DOJ
10.5005/jp-journals-10017-1069
Technical Report
Technical Aspects of Addressing Multiligament
Knee Instability
1
Travis J Dekker MD, 2Beau J Kildow MD, 3Evan M Guerrero MD, 4Claude T Moorman III MD
abstract
Multiligament Knee Injuries (MLKI) are rare but devastating
injuries that require both acute and chronic management. These
injuries necessitate operative management with individual
patient factors dictating management in an acute (<6weeks)
versus chronic (>6 weeks) time frame. Anterior cruciate liga-
ment, posterior cruciate ligament and posterolateral corner
reconstruction remains the gold standard for operative man-
agement while most medial collateral ligament injuries can be
managed non-operatively. Graft fixation sequence is essential
in re-tensioning the soft tissues to allow for a functional and
balanced knee post-operatively- the PCL is first fixed in flexion,
followed by the ACL in extension, and then lastly, the PLC and
MCL are addressed as needed. This review paper highlights
technical considerations demonstrated in two case reports
to include timing of surgery, graft selection and sequence of
graft fixation.
Key words: Graf t fixation sequence, Graf t selection,
Multligament knee injury, Technical considerations.
Dekker TJ, Kildow BJ, Guerrero EM, Moorman CT III.
Technical Aspects of Addressing Multiligament Knee
Instability. The Duke Orthop J 2016;6(1):47-53.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Multiligament knee injuries (MLKIs) by definition
include at least two of the four major ligamentous
stabilizers of the knee: The anterior cruciate ligament
(ACL), posterior cruciate ligament (PCL), posterolateral
corner (PLC), and the posteromedial corner (PMC).1
This rare injury (< 0.02% of all knee injuries) can be
devastating. They typically occur secondary to a knee
dislocation due to a high-energy trauma (54%) (i.e., a
motor vehicle collision) or a low-energy mechanism
(46%) like a sporting event.2,3 These patients will typically
1-3
Resident, 4Professor and Vice Chair
1-4
Department of Orthopaedic Surgery, Duke University Medical
Center, Durham, North Carolina, USA
Corresponding Author: Claude T Moorman III, Professor and
Vice Chair, Department of Orthopaedic Surgery, Duke University,
Medical Center Box 3439, Durham, North Carolina-27710, USA
Phone: +9196843170, e-mail: t.moorman@dm.duke.edu
The Duke Orthopaedic Journal, July 2015-June 2016;6(1):47-53
Technical Aspects of Addressing Multiligament Knee Instability
present acutely, and a complete work-up is a necessity in
order to avoid disastrous events, such as compartment
syndrome, vascular or neurologic compromise.4
A thorough history can aid the physician in under-
standing not only the mechanism of the sustained injury
but also whether signs point to a prior dislocation that
spontaneously reduced. If the patient presents with a
dislocated knee, immediate reduction through open or
closed techniques is required. Of note, a medial dimple
sign points toward an irreducible posterolateral dislo­
cation with the medial femoral condyle penetrating the
medial joint capsule. Failure to promptly reduce a knee
dislocation can lead to skin necrosis and vascular com-
promise.5 After reduction, the neurovascular status along
with compartment pressures should be closely evalu-
ated. Many authors advocate for performing immediate
ankle-brachial index (ABI) measurements. If the result is
less than 0.9 (100% specificity and sensitivity for arterial
injury), then more invasive evaluation with a computed
tomography (CT) arteriogram (CTA) or magnetic reso-
nance angiography is warranted.6 Due to constraints of
warm ischemia time as well as the ease of pan-scan CT
scans in the setting of major traumas, our home institution
has utilized CTA as its imaging modality of choice if ABIs
are abnormal. Computed tomography arteriogram has
demonstrated equally accurate results to formal angio­
gram but require less time and radiation.7 Emergency
surgery is reserved for irreducible knee dislocations,
compartment syndrome, or vascular compromise when
limb viability is threatened. In all three of these circum-
stances, a spanning external fixator is used to maintain
adequate reduction temporarily, to allow access to the soft-
tissues, and to protect any vascular repairs that have been
performed. In the setting of compartment syndrome or
revascularization after a prolonged period of arterial
compromise, a four-compartment fasciotomy is indicated.
