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. 2021 Nov 11;1(6):26350254211039223.
doi: 10.1177/26350254211039223. eCollection 2021 Nov-Dec.

Anatomic Multiple Ligament Reconstructions of the Knee

Edward R Floyd  1   2 , Gregory B Carlson  3 , Jill K Monson  4 , Robert F LaPrade  3
Affiliations

Anatomic Multiple Ligament Reconstructions of the Knee

Edward R Floyd et al. Video J Sports Med. .

Abstract

Background: Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage.

Indications: After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (<3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis.

Technique: We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary.

Results: Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed.

Discussion/conclusion: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.

Keywords: ACL reconstruction; double bundle PCL reconstruction; multiple ligament injuries; posterolateral corner; varus/valgus stress.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: R.F.L. received research grants from Smith & Nephew and Ossur; received royalties from Arthrex, Ossur, and Smith & Nephew; is a consultant for Arthrex, Ossur, Smith & Nephew, and Linvatex; is a member of the editorial board for AOSSM, JEO, and KSSTA; and is a committee member of AOSSM, AANA, and ISAKOS. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Graphical Abstract
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References

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    1. Chahla J, Nitri M, Civitarese D, Dean CS, Moulton SG, LaPrade RF. Anatomic double-bundle posterior cruciate ligament reconstruction. Arthrosc Tech. 2016;5(1):e149-e156. - PMC - PubMed
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    1. LaPrade RF, Chahla J, DePhillipo NN, et al.. Single-stage multiple-ligament knee reconstructions for sports-related injuries: outcomes in 194 patients. Am J Sports Med. 2019;47(11):2563-2571. - PubMed

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