction of theultiple-ligament injured knee. Nearly all of their

atients were able to return to normal activities ofaily living; however, the ability of their patients toeturn to high-demand sports and strenuous manualabor was less predictable.

anelli Sports Injury Clinic Results

We have previously published the results of ourrthroscopically assisted combined ACL/PCL andCL/posterolateral complex reconstructions using theeconstructive technique described in this article.6-8

ur results of combined ACL/PCL reconstructionsere presented in 2002.50 This study presented the 2-

o 10-year (24 to 120 month) results of 35 arthroscopi-ally assisted combined ACL/PCL reconstructionsvaluated preoperatively and postoperatively using theysholm, Tegner, and HSS knee ligament ratingcales, KT-1000 arthrometer testing, stress radiogra-hy, and physical examination.The study population included 26 male and 9 fe-ale patients with 19 acute and and 16 chronic knee

njuries. Ligament injuries included 19 ACL/PCL/osterolateral instabilities, 9 ACL/PCL/MCL instabil-ties, 6 ACL/PCL/posterolateral/MCL instabilities,nd 1 ACL/PCL instability. All knees had grade IIIreoperative ACL/PCL laxity, and were assessed pre-peratively and postoperatively with arthrometer test-ng, 3 different knee ligament rating scales, stressadiography, and physical examination. Arthroscopi-ally assisted combined ACL/PCL reconstructionsere performed using the single-incision endoscopicCL technique, and the single femoral tunnel–singleundle transtibial tunnel PCL technique. PCLs wereeconstructed with allograft Achilles tendon (26), au-ograft BTB (7), and autograft semitendinosus/gracilis2). ACLs were reconstructed with autograft BTB16), allograft BTB (12), Achilles tendon allograft (6),nd autograft semitendinosus/gracilis (1). MCL inju-ies were treated with bracing or open reconstruction.osterolateral instability was treated with biceps fem-ris tendon transfer, with or without primary repair,nd posterolateral capsular shift procedures as indicated.

Postoperative physical examination results revealedormal posterior drawer/tibial step-off in 16 of 35nees (46%) and normal Lachman and pivot-shift tests
n 33 of 35 knees (94%). Posterolateral stability was p
estored to normal in 6 of 25 knees (24%), and tighterhan the normal knee in 19 of 25 knees (76%) evalu-ted with the external rotation thigh-foot angle test:0° varus stress testing was normal in 22 of 25 knees88%), and showed grade 1 laxity in 3 of 25 knees12%); 30° valgus stress testing was normal in 7 of 7urgically treated MCL tears (100%), and normal in 7f 8 of brace-treated knees (87.5%). PostoperativeT-1000 arthrometer testing mean side-to-side differ-

nce measurements were 2.7 mm (PCL screen), 2.6m (corrected posterior), and 1.0 mm (corrected an-

erior) measurements, a statistically significant im-rovement from preoperative status (P � .001). Post-perative stress radiographic side-to-side differenceeasurements measured at 90° of knee flexion and 32

b of posteriorly directed proximal force were 0 to 3m in 11 of 21 knees (52.3%), 4 to 5 mm in 5 of 21

nees (23.8%), and 6 to 10 mm in 4 of 21 knees19%). Postoperative Lysholm, Tegner, and HSS kneeigament rating scale mean values were 91.2, 5.3, and6.8, respectively, which shows a statistically signif-cant improvement from preoperative status (P �001).

The conclusions drawn from the study were thatombined ACL/PCL instabilities could be success-ully treated with arthroscopic reconstruction and theppropriate collateral ligament surgery. Statisticallyignificant improvement was noted from the preoper-tive condition at 2- to 10-year follow-up using ob-ective parameters of knee ligament rating scales, ar-hrometer testing, stress radiography, and physicalxamination. Postoperatively, these knees are not nor-al, but they are functionally stable. Continuing tech-

ical improvements will most likely improve futureesults.

Another group of multiple-ligament reconstructionshat warrant attention are our 2- to 10-year results ofombined PCL-posterolateral reconstruction.51 Thistudy presented the 2- to 10-year (24 to 120 month)esults of 41 chronic arthroscopically assisted com-ined PCL/posterolateral reconstructions evaluatedreoperatively and postoperatively using Lysholm,egner, and HSS knee ligament rating scales, KT-000 arthrometer testing, stress radiography, andhysical examination.This study population included 31 male and 10

emale patients with 24 left and 17 right chronicCL/posterolateral knee injuries and functional insta-ility. The knees were assessed preoperatively andostoperatively with arthrometer testing, 3 differentnee ligament rating scales, stress radiography, and
hysical examination. PCL reconstructions were per-

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ormed using the arthroscopically assisted single fem-ral tunnel–single bundle transtibial tunnel PCL re-onstruction technique using fresh-frozen Achillesendon allografts in all 41 cases. In all 41 cases,osterolateral instability reconstruction was per-ormed with combined biceps femoris tendon tenode-is and posterolateral capsular shift procedures. Theaired t test and power analysis were the statisticalests used; 95% confidence intervals were usedhroughout the analysis.