This review paper will highlight surgical considerations
after the orthopaedic trauma team has performed the
initial evaluation and management from the emergency
department. These surgical highlights will be represented
in two cases performed by the senior author (Claude T
Moorman III). Among many essential aspects of surgery
when approaching this complex pathology, we will
attempt to focus on three key surgical elements when
approaching MLKIs: timing of surgery/staging of surgery,
graft selection, and order of graft fixation and tensioning.
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Travis J Dekker et al
TIMING AND STAGING OF SURGERY FOR
MULTILIGAMENT KNEE INSTABILITY
After immediately addressing any sources of potential
tissue hypoxia, if present, and temporarily stabilizing the
knee, some controversy exists about timing of reconstruc-
tion. In the experience of our senior author, he has waited
6 weeks after vascular repair to allow re-epithelialization
of the graft before placing a tourniquet, per the recom-
mendation of vascular surgeons; he has done so on greater
than 100 cases without complication. Each case should be
evaluated independently, and individual factors should
be taken into account including concomitant ipsilateral
fractures, medical comorbidities, and the patient’s overall
state of health. Historically, surgery is considered acute
if performed within 6 weeks, and surgery is considered
chronic after that point in time. Theoretically, the benefit
of acute surgery is the clear identification of tissue planes
during surgery before scar tissue forms, and the proposed
risk of acute reconstruction is arthrofibrosis leading to
stiffness.8 Subbiah et al9 found no significant difference
in terms of Lysholm score, International Knee Documen-
tation Committee grade, range of motion, or functional
outcome between surgeries that occurred before and
after 3 weeks. A study by Karataglis et al10 concluded
that although chronic reconstruction rarely results in a
“normal” knee, citing pain on exertion as a considerable
problem, it offers significant improvement and satisfac-
tory stability. Tzurbakis et al11 compared acute vs chronic
reconstruction and found improved scores in multiple
systems among acute repairs; however, the difference
was not statistically significant. In a systematic review
of 24 retrospective studies including 396 knees, Mook
et al12 found that acute treatment was associated with
significant residual anterior knee instability and flexion
deficits, and patients were more likely to need additional
treatment for joint stiffness compared with chronic treat-
ment. They found that staged reconstruction resulted in
the highest percentage of excellent and good subjective
outcomes.
In the experience of our senior author, acute treatment
offers the advantage of clear tissue planes during
surgery. He feels that the arthrofibrosis that occurs
following surgery may be protective and beneficial in
the healing process, with the decreased range of motion
being amenable to rehabilitation. For these reasons,
he recommends acute treatment in the absence of
complicating factors. He emphasizes the importance of
having an experienced operating team and thorough
preoperative planning. Our senior author rarely stages
this procedure, although he stresses the importance of
being cognizant of tourniquet time, even addressing the
lateral collateral ligament (LCL) with tourniquet down
if warranted.12
48
GRAFT SELECTION
Although there have been few studies reporting good
outcomes with primary ligament repair, reconstruction
remains the standard of care when surgically treating
multiligament injuries. Specifically, ACL/PCL/PLC
injuries require reconstruction, while most medial
collateral ligament (MCL) injuries are amenable to repair
with the exception of those that are mid-substance or
chronic. A prospective level II study by Stannard et al13
reported a 37% failure rate in repair compared with a
9% failure in reconstruction of PCL tears in MLKIs at
a 2-year follow-up. A key principle in reconstruction
is choosing a durable graft that will incorporate at
the graft–bone interface. When managing isolated
ligamentous injuries, autografts are popular due to faster
revascularization and maturity.14 However, with multiple
ligament reconstructions, allografts allow many graft
size options, decreased donor site morbidity, and shorter
tourniquet times.15 There have been multiple studies
showing excellent results with allograft reconstruction.15
A study by Fanelli et al16 shows no significant difference
in return to activity and functional stability in patients
who suffered MLKIs between allograft and autograft
reconstruction.
