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DOJ

10.5005/jp-journals-10017-1069
Technical Aspects of Addressing Multiligament Knee Instability
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 present acutely, and a complete work-up is a necessity in


Multiligament Knee Injuries (MLKI) are rare but devastating order to avoid disastrous events, such as compartment
injuries that require both acute and chronic management. These syndrome, vascular or neurologic compromise.4
injuries necessitate operative management with individual A thorough history can aid the physician in under-
patient factors dictating management in an acute (<6weeks) standing not only the mechanism of the sustained injury
versus chronic (>6 weeks) time frame. Anterior cruciate liga- but also whether signs point to a prior dislocation that
ment, posterior cruciate ligament and posterolateral corner
reconstruction remains the gold standard for operative man-
spontaneously reduced. If the patient presents with a
agement while most medial collateral ligament injuries can be dislocated knee, immediate reduction through open or
managed non-operatively. Graft fixation sequence is essential closed techniques is required. Of note, a medial dimple
in re-tensioning the soft tissues to allow for a functional and sign points toward an irreducible posterolateral dislo­
balanced knee post-operatively- the PCL is first fixed in flexion, cation with the medial femoral condyle penetrating the
followed by the ACL in extension, and then lastly, the PLC and
medial joint capsule. Failure to promptly reduce a knee
MCL are addressed as needed. This review paper highlights
technical considerations demonstrated in two case reports dislocation can lead to skin necrosis and vascular com-
to include timing of surgery, graft selection and sequence of promise.5 After reduction, the neurovascular status along
graft fixation. with compartment pressures should be closely evalu-
Key words: Graf t fixation sequence, Graf t selection, ated. Many authors advocate for performing immediate
Multligament knee injury, Technical considerations. ankle-brachial index (ABI) measurements. If the result is
less than 0.9 (100% specificity and sensitivity for arterial
Dekker TJ, Kildow BJ, Guerrero EM, Moorman CT III. injury), then more invasive evaluation with a computed
Technical Aspects of Addressing Multiligament Knee
tomography (CT) arteriogram (CTA) or magnetic reso-
Instability. The Duke Orthop J 2016;6(1):47-53.
nance angiography is warranted.6 Due to constraints of
Source of support: Nil warm ischemia time as well as the ease of pan-scan CT
scans in the setting of major traumas, our home institution
Conflict of interest: None
has utilized CTA as its imaging modality of choice if ABIs
are abnormal. Computed tomography arteriogram has
demonstrated equally accurate results to formal angio­
INTRODUCTION
gram but require less time and radiation.7 Emergency
Multiligament knee injuries (MLKIs) by definition surgery is reserved for irreducible knee dislocations,
include at least two of the four major ligamentous compartment syndrome, or vascular compromise when
stabilizers of the knee: The anterior cruciate ligament limb viability is threatened. In all three of these circum-
(ACL), posterior cruciate ligament (PCL), posterolateral stances, a spanning external fixator is used to maintain
corner (PLC), and the posteromedial corner (PMC).1 adequate reduction temporarily, to allow access to the soft-
This rare injury (< 0.02% of all knee injuries) can be tissues, and to protect any vascular repairs that have been
devastating. They typically occur secondary to a knee performed. In the setting of compartment syndrome or
dislocation due to a high-energy trauma (54%) (i.e., a revascularization after a prolonged period of arterial
motor vehicle collision) or a low-energy mechanism compromise, a four-compartment fasciotomy is indicated.
(46%) like a sporting event.2,3 These patients will typically This review paper will highlight surgical considerations
after the orthopaedic trauma team has performed the
initial evaluation and management from the emergency
1-3
Resident, 4Professor and Vice Chair department. These surgical highlights will be represented
1-4
Department of Orthopaedic Surgery, Duke University Medical in two cases performed by the senior author (Claude T
Center, Durham, North Carolina, USA Moorman III). Among many essential aspects of surgery
Corresponding Author: Claude T Moorman III, Professor and when approaching this complex pathology, we will
Vice Chair, Department of Orthopaedic Surgery, Duke University, attempt to focus on three key surgical elements when
Medical Center Box 3439, Durham, North Carolina-27710, USA approaching MLKIs: timing of surgery/staging of surgery,
Phone: +9196843170, e-mail: t.moorman@dm.duke.edu
graft selection, and order of graft fixation and tensioning.
The Duke Orthopaedic Journal, July 2015-June 2016;6(1):47-53 47
Travis J Dekker et al

