Multiple Ligament Injuries around the Knee

Assessment and Management

Mark BlythConsultant Orthopaedic SurgeonGlasgow Royal Infirmary

GOTC Teaching Knee Term 2011

Spectrum of injury•Isolated single ligament injury•Two ligament injuryLiow 2003, Brautigan 2000, Taft 1994•Dislocatable kneeTwaddle 2003 •Bicruciate injurySchenck 1994, Wascher 1997, Harner 2004•Frank dislocationRichter 2002, Rios 2003

MULTIPLE LIGAMENT = DISLOCATION

Serious injuriesAssessment and management difficultOutcomes uncertain

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

ACLPCLMCL + Posteromedial LCL + Posterolateral

ACL/PCL/MCL 41%ACL/PCL/PLC 28%ACL/PCL/MCL/PLC 9%

Assessment•AetiologyRobertson 2006RTA 57%Sports 32%Low EnergyBilateral 5%

•EvaluationPolytrauma (ISS>25 - 26% Richter 2002)Vascular injuryNeural injuryLigament evaluation

Vascular injury

Incidence 10-40% arterial injuryAnterior dislocation intimal tearsPosterior dislocation rupture

Stannard 2004 136 kneesIncidence 7% surgical repairIntimal tears <50% treated expectantly

Vascular injury•Stannard 2004•Selective arteriography•Serial physical examination (6,24 and 48 hrs)

Decreased pulses (ABIs)Expanding haematomaHistory dysvascular foot

90% positive predictive value100% negative predictive value

Selective arteriographyIntimal tears <50% No flow limitCan be treated expectantly

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

ACL

Difficult in the acute phase +/- EUA

Lachman (Jonsson 1982, Torg 1976)Beware PCL false positivePivot shift may be negative

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

Valgus stress at 300

Grade 1 0-5mmGrade 2 5-10mmGrade 3 10+mmGrade 3+ Valgus in extn

MCL/posteromedial corner

Grade 3+ suspect posteromedialcorner and cruciate injury

Varus stress at 300

Grade 1 0-2mmGrade 2 5-10mmGrade 3 10+mm

Dial testat 300 only Posterolateral cornerat 300+900 PCL+posterolateral cornerReverse pivot shift testHughstons hyperextension ext rotation test

LCL/posterolateral corner

Grade 2+3 suspectposterolateral injury

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

Imaging•Plain XRAvulsion fractures

PCL,ACL from tibia and biceps

Segond fracturesStress views

Imaging•MRI100% 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 operativeTiming of surgeryRepair versus reconstructionAllograft versus autograftPartial versus total repairImmediate 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 kneessuperior results surgical group

Levy meta-analysis 2009IKDC 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 optionsDifficult in acute phaseRisk of compartment syndrome with capsular disruptionDegree of instabilityAvulsion or midsubstance ruptureAssociated injuries

Definite indications early surgeryBony avulsions ACL and PCLDistal avulsion dynamic stabilisers – popliteus and biceps

Summary of acute surgical options

ACL - reconstruction (?? repair tibial avulsion)PCL - reconstruction (? repair femoral avulsion)

Relative indications early surgery-Everything else

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 instabilitiesArthrofibrosis

Liow 2003, 22 knees, Harner 2004, 31 kneesSlightly better results acute groupNo difference ROM

Levy Arthroscopy 20095 studies nowLysholm 90 acute vs 82IKDC 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 AutograftGood theoretical advantagesDonor site morbidityAmount of tissue availableStrength of graft for PCL reconstruction(Harner 2004, Liow 2003, Fanelli 1999,Noyes 1997)

Disease transmissionIrradiation 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 reconstnSubjective poorIKDC nearly normal 50%

abnormal 40%severely abnormal 10%

Lysholm 70-80Tegener 3-450 % 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

Thank you