An overview on management in multi ligamentous knee injury in orthopaedics.

1. Management in
Multi- ligamentous knee injury
(MLKI)
Dr. Jose Austine
Resident, Dept. of Orthopaedic surgery,
Kasturba Medical College, Mangalore
Moderators
Dr. Atmananda Hegde
Dr. Sunil Murthy

3. • Knee dislocation and
MLKI
• <0.02% incidence
• Life and limb
threatening(neuro-
vascular) complications
• Large-scale data for
comparative analysis
and defining a standard
treatment protocol are
not available.

4. • Conservative vs operative
• Timing of surgery
• Repair vs reconstruction
• Allograft vs autograft
• Partial vs total repair
• Immediate vs delayed mobilization
Management Controversies
All ‘supported’ by at best Level 3 evidence.

6. 1
2
3

7. MLKI
Acute Chronic

8. Acute
MLKI

9. Popliteal artery injury ~ 30 % CPN injury ~ 35 %

10. Acute MLKI- Emergency Mx
• Prompt reduction of dislocation in the ER
• Re-evaluate the neurovascular status
• Splint the limb

12. Ankle brachial index (ABI)
ABI = Doppler systolic blood pressure in the injured limb(A)
Systolic blood pressure in the uninjured upper limb(B)
ABI <0.8 or <0.9 then angiogram

13. Revascularisation
of popliteal artery
Temporary
external fixation

14. Chronic MLKI

17. • In chronic cases, long-leg radiographs
are recommended to evaluate
alignment.
• Patients with chronic PLC injuries and
varus malalignment should be treated
with an osteotomy to correct
malalignment prior to PLC
reconstruction.
• Untreated mal-alignment will likely
cause the grafts to stretch over time
and fail.

18. Surgical vs Non-surgical Mx
• Dedmond et al (Meta analysis 2001)
• Richter et al (Meta analysis 2002)
• Levy et al (Meta analysis 2009)
üLiterature supports surgical treatment and
postoperative functional rehabilitation of multi-
ligament knee injuries.
üRare occasions such as advanced age, immobility and
comorbidities that nonsurgical treatment can be
considered.

19. Repair vs reconstruction
• Patients with repair of cruciate ligaments had higher rates of flexion deficit >6°, higher rates of posterior
instability and lower rates of return to preinjury activity levels. (Mariani et al)
• High reoperation rates have been reported in patients with posterolateral injuries treated with repair.
ü Anatomic reconstruction of the injured structures using biomechanically validated techniques
yield improved outcomes.
ü In the setting of multi-ligament injuries, reconstruction of the torn ligaments is recommended.
ü Repair of the collaterals is usually reserved for bony avulsion injuries.

20. Timing of surgery

21. Timing of surgery
• Early surgery (<3 week) has shown higher incidences of postoperative
stiffness and a fixed flexion deformity with higher rates of manipulation
under general anesthesia as compared to delayed repair.
• Delayed repair has higher chances of scarring of soft tissue with more
difficulty in identification and navigation in the joint leading to higher
chances of vascular complications.
• No conclusive evidence is suggestive of an advantage offered by a single
or a staged procedure.

22. Timing of surgery
• Acute- generally favoured in literature
- 3 weeks( before scarring or necrosis occurs)
(Engebretsen et al , Mariani et al , Fanelli et al, Harner et al)
- 6 weeks regarded as acute by Levy et al, Laprade et al
• Chronic – Not recommended unless forced delay
(eg- vascular injury)

23. Choice of graft- Auto vs Allo
Auto-grafts Allo-grafts
• Tensor fascia lata
• Bone patella tendon
bone
• Hamstring
• Quadriceps
• Peroneus longus
• Tibialis posterior/ anterior
• Tendoachilles
• Patellar tendon
• Hamstrings

25. La Prade
Anatomical mcl
reconstruction
La Prade
Anatomical PLC
reconstruction

26. Surgical
Principles
Avoiding
tunnel
convergence
Tensioning
sequence

27. Avoiding tunnel convergence
• Tunnel convergence increases the risk of
reconstruction graft failure.
• Potential damage to reconstruction grafts and
fixation devices.
• Not having sufficient bone stock between the grafts
for fixation and graft incorporation.

31. Tensioning sequence
Moatshe G, Laprade et al
• AL bundle of PCL at 90°(restore normal tibial step off)
• PM bundle of PCL in extension
• FCL at 20°−30° knee flexion and slight valgus.
• Other PLC structures at 60°of flexion and neutral rotation.
• ACL near full extension
• Finally, Posteromedial corner.

34. Major Pitfalls
Ø Patient positioning
Ø Graft preparation- Prevent oversizing, ensure availability
Ø Tunnel convergence
Ø Meniscal root injuries- Malposition of PCL and ACL tunnel
Ø Neurovascular complications- when creating tibial tunnels
Ø Fixation

36. Summary
Ø Complex problem
Ø Assessment of vascular and neurological injury paramount.
Ø Data lacking for definitive management protocols.
Ø Any intervention needs to be individualized by the presence of any life- or limb-threatening
complication
Ø Early operative treatment yields improved functional and clinical outcomes compared with non-
operativemanagement or delayed surgery.