TIMING AND STAGING OF SURGERY FOR GRAFT SELECTION


MULTILIGAMENT KNEE INSTABILITY
Although there have been few studies reporting good
After immediately addressing any sources of potential outcomes with primary ligament repair, reconstruction
tissue hypoxia, if present, and temporarily stabilizing the remains the standard of care when surgically treating
knee, some controversy exists about timing of reconstruc- multiligament injuries. Specifically, ACL/PCL/PLC
tion. In the experience of our senior author, he has waited injuries require reconstruction, while most medial
6 weeks after vascular repair to allow re-epithelialization collateral ligament (MCL) injuries are amenable to repair
of the graft before placing a tourniquet, per the recom- with the exception of those that are mid-substance or
mendation of vascular surgeons; he has done so on greater chronic. A prospective level II study by Stannard et al13
than 100 cases without complication. Each case should be reported a 37% failure rate in repair compared with a
evaluated independently, and individual factors should 9% failure in reconstruction of PCL tears in MLKIs at
be taken into account including concomitant ipsilateral a 2-year follow-up. A key principle in reconstruction
fractures, medical comorbidities, and the patient’s overall is choosing a durable graft that will incorporate at
state of health. Historically, surgery is considered acute the graft–bone interface. When managing isolated
if performed within 6 weeks, and surgery is considered ligamentous injuries, autografts are popular due to faster
chronic after that point in time. Theoretically, the benefit revascularization and maturity.14 However, with multiple
of acute surgery is the clear identification of tissue planes ligament reconstructions, allografts allow many graft
during surgery before scar tissue forms, and the proposed size options, decreased donor site morbidity, and shorter
risk of acute reconstruction is arthrofibrosis leading to tourniquet times.15 There have been multiple studies
stiffness.8 Subbiah et al9 found no significant difference showing excellent results with allograft reconstruction.15
in terms of Lysholm score, International Knee Documen- A study by Fanelli et al16 shows no significant difference
tation Committee grade, range of motion, or functional in return to activity and functional stability in patients
outcome between surgeries that occurred before and who suffered MLKIs between allograft and autograft
after 3 weeks. A study by Karataglis et al10 concluded reconstruction.
that although chronic reconstruction rarely results in a The first published article describing ACL/PCL
“normal” knee, citing pain on exertion as a considerable reconstruction in an MLKI was by Dr EW Hey Groves
problem, it offers significant improvement and satisfac- in 1917. He describes using a iliotibial (IT) band autograft
tory stability. Tzurbakis et al11 compared acute vs chronic reconstruction of the ACL and semitendinosus autograft
reconstruction and found improved scores in multiple for the PCL.17 Since this time, research has evolved
systems among acute repairs; however, the difference to find better techniques using a variety of grafts for
was not statistically significant. In a systematic review reconstruction. When deciding on graft selection, it is
of 24 retrospective studies including 396 knees, Mook important to first identify which ligaments/structures
et al12 found that acute treatment was associated with need reconstruction. As mentioned earlier, involved
significant residual anterior knee instability and flexion structures amenable to reconstruction include the PCL,
deficits, and patients were more likely to need additional ACL, PLC/LCL, and PMC/MCL. For PCL reconstruction,
treatment for joint stiffness compared with chronic treat- successful outcomes have been reported with Achilles
ment. They found that staged reconstruction resulted in tendon allograft for single bundle and adding tibialis
the highest percentage of excellent and good subjective anterior allograft for double bundle reconstruction.18
outcomes. A cohort study by Kim et al19 reported no difference in
In the experience of our senior author, acute treatment stability and outcomes in double vs single bundle PCL
offers the advantage of clear tissue planes during reconstruction in combination with PLC reconstruction.
surgery. He feels that the arthrofibrosis that occurs Although there are a number of studies looking at
following surgery may be protective and beneficial in optimal graft options for isolated ACL tears, in the
the healing process, with the decreased range of motion setting of multiligament injures, ACL reconstruction with
being amenable to rehabilitation. For these reasons, bone–tendon–bone (BTB) allograft and Achilles tendon
he recommends acute treatment in the absence of allograft have shown promising long-term outcomes.20
complicating factors. He emphasizes the importance of Many advancements have been made in PLC
having an experienced operating team and thorough reconstruction since the first attempt by Dr Leo Mayer
preoperative planning. Our senior author rarely stages in 1930, which involved stripping the IT band and biceps
this procedure, although he stresses the importance of femoris tendon. Posterolateral corner reconstruction is
being cognizant of tourniquet time, even addressing the known to be the most challenging step in multligament
lateral collateral ligament (LCL) with tourniquet down knee injury management due to the complexity of its
if warranted.12 anatomy. Attention in the literature is more focused on

