3. • 17 y/o male
• Outside linebacker, felt knee “buckle & pop”
while making a tackle during a game
• Evaluated by on-field personnel
– RICE technique implemented
– Lost to follow-up
• Presented to clinic 5 weeks after the injury
Case #1
3
4. • Physical Exam
– Crutches
– Large effusion
– 2+ opening to varus at 0 and 30; Grade 2B
Lachman
– + quad atrophy
– 2+ dp/pt pulses
– 0/5 EHL and tib-ant motor
– 5/5 FHL and gastric
– No sensation over dorsum of foot
Case #1 - Exam
4
8. Multiple Ligament Knee Injuries
• Non-operative vs. operative treatment
• Early vs. delayed surgery
• Early vs. delayed rehabilitation
Controversies for Treatment:
9. Multiple Ligament Knee Injuries
• Multiple studies consistently demonstrate
operative treatment is superior to non-operative
treatment
– More likely to return to work and sports
– Higher patient-reported outcomes
– Lower rates of PTOA
Non-Operative vs Operative Treatment:
10. Timing of Surgery
10
• Some advocate for early surgical intervention within 3
to 6 weeks:
– Tissue planes more easily identified
– Tissue quality sufficient to hold sutures for repair
– Less retraction of tissues, such as tendon
• Others advocate for delayed surgery to decrease
surgical risks:
– Compartment syndrome due to extravasation of fluid during
surgery
– Post-operative arthrofibrosis
11. Timing of Surgery
11
– Early (0-3 weeks)
Hamstring/ITB Avulsion
Nerve injury?
Locked knee, bucket handle, etc
– Delayed (3+ weeks)
Reconstruction
Fracture (+/- ORIF)
Prefer to get full motion back first
12. A Multicenter Randomized Clinical is
Needed to Provide Level 1 Evidence
for the Timing of Surgery & Post-
operative Rehabilitation for Treatment
of MLKIs
Surgical Timing and Rehabilitation (STaR)
Trial for Multiple Ligament Knee Injuries
13. Injury Technique Graft
ACL Anatomic AM portal or
outside-in
Quad or BTB auto
PCL Anatomic Single Bundle BTB/Quad auto or Achilles
Allo
PLC/LCL Primary repair + Modified
LaPrade, Arciero, or
Larson
Semi-T allograft
MCL/PMC Primary repair +
reconstruction (sMCL or
Anatomic)
Achilles Allo with Bone
Block or Semi-T
Preferred Graft Types & Techniques
13
23. Injury Order Position
PCL First • 90º (SB or PL bundle)
• 0º (PM bundle)
Posterolateral Corner Second • 20-30º w/ valgus (FCL)
• 60º (rest of PLC
structures)
ACL Third 10-20º w/ posterior
drawer, axial load, neutral
rotation
MCL/PMC Last 20º w/ slight varus
Graft Tensioning and Fixation
23
24. • Hinged Knee Brace for 6 weeks
• Partial weight bearing in brace (50%) x 4 weeks
• 0-90 ROM x 4 weeks
• D/C brace, start full ROM and WBAT after 6 weeks
• 6-12 months RTP, no contact sports for 12 months
Postop Rehab
24
* Based on Weak
Evidence *
25. • 17 y/o male
• Outside linebacker, felt knee “buckle & pop” while
making a tackle during a game
• Evaluated by on-field personnel
– RICE technique implemented
– Lost to follow-up
• Presented to clinic 5 weeks after the injury
Case #1
25
26. • Physical Exam
– Crutches
– Large effusion
– 2+ opening to varus at 0 and 30; Grade 2B Lachman
– + quad atrophy
– 2+ dp/pt pulses
– 0/5 EHL and tib-ant motor
– 5/5 FHL and gastric
– No sensation over dorsum of foot
Case #1 - Exam
26