Postoperative physical examination revealed nor-al posterior drawer/tibial step-off in 29 of 41 knees

70%). Posterolateral stability was restored to normaln 11 of 41 knees (27%), and tighter than the normalnee in 29 of 41 knees (71%) evaluated with thexternal rotation thigh-foot angle test: 30° varus stressesting was normal in 40 of 41 knees (97%), and grade

laxity was shown in 1 of 41 knees (3%). Postoper-tive KT-1000 arthrometer testing mean side-to-sideifference measurements were 1.80 mm (PCL screen),.11 mm (corrected posterior), and 0.63 mm (cor-ected anterior) measurements. This is a statisticallyignificant improvement from preoperative status forhe PCL screen and the corrected posterior measure-ents (P � .001). The postoperative stress radio-

raphic mean side-to-side difference measurementeasured at 90° of knee flexion and 32 lb of posterior

irected force applied to the proximal tibia using theelos device was 2.26 mm. This is a statisticallyignificant improvement from preoperative measure-ents (P � .001). Postoperative Lysholm, Tegner,

nd HSS knee ligament rating scale mean values were1.7, 4.92, and 88.7, respectively, showing a statisti-ally significant improvement from preoperative sta-us (P � .001).

Conclusions drawn from this study were thathronic combined PCL/posterolateral instabilitiesould be successfully treated with arthroscopic PCLeconstruction using fresh-frozen Achilles tendon al-ograft combined with posterolateral corner recon-truction using biceps tendon transfer combined withosterolateral capsular shift procedure. Statisticallyignificant improvement is noted (P � .001) from thereoperative condition at 2- to 10-year follow-up us-ng objective parameters of knee ligament ratingcales, arthrometer testing, stress radiography, andhysical examination.

CONCLUSIONS AND SUMMARY

Multiple-ligament injuries of the knee are complex
njuries requiring a systematic approach to evaluation 1
nd treatment. Gentle reduction and documentationnd treatment of vascular injuries are primary con-erns in the acute dislocated/multiple-ligament injurednee. Arthroscopically assisted combined ACL/PCLeconstruction with appropriate collateral ligamenturgery is a reproducible procedure. Knee stability ismproved postoperatively when evaluated with kneeigament rating scales, arthrometer testing, and stressadiographic analysis. Acute MCL tears when com-ined with ACL/PCL tears may in certain cases bereated with bracing. Posterolateral corner injuriesombined with ACL/PCL tears are best treated withrimary repair as indicated, combined with recon-truction using a post of strong autograft (split bicepsendon, biceps tendon, semitendinosus) or allograftissue. Surgical timing depends on the ligaments in-ured, the vascular status of the extremity, reductiontability, and the overall health of the patient. Werefer the use of allograft tissue for reconstruction inhese cases because of the strength of these largerafts, and the absence of donor-site morbidity.

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4. Gollehon DL, Torzilli PA, Warren RF. The role of the poste-rior lateral corner and cruciate ligaments in the stability of thehuman knee. A biomechanical study. J Bone Joint Surg Am1987;69:233-242.

5. Seebacher JR, Inglis AE, Marshall JL, et al. The structure ofthe posterolateral aspect of the knee. J Bone Joint Surg Am1982;64:536-541.

6. Fanelli GC, Gianotti BF, Edson CJ. Arthroscopically assistedcombined anterior and posterior cruciate ligament reconstruc-tion. Arthroscopy 1996;12:5-14.

7. Fanelli GC, Gianotti BF, Edson CJ. Arthroscopically assistedcombined posterior cruciate ligament/posterior lateral complexreconstruction. Arthroscopy 1996;12:521-530.

8. Fanelli GC, Gianotti BF, Edson CJ. The posterior cruciateligament: Arthroscopic evaluation and treatment. Arthroscopy1994;10:673-688.

9. Ghalambor N, Vangsness CT. Traumatic dislocation of theknee: A review of the literature. Bull Hosp Joint Dis 1995;54:19-24.

0. Good L, Johnson RJ. The dislocated knee. J Am Acad OrthopSurg 1995;3:284-292.

1. Shelbourne KD, Porter DA, Clingman JA, et al: Low-velocityknee dislocation. Orthop Rev 1991;20:995-1004.

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