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Technical Aspects of Addressing Multiligament Knee Instability

technique as opposed to graft selection; as a result, there Posterior Cruciate Ligament


is a lack of evidence comparing graft options. The most
After a thorough diagnostic arthroscopy, a posteromedial
important factor consists of restoring the popliteofibular
portal can be used as both a working and viewing portal
ligament and stabilizing the LCL.21 Using Achilles tendon
site to adequately prepare the tibial PCL footprint (Fig. 1).
allograft for the PLC in the setting of multiligament
In our case, with the use of fluoroscopy and an adequate
reconstruction, despite few reports, shows promising
notchplasty, viewing of the PCL footprint can be seen
clinical outcomes when sources of autograft are limited.22
through the anterolateral portal. The view of the PCL
Depending on the technique used, a split biceps tendon
footprint is maximized using and interchanging 30 and
transfer and semitendinosus autograft are often the grafts
70° scopes as needed. Of note, the popliteal artery and
of choice.20,21 The senior author has seen best results for
tibial nerve run approximately 1.5 cm behind the capsule
PLC reconstruction using hamstring autograft, but will
at the level of the joint, and great care should be taken to
resort to Achilles tendon allograft if reconstruction of both
not extend beyond the capsule.30 The two primary surgi-
the MCL and LCL are required. Lateral collateral ligament
repair vs reconstruction remains controversial; however, cal techniques for PCL reconstruction are the tibial inlay
many techniques describe a primary repair, if possible, and technique and the transtibial technique. The advantage
allograft augmentation with capsular shift procedure.21,23 of the tibial inlay is preventing graft lengthening and
Isolated LCL injuries can often be treated nonoperatively; thinning, while a “killer curve” has been described in
however, in the setting of LCL/popliteofibular ligament transtibial tunnel fixation of the PCL that in cadaveric
injury, Stannard et al13 demonstrate better results with studies leads to graft attenuation.31 However, clinical
reconstruction over repair. studies have demonstrated equivocal results. 32 The
For PMC/MCL injuries, a retrospective study by senior author performs the PCL reconstruction with the
Stannard et al reveals 21% (5/24) failure rate with MCL transtibial technique using an Achilles allograft with
repair as opposed to a 4% (2/48) failure rate with re- calcaneal bone plug. In our case (Fig. 1), the PCL tibial
construction in multiligament injuries. Reconstructing tunnel is drilled under fluoroscopic guidance, carefully
the PMC involves augmenting the MCL along with rec- placing it 7 mm off the back wall as measured along the
reating dynamic stability from the semimembranosus PCL facet. Next, the PCL femoral tunnel is drilled with
tendon and posterior oblique ligament.21 Reconstruc- a PCL guide at the junction of the roof and wall of the
tion techniques and graft selection for the PMC, like medial femoral condyle 1 cm posterior to the articular
other structures, are based on expert opinion/surgeon surface utilizing prior remnant PCL landmarks. This
preference. Graft choice includes, but are not limited to, is drilled in an outside-in manner and docked into the
Achilles tendon allograft,24 semitendinosus autograft,25 lateral femoral condyle (Fig. 1). In order to minimize the
and tibialis anterior allograft.26 Overall graft selection acute angle of the “killer curve,” the lead author utilizes
for multiligament reconstructions should follow basic an Arthrex Gore Smoother graft passer®. The bone plug
principles. The graft material should be strong, easy to from the Achilles allograft is fixed in the femoral tunnel
pass through bone tunnels, readily available, and able with a biologic interference screw passed retrograde
to incorporate at bone–graft interface.23 All allografts (Milagro biocomposite screw® in our case) and the soft
should sterilized, tested, and screened in accordance to tissue portion of the graft, utilizing FiberLoop® in a
the American Associated of Tissue Banks guidelines.15 whip stitch pattern, is fixed into the tibia with a post and
washer (low-profile Arthrex 12 mm washer® and 6.5 mm
GRAFT FIXATION SEQUENCE cancellous screw) and supplemented by another retro-
grade biocomposite interference screw. An important
Graft fixation sequence has been well described by mul-
technical point in PCL fixation is performing an anterior
tiple sources.27-30 Originally described by Marks et al, the
drawer on the tibia during fixation of the PCL while the
graft fixation sequence is as follows: Prepare both PCL
leg is 70 to 90° of flexion (Fig. 1).
and ACL tunnels first, pass and fix the PCL in flexion,
fix the ACL in extension, and finally, address remain-
Anterior Cruciate Ligament
ing lateral and medial ligamentous laxity. The senior
author’s preference is the following: Repair MCL unless Anterior cruciate ligament fixation (Fig. 2) is typically
tear is mid-substance or chronic, reconstructions of the performed with BTB autograft or allograft based on
MCL are completed with a modified Bosworth technique surgeon preference and experience. Despite vastly
with semitendinosus autograft, and PLC injuries are different trajectories, it is essential to ensure that there
reconstructed using a fibular-based Figure 8 graft with is a large enough bone bridge between the two tibial
hamstring autograft knowing there is little role for true tunnels of the ACL and PCL on the anteromedial tibia.
PLC injuries. Debridement from diagnostic arthroscopy should ensure
The Duke Orthopaedic Journal, July 2015-June 2016;6(1):47-53 49
Travis J Dekker et al