The first published article describing ACL/PCL
reconstruction in an MLKI was by Dr EW Hey Groves
in 1917. He describes using a iliotibial (IT) band autograft
reconstruction of the ACL and semitendinosus autograft
for the PCL.17 Since this time, research has evolved
to find better techniques using a variety of grafts for
reconstruction. When deciding on graft selection, it is
important to first identify which ligaments/structures
need reconstruction. As mentioned earlier, involved
structures amenable to reconstruction include the PCL,
ACL, PLC/LCL, and PMC/MCL. For PCL reconstruction,
successful outcomes have been reported with Achilles
tendon allograft for single bundle and adding tibialis
anterior allograft for double bundle reconstruction.18
A cohort study by Kim et al19 reported no difference in
stability and outcomes in double vs single bundle PCL
reconstruction in combination with PLC reconstruction.
Although there are a number of studies looking at
optimal graft options for isolated ACL tears, in the
setting of multiligament injures, ACL reconstruction with
bone–tendon–bone (BTB) allograft and Achilles tendon
allograft have shown promising long-term outcomes.20
Many advancements have been made in PLC
reconstruction since the first attempt by Dr Leo Mayer
in 1930, which involved stripping the IT band and biceps
femoris tendon. Posterolateral corner reconstruction is
known to be the most challenging step in multligament
knee injury management due to the complexity of its
anatomy. Attention in the literature is more focused on

technique as opposed to graft selection; as a result, there
is a lack of evidence comparing graft options. The most
important factor consists of restoring the popliteofibular
ligament and stabilizing the LCL.21 Using Achilles tendon
allograft for the PLC in the setting of multiligament
reconstruction, despite few reports, shows promising
clinical outcomes when sources of autograft are limited.22
Depending on the technique used, a split biceps tendon
transfer and semitendinosus autograft are often the grafts
of choice.20,21 The senior author has seen best results for
PLC reconstruction using hamstring autograft, but will
resort to Achilles tendon allograft if reconstruction of both
the MCL and LCL are required. Lateral collateral ligament
repair vs reconstruction remains controversial; however,
many techniques describe a primary repair, if possible, and
allograft augmentation with capsular shift procedure.21,23
Isolated LCL injuries can often be treated nonoperatively;
however, in the setting of LCL/popliteofibular ligament
injury, Stannard et al13 demonstrate better results with
reconstruction over repair.
For PMC/MCL injuries, a retrospective study by
Stannard et al reveals 21% (5/24) failure rate with MCL
repair as opposed to a 4% (2/48) failure rate with re-
construction in multiligament injuries. Reconstructing
the PMC involves augmenting the MCL along with rec-
reating dynamic stability from the semimembranosus
tendon and posterior oblique ligament.21 Reconstruc-
tion techniques and graft selection for the PMC, like
other structures, are based on expert opinion/surgeon
preference. Graft choice includes, but are not limited to,
Achilles tendon allograft,24 semitendinosus autograft,25
and tibialis anterior allograft.26 Overall graft selection
for multiligament reconstructions should follow basic
principles. The graft material should be strong, easy to
pass through bone tunnels, readily available, and able
to incorporate at bone–graft interface.23 All allografts
should sterilized, tested, and screened in accordance to
the American Associated of Tissue Banks guidelines.15
GRAFT FIXATION SEQUENCE
Graft fixation sequence has been well described by mul-
tiple sources.27-30 Originally described by Marks et al, the
graft fixation sequence is as follows: Prepare both PCL
and ACL tunnels first, pass and fix the PCL in flexion,
fix the ACL in extension, and finally, address remain-
ing lateral and medial ligamentous laxity. The senior
author’s preference is the following: Repair MCL unless
tear is mid-substance or chronic, reconstructions of the
MCL are completed with a modified Bosworth technique
with semitendinosus autograft, and PLC injuries are
reconstructed using a fibular-based Figure 8 graft with
hamstring autograft knowing there is little role for true
PLC injuries.
