SURGICAL TREATMENT OF COMBINED INJURY TO ANTERIOR CRUCIATE LIGAMENT, POSTERIOR CRUCIATE LIGAMENT, AND MEDIAL STRUCTURES

doi:10.1016/S0278-5919(05)70219-2

Clinics in Sports Medicine

Volume 19, Issue 3, 1 July 2000, Pages 479-492

https://doi.org/10.1016/S0278-5919(05)70219-2 Get rights and content

Although uncommon, knee dislocations do present at least once and possibly more during an orthopaedic surgeon's career. The rate of dislocation has been reported to be 0.001% to 0.013% per year at various institutions.10, 18, 19, 26, 27; however, true data are difficult to obtain because a percentage of knee dislocations spontaneously reduce and are not diagnosed at the time of injury.5, 26 A dislocation should be suspected in a knee with gross instability of two or more ligaments following trauma, despite a reduced joint on radiographs.⁵ Subsequent evaluation and treatment should be performed under the assumption that a dislocation has occurred.²⁶ This can be the case with injuries involving the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), combined with injuries in the medial collateral ligament (MCL). High-energy injuries involving a combined valgus and external axial moment can produce this injury complex, which is the focus of this article.

Section snippets

ANATOMY AND BIOMECHANICS

Injuries involving the ACL–PCL–MCL complex result in multiplanar instability. Analyzed separately, the ACL and PCL are the primary stabilizers of the knee, resisting anterior and posterior translation, respectively. As a separate entity, the superficial medial collateral ligament, has been shown to resist primarily valgus stress at 0° and 45°.³⁰ Combined with a posterior cruciate ligament injury, however, these structures have been shown to function as a secondary restraint to posterior

EVALUATION

Most knee dislocations are obvious on initial clinical presentation, whereas evaluation of patients with multiple-ligamentous knee injuries requires a high index of suspicion to exclude the possibility of knee dislocation with spontaneous reduction. The treatment algorithm for the evaluation and treatment of these injuries in this article is illustrated in Figure 1. The process begins with a brief history that includes the mechanism of injury and associated injuries. A careful vascular and

TREATMENT APPROACH

Reports that address multiple-ligament knee injury results advocate an operative reconstruction of the cruciate ligaments with variability in the approach towards the medial structures. Timing of the procedure is based on the degree of injury involving the medial collateral ligament.19, 20, 23, 25, 29 The MCL is an extra-articular structure with a capacity for healing without operative repair. Basic science and clinical studies support a conservative approach when dealing with these injuries in

SURGICAL TECHNIQUE

A recent method of reconstruction of the posterior cruciate ligament uses a double-bundle technique that reconstructs the anterolateral and posteromedial components of the posterior cruciate ligaments, whereas the traditional single-bundle techniques recreate the larger anterolateral component of this structure.⁷ Although biomechanical studies have demonstrated the superiority of this technique in a cadaveric model, in which properties of the double-bundle construct more closely resemble the

TREATMENT RESULTS

Different approachs have been reported with respect to this combination of injury, and no specific treatment consensus exists. Although the treatment approach of isolated injuries to the MCL and ACL–MCL injuries is accepted, these treatment principles cannot be extrapolated to ACL–PCL–MCL injuries.2, 3, 4, 13, 14, 15, 16, 17, 24 Presently, two treatment approaches have been recommended for this injury complex.

The authors' treatment approach, as outlined, recommends repair or reconstruction of

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Cited by (55)

Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment
2022, Arthroscopy, Sports Medicine, and Rehabilitation
To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.
The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ² tests, and Fisher exact tests were used with an α level of .05 set as significant.
We identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group.
Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.
Level III, retrospective cohort study.
Open reduction and internal fixation in a one-stage anterior cruciate ligament reconstruction surgery for the treatment of tibial plateau fractures: A case report and literature review
2018, Injury
Citation Excerpt :
With a minimum follow-up of 2 years, good results were seen in functional outcomes, range of motion, and strength. Similarly, several other studies reported satisfactory outcomes [16–23]. Millett et al.described [17] that the valgus laxity in the MCL deficient knee was stabilised by remaining structures, particularly the ACL.
Treatment of tibial plateau fractures associated with anterior cruciate ligament (ACL) injuries can be challenging. Maintaining the joint surface and axis are two main principles for the management of patients with tibial plateau fractures. Herein, we describe a patient with tibial plateau fracture of Schatzker type VI associated with complete ACL rupture. Although in a two-stage reconstruction surgery for treatment of its rupture seem to be accepted by most orthopaedic surgeons in cases of ACL injuries, we treated our patient with ORIF in a one-stage ACL reconstruction surgery. At the 1-year follow-up, the patient gained full range of motion and was functioning well. We reviewed the literature on performing ORIF in a one-stage ACL reconstruction for the treatment of tibial plateau fractures, which seemed to be a reasonable management approach that supported its use for the treatment of this patient.
Staged management of knee dislocation in polytrauma injured patients
2013, Injury
Citation Excerpt :
This injury could be an isolated soft tissue lesion or it can be more extensive involving bone, ligament, vascular and neural tissue damage. There are several principles that guide the management of knee dislocation.3–11 However, optimal management strategy for this type of injury in polytrauma injured patients remains controversial and has not been investigated adequately.
Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution.
From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months).
Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant.
The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.
Acute knee dislocation: An evidence based approach to the management of the multiligament injured knee
2011, Injury
Citation Excerpt :
The phenomenon of the PCL – intact knee dislocation has been reported, however [7,11,62]. Knee dislocation is uncommon, representing 0.02–0.2% of orthopaedic injuries [23,25,28,72,76]. It occurs in younger patients with a male-to-female ratio of 4:1.
Traumatic knee dislocations are uncommon yet serious injuries that historically have had variable prognosis. The evaluation and management of traumatic knee dislocations remains controversial. Appropriate early management has been shown to have a significant impact on long term functional outcome. A comprehensive review of the recent literature is presented alongside our current approach to management.
The dislocated knee is an under diagnosed injury which relies on a high index of clinical suspicion on presentation of any knee injury. There is now a degree of consensus regarding need for surgery, timing of surgery, vascular investigations, surgical techniques and rehabilitation protocols.
Vigilant monitoring for neurovascular complications, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament surgeries is the key to successful management of these difficult injuries.
Machine Learning-Based Performance Comparison to Diagnose Anterior Cruciate Ligament Tears
2022, Journal of Healthcare Engineering
Sensitivity analysis of the knee ligament forces to the surgical design variation during anterior cruciate ligament reconstruction: a finite element analysis
2022, Computer Methods in Biomechanics and Biomedical Engineering

View all citing articles on Scopus

: Address reprint requests to Christopher D. Harner, MD, UPMC, Center for Sports Medicine and Rehabilitation, 4601 Baum Boulevard, Pittsburgh, PA 15213

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SURGICAL TREATMENT OF COMBINED INJURY TO ANTERIOR CRUCIATE LIGAMENT, POSTERIOR CRUCIATE LIGAMENT, AND MEDIAL STRUCTURES

Section snippets

ANATOMY AND BIOMECHANICS

EVALUATION

TREATMENT APPROACH

SURGICAL TECHNIQUE

TREATMENT RESULTS

Surg Clin North Am

J Biomech

Healing of the medial collateral ligament following a triad injury: A biomechanical and histologic study of the knee in rabbitts

J Orthop Res

Medial collateral ligament injuries in football: Nonoperative management of grade I and grade II sprains

Am J Sports Med

The non-operative treatment of collateral ligament injuries of the knee in professional football players: An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically

J Bone Joint Surg [Am]

Medial collateral ligament injuries of the knee: A rationale for treatment

Clin Orthop

The dislocated knee

J Am Acad Orthop Surg

Loss of motion after anterior cruciate reconstruction

Am J Sports Med

Complications of posterolateral dislocation of the knee: Case report and literature review

Clin Orthop

Combined injuries to the anterior cruciate and medial collateral ligaments of the knee

J Bone Joint Surg Am

Acute anteromedial rotatory instability: Long-term results of surgical repair

J Bone Joint Surg Am

Acute tears of the posterior cruciate ligament: Results of operative treatment

J Bone Joint Surg Am

Non-operative treatment of complete tears of the medial collateral ligament of the knee

J Bone Joint Surg Am

Isolated medial collateral ligament injuries in the knee

J Am Acad Orthop Surg

Non-operative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players

Clin Orthop