Fig. 1: Multiligament knee injury technical considerations in PCL reconstruction

adequate visualization of the tibial ACL footprint placing valgus stability of the knee. Four well-known techniques
the center of the guide just medial to the anterior horn of were compared in a cadaveric study by Feeley et al:
the lateral meniscus. Multiple guides allow for anatomic Bosworth, modified Bosworth, anatomical single bundle,
placement of the femoral ACL tunnel ensuring adequate and anatomical double bundle. They demonstrated that
bone stock of the back wall and placing it in a 10:30 or double bundle configurations (modified Bosworth and
2:30 placement for right and left knees respectively. The anatomic double bundle) best approximate the native MCL
senior author utilizes a flexible reamer system to next stability with regard to external rotation and decreased
prepare the femoral ACL tunnel with a 7 mm offset to valgus laxity.33 In the setting of concomitant ACL utiliz-
prevent blowout of the back wall. The ACL is tensioned ing a BTB autograft, the incision from the BTB can be
in complete extension and in our case, fixed with biologic extended proximally and mobilized to facilitate fixation of
interference fixation (Milagro biocomposite screw®). the MCL. In the case example, semitendinosus autograft
was used in a modified Bosworth fixation using Arthrex
Medial Collateral Ligament low-profile washers and screws. The senior author elects
Medial collateral ligament fixation (Fig. 3) is based on to reconstruct MCL in the setting of MLKI in Grade II+
preoperative exam and degree of laxity. Multiple proce- MCL tears, midsubstance tears, a Stener lesion of the
dures have compared different fixation methods to obtain MCL, persistent laxity after ACL/PCL fixation, and

Fig. 2: Multiligament knee injury technical considerations in ACL reconstruction

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Technical Aspects of Addressing Multiligament Knee Instability

Fig. 3: Multiligament knee injury technical considerations in MCL reconstruction

anteromedial rotatory instability. Important technical of fibular slings, capsular shifts, and anatomic-based
points of the procedure are ensuring identification of techniques with a variation including a fibular tunnel
the origin and insertion of the MCL. This technique and a tibial tunnel. The senior author has experienced
has been described by multiple sources – proximally, good anecdotal results with a fibular-based reconstruc-
the MCL is situated between the medial epicondyle and tion of the PLC. He utilizes a single femoral tunnel to
the adductor tubercle. On a lateral radiograph, the inser- act as the footprint for both the popliteus and fibular
tion is in line with the posterior cortex 3 to 5 mm proximal collateral ligament. This is achieved with the use of an
and posterior to the medial epicondyle. Distally, the graft 18 mm washer, as the average distance between these
itself or a temporary suture can be held on the tibia just two points coincides with this measurement. The surgi-
posterior to the pes anserine to determine the isometric cal technique (Fig. 4) begins with a separate lateral inci-
point ranging the knee from 0 to 90°. The knee should be sion proximal to the lateral epicondyle extending distal
placed in 20 to 30° of flexion with varus stressing to tension to the joint midway between Gerdy’s tubercle and the
the graft appropriately.24 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-
Lateral Collateral Ligament/Posterolateral Corner
ment. Next, the head of the fibula is carefully accessed
One of the leading causes of ACL graft reconstruction in two planes: one is between insertion of the long and
failure is an unrecognized and untreated PLC injury of short head of the biceps femoris and the other is poste-
the knee.34 The anatomy of the posterior lateral corner rior to the biceps femoris. Using appropriate retractors
of the knee consists of the LCL, the arcuate complex, to protect the common peroneal nerve, a fibular tunnel
the popliteal tendon, and the popliteal-fibular ligament is drilled with a guide-pin followed by a size No. 6
(Fig. 4).35 In a recent systematic review by LaPrade et al, reamer in an anterior to posterior direction. A low-profile
it was found that staged reconstruction of the PLC and Arthrex cancellous screw with an 18 mm washer is
cruciates places a higher demand on the PLC repair, placed in the femoral tunnel and the semitendinosus
leading to a 38% overall failure rate, whereas a single autograft, with ends of the tendon fixed in a whipstitch
staged cruciate and PLC reconstruction decreased the pattern looped through the fibular tunnel, around the
failure rate to 9%. Furthermore, in both acute and chronic post, and tied to itself. The graft is tensioned with the
injuries, no exact repair technique could be recommended leg in 30° of flexion, internal rotation, and valgus-directed
over another.36,37 Surgical techniques include variations force.
The Duke Orthopaedic Journal, July 2015-June 2016;6(1):47-53 51
Travis J Dekker et al

Fig. 4: Multiligament knee injury technical considerations in posterolateral corner reconstruction

CONCLUSION 4. Medina O, Arom GA, Yeranosian MG, Petrigliano FA,


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