Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports

Abstract

Objective: The correct management of multiple-ligament injured knees (MLIKs) remains controversial. This study aimed to summarize the epidemiological features and short-term results of patients treated in our department.

Methods: Sixty-six patients diagnosed with MLIKs from 2009 to 2011 were enrolled. Relevant patient characteristics and clinical variables were analyzed to characterize the epidemiology. A surgical algorithm based on a knee dislocation classification system and postoperative rating scales, including Lysholm and Tegner rating, as well as joint mobility, stability and radiography were collected for functional evaluation at 2.5-year follow-up.

Results: The epidemiological profile demonstrated that 30- to 50-year-old men were at the highest risk. The primary causes were vehicle accidents and falls and most common injury type cruciate combined collateral ligament injuries. Final follow-up analysis comparing operative versus conservative management and surgically treated mild versus severe MLIKs showed significant differences in Lysholm and Tegner scale scores, as well as knee mobility and stability.

Conclusion: The therapeutic outcome of MLIKs depends on various clinical variables and a surgical algorithm. Satisfactory restoration of function was acquired in the majority of our surgically treated MLIK cases; however, most patients had not achieved their pre-injury activity levels by the follow-up endpoint.

Keywords: Follow-up; Knee; Ligament injury; Reconstruction.

Figure 1

Schematic outlines of (A, B) lateral and medial layered structures of the knee and (C) thee general principles for ligamentous repair. ①, patellar tendon; ②, iliotibial tract; ③, popliteal tendon; ④, LCL; ⑤, biceps femoris tendon; ⑥, ACL; ⑦, superficial MCL; ⑧, deep MCL; ⑨, pes anserinus.

Figure 2

Preoperative evaluation of the ligamentous laxity under different stress conditions. (A) Radiological appearance of a dislocated knee in the emergency room. (B) The reduced knee showing a normal articular match (distance of the joint gap [d] = 7.5 mm, angle of the articular surface [θ] = 0°). (C) An axial pulling view showing equally widened medial and lateral joint spaces (d = 13.8 mm, θ = 0°). (D) A varus stress radiograph showing a Grade II injury of the LCL (d = 13.2 mm, θ = 8.5°). (E) A valgus stress radiograph showing a Grade III injury of the MCL (d = 21.3 mm, θ = 14.2°). (F) A lateral radiograph of the knee maintained in the neutral position. (G) Posterior movement of 8.8 mm of the tibia to the femur, indicating a torn PCL. (H) Anterior movement of 19.2 mm of the tibia on the femur, indicating a torn ACL.

Figure 3

Reconstruction of bicruciate injury. (A) MRI showing discontinuity and disappearance of bicruciate ligaments. (B) Schematic representation of transosseous tunnels (anteroposterior view). (C) and (D) Intraoperative determination of transosseous tunnels for ACL and PCL by fluoroscopy (lateral views). (E) Arthroscopic view of bicruciate ligament reconstruction. (F) Preparation of a tibialis anterior allograft.

Figure 4

Surgical management of combined MCL injury. (A) MRI showing a proximal tear of the MCL from the medial epicondyle. (B) Postoperative fluoroscopy showing MCL repair and bicruciate reconstruction. (C) Schematic representation of a reconstructed MCL and its anatomical attachments. (D) Intraoperative reconstruction of the MCL via a medial approach.

Figure 5

Surgical management of lateral side injury. (A) MRI showing complete avulsion of the LCL from the fibular head (Grade III). (B) LCL reconstruction via a fibular‐based approach. (C) MRI showing a Grade II popliteal tendon injury. (D) Schematic representation of PLC reconstruction technique with oblique transfibular and axial transcondylar tunnels using a “popliteal bypass” technique.

Figure 6

Surgical management of a cruciate combined PT injury. (A) MRI showing an associated PT rupture. (B) Schematic representation of the reconstructed PT and its attachments. (C) Intraoperative reconstruction of the PT via a medial approach.

Figure 7

Graphs showing relevant patient characteristics and clinical variables for patients with MLIKs. (A) Patient age distribution. (B) The mechanism of injury for the MLIK population. (C) Quantitative MLIK classification according to a modified Schenk system. Knee dislocation (KD) I, single cruciate combined with either MCL or LCL injury; KD II, injury with anterior‐posterior instability; KD III, bicruciate and either MCL or LCL/PLC injury; KD IV, total bicruciate injury on both the medial and lateral sides; KD V, MLIK associated with periarticular fracture (Fx).