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Technical Aspects of Addressing Multiligament Knee Instability
Posterior Cruciate Ligament
After a thorough diagnostic arthroscopy, a posteromedial
portal can be used as both a working and viewing portal
site to adequately prepare the tibial PCL footprint (Fig. 1).
In our case, with the use of fluoroscopy and an adequate
notchplasty, viewing of the PCL footprint can be seen
through the anterolateral portal. The view of the PCL
footprint is maximized using and interchanging 30 and
70° scopes as needed. Of note, the popliteal artery and
tibial nerve run approximately 1.5 cm behind the capsule
at the level of the joint, and great care should be taken to
not extend beyond the capsule.30 The two primary surgi-
cal techniques for PCL reconstruction are the tibial inlay
technique and the transtibial technique. The advantage
of the tibial inlay is preventing graft lengthening and
thinning, while a “killer curve” has been described in
transtibial tunnel fixation of the PCL that in cadaveric
studies leads to graft attenuation.31 However, clinical
studies have demonstrated equivocal results. 32 The
senior author performs the PCL reconstruction with the
transtibial technique using an Achilles allograft with
calcaneal bone plug. In our case (Fig. 1), the PCL tibial
tunnel is drilled under fluoroscopic guidance, carefully
placing it 7 mm off the back wall as measured along the
PCL facet. Next, the PCL femoral tunnel is drilled with
a PCL guide at the junction of the roof and wall of the
medial femoral condyle 1 cm posterior to the articular
surface utilizing prior remnant PCL landmarks. This
is drilled in an outside-in manner and docked into the
lateral femoral condyle (Fig. 1). In order to minimize the
acute angle of the “killer curve,” the lead author utilizes
an Arthrex Gore Smoother graft passer®. The bone plug
from the Achilles allograft is fixed in the femoral tunnel
with a biologic interference screw passed retrograde
(Milagro biocomposite screw® in our case) and the soft
tissue portion of the graft, utilizing FiberLoop® in a
whip stitch pattern, is fixed into the tibia with a post and
washer (low-profile Arthrex 12 mm washer® and 6.5 mm
cancellous screw) and supplemented by another retro-
grade biocomposite interference screw. An important
technical point in PCL fixation is performing an anterior
drawer on the tibia during fixation of the PCL while the
leg is 70 to 90° of flexion (Fig. 1).
Anterior Cruciate Ligament
Anterior cruciate ligament fixation (Fig. 2) is typically
performed with BTB autograft or allograft based on
surgeon preference and experience. Despite vastly
different trajectories, it is essential to ensure that there
is a large enough bone bridge between the two tibial
tunnels of the ACL and PCL on the anteromedial tibia.
Debridement from diagnostic arthroscopy should ensure
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Travis J Dekker et al
Fig. 1: Multiligament knee injury technical considerations in PCL reconstruction
adequate visualization of the tibial ACL footprint placing
the center of the guide just medial to the anterior horn of
the lateral meniscus. Multiple guides allow for anatomic
placement of the femoral ACL tunnel ensuring adequate
bone stock of the back wall and placing it in a 10:30 or
2:30 placement for right and left knees respectively. The
senior author utilizes a flexible reamer system to next
prepare the femoral ACL tunnel with a 7 mm offset to
prevent blowout of the back wall. The ACL is tensioned
in complete extension and in our case, fixed with biologic
interference fixation (Milagro biocomposite screw®).
