Surgical Management of the Multiple-Ligament Knee Injury

Abstract

The management of multiligament knee injury is a complex process starting with the adequate identification of the injury. A detailed physical and radiographic examination with a thorough understanding of knee anatomy is crucial to assess all damaged structures: anterior cruciate ligament, posterior cruciate ligament, posteromedial corner including the medial collateral ligament, and posterolateral corner including the lateral collateral ligament. Several surgical techniques have been developed throughout the years to adequately address these ligament insufficiencies. In this surgical technique description, we describe a reproducible method for the assessment and surgical management of a knee dislocation (KDIV) injury. Our approach includes using anatomic single-bundle cruciate ligament reconstructions with modified Bosworth technique for medial-side injuries and a combination of Müller popliteal bypass and Larson figure-of-8 techniques for posterolateral corner injuries. The orders of surgical steps is described concisely, and technical controversies such as graft choice, tunnel positioning, and sequence of graft fixation are discussed in detail.

Fig 1

First row: right knee radiographs. (A-C) Dislocated knee and immediate reduction anterior-posterior and lateral radiographs. Second row: right knee magnetic resonance images. (D) Axial image with yellow arrowheads reveals medial soft-tissue sleeve injury (medial collateral ligament, medial patellofemoral ligament, and medial retinaculum). (E) Sagittal image: bicruciate injury. (F) Sagittal image: posterolateral corner injury.

Fig 2

(A-D) Anterior-posterior images of injured right knee with marker compared to contralateral uninjured knee. Note the side-to-side difference under varus stress (A/B) and valgus stress (C/D). (E) Lateral injured right knee with posterior drawer test performed as exam under anesthesia. ∗Surgeons should confirm that the side-to-side difference is >4 mm.

Fig 3

Intraoperative images, right knee. (A) Lateral incision for posterolateral corner approach also used as an egress incision. (B) Avulsed biceps is dissected. (C) Peroneal nerve is dissected. (D) Biceps is secured with no. 2 fiber wire suture (Arthrex). (E) Peroneal nerve with a Penrose drain looped around it. (F) Intraoperative image, left knee showing common peroneal nerve split proximally into the superficial and deep branches.

Fig 4

Intraoperative images, right knee. (A, B) Bone patellar tendon bone autograft harvest for posterior cruciate ligament graft and hamstring autograft harvest for ACL graft. (C) Hamstring allografts prepared for posterolateral corner and medial collateral ligament reconstructions. (D) Bone patellar tendon bone autograft preparation.

Fig 5

Arthroscopic images, right knee. (A) Note the bicruciate ligament injury visualized through the anterolateral portal. (B) Lateral drive-through sign with gross hematoma appreciated at popliteus tendon. (C) Medial drive-through sign with medial meniscus tear, associated medial soft-tissue hemorrhage, and femoral-sided medial collateral ligament injury given the meniscus stays with the tibial surface during valgus stress.

Fig 6

(A) Intraoperative image, right knee. Inside-out lateral meniscus repair in figure-of-4 position using window 2 for suture placement. (B, C) Arthroscopic image, right knee lateral meniscus repair as a “cross stitch” viewed through the anterolateral portal.

Fig 7

Intraoperative images, right knee. (A) Transseptal portal establishment. Camera is introduced through the posteromedial portal, and electocautery device is advanced through posteromedial portal. (B) Remnant posterior cruciate ligament stump is easily debrided by VAPR electrocautery device (Depuy) after establishment of posterior transseptal portal. Note the transseptal portal is made with the debridement devices aimed anteriorly to limit injury to the posterior neurovascular bundle.

Fig 8

Arthroscopic images, right knee. (A) Outside-in posterior cruciate ligament femoral tunnel pin placement. (B) Accessory anteromedial anterior cruciate ligament femoral tunnel pin placement.

Fig 9

Intraoperative and correlating arthroscopic images of right knee. (A, B) Guide pins placed to planned tunnel locations: (A) anterior cruciate ligament tibial tunnel pin placement and (B) posterior cruciate ligament tibial tunnel under direct visualization through posteromedial portal.

Fig 10

Intraoperative images with corresponding C-Arm images of right knee. (A-D) Check guide pin positions and directions to prevent possible malpositioned tunnels and tunnel convergence.

Fig 11

Intraoperative images with corresponding C-Arm images of right knee. (A) Rasp tunnel edges to facilitate graft passage. (B) Graft passing. Arthroscopic images. (C) Viewing through the notch, with the help of a probe advanced through the posteromedial portal, the posterior cruciate ligament graft is shuttled. (D) Anterior cruciate ligament graft is seated into the femoral tunnel.

Fig 12

C-Arm images of right knee. (A, B) Tunnel positions for posterolateral corner (PLC) and medial collateral ligament (MCL) reconstructions. Intraoperative images. (C, D) MCL and PLC are checked; note the luque wires (long arrows) used for the tibia and fibular tunnels (Larson and Müller reconstructions) and the proximity of the peroneal nerve (asterisks).

Fig 13

Right knee intraoperative images with schematic correlation. (A-C) Graft passage for posterolateral corner reconstruction of lateral collateral ligament, popliteofibular ligament, and popliteal bypass.

Fig 14

Right knee intraoperative images and schematic correlation. (A, B) Medial-sided incision showing medial collateral ligament injury and planned reconstruction.

Fig 15

Arthroscopic images of right knee. (A) Anterior cruciate ligament, posterior cruciate ligament graft assessment after finalizing tibial fixation. Intraoperative images. (B, C) Posterolateral corner and medial collateral ligament reconstruction, respectively, after final graft fixation.

Fig 16

Postoperative radiographs of right knee. (A, B) AP/lateral status postsurgery completion.