Medial Collateral Ligament
Medial collateral ligament fixation (Fig. 3) is based on
preoperative exam and degree of laxity. Multiple proce-
dures have compared different fixation methods to obtain
Fig. 2: Multiligament knee injury technical considerations in ACL reconstruction
50
valgus stability of the knee. Four well-known techniques
were compared in a cadaveric study by Feeley et al:
Bosworth, modified Bosworth, anatomical single bundle,
and anatomical double bundle. They demonstrated that
double bundle configurations (modified Bosworth and
anatomic double bundle) best approximate the native MCL
stability with regard to external rotation and decreased
valgus laxity.33 In the setting of concomitant ACL utiliz-
ing a BTB autograft, the incision from the BTB can be
extended proximally and mobilized to facilitate fixation of
the MCL. In the case example, semitendinosus autograft
was used in a modified Bosworth fixation using Arthrex
low-profile washers and screws. The senior author elects
to reconstruct MCL in the setting of MLKI in Grade II+
MCL tears, midsubstance tears, a Stener lesion of the
MCL, persistent laxity after ACL/PCL fixation, and

Fig. 3: Multiligament knee injury technical considerations in MCL reconstruction
anteromedial rotatory instability. Important technical
points of the procedure are ensuring identification of
the origin and insertion of the MCL. This technique
has been described by multiple sources – proximally,
the MCL is situated between the medial epicondyle and
the adductor tubercle. On a lateral radiograph, the inser-
tion is in line with the posterior cortex 3 to 5 mm proximal
and posterior to the medial epicondyle. Distally, the graft
itself or a temporary suture can be held on the tibia just
posterior to the pes anserine to determine the isometric
point ranging the knee from 0 to 90°. The knee should be
placed in 20 to 30° of flexion with varus stressing to tension
the graft appropriately.24
Lateral Collateral Ligament/Posterolateral Corner
One of the leading causes of ACL graft reconstruction
failure is an unrecognized and untreated PLC injury of
the knee.34 The anatomy of the posterior lateral corner
of the knee consists of the LCL, the arcuate complex,
the popliteal tendon, and the popliteal-fibular ligament
(Fig. 4).35 In a recent systematic review by LaPrade et al,
it was found that staged reconstruction of the PLC and
cruciates places a higher demand on the PLC repair,
leading to a 38% overall failure rate, whereas a single
staged cruciate and PLC reconstruction decreased the
failure rate to 9%. Furthermore, in both acute and chronic
injuries, no exact repair technique could be recommended
over another.36,37 Surgical techniques include variations
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Technical Aspects of Addressing Multiligament Knee Instability
of fibular slings, capsular shifts, and anatomic-based
techniques with a variation including a fibular tunnel
and a tibial tunnel. The senior author has experienced
good anecdotal results with a fibular-based reconstruc-
tion of the PLC. He utilizes a single femoral tunnel to
act as the footprint for both the popliteus and fibular
collateral ligament. This is achieved with the use of an
18 mm washer, as the average distance between these
two points coincides with this measurement. The surgi-
cal technique (Fig. 4) begins with a separate lateral inci-
sion proximal to the lateral epicondyle extending distal
to the joint midway between Gerdy’s tubercle and the
fibular head. By splitting the anterior one-third of the IT
band, the first window allows access to the lateral
epicondyle and exposure for the femoral tunnel place-
ment. Next, the head of the fibula is carefully accessed
in two planes: one is between insertion of the long and
short head of the biceps femoris and the other is poste-
rior to the biceps femoris. Using appropriate retractors
to protect the common peroneal nerve, a fibular tunnel
is drilled with a guide-pin followed by a size No. 6
reamer in an anterior to posterior direction. A low-profile
Arthrex cancellous screw with an 18 mm washer is
placed in the femoral tunnel and the semitendinosus
autograft, with ends of the tendon fixed in a whipstitch
pattern looped through the fibular tunnel, around the
post, and tied to itself. The graft is tensioned with the
leg in 30° of flexion, internal rotation, and valgus-directed
force.
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Travis J Dekker et al
Fig. 4: Multiligament knee injury technical considerations in posterolateral corner reconstruction
CONCLUSION
An MLKI is often due to a knee dislocation, which
requires prompt reduction, neurovascular monitoring,
and occasionally vascular repair if needed. Reconstruc-
tion has shown a lower risk of failure compared with that
of repair alone for ACL/PCL/PLC injuries, while most
MCL injuries are amenable to repair. Surgical reconstruc-
tion in less than 6 weeks allows for fresh tissue planes
that facilitate dissection and is recommended by the
senior author. This complex surgery requires extensive
presurgical planning for use of autograft and allograft,
and both should be available on the day of surgery. Lastly,
technical considerations in regard to sequence of bone
tunnel preparation as well as fixation and tensioning
sequence must be thought of carefully prior to the case
in order to maximize the surgical benefit.
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