Combined ACL-PCL-Medial and Lateral Side Injuries (Global Laxity).

The multiple ligament injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurological status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends upon the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.

Long-term followup of surgically treated knee dislocations: stability restored, but arthritis is common.

BACKGROUND: Surgical treatment of knee dislocations is intended to correct the anatomic injury and restore knee stability and patient function. Several studies have shown successful results with surgical treatment of knee dislocations with up to 10 years of followup, but longer-term studies are uncommon. QUESTIONS/PURPOSES: We evaluated patients treated surgically for knee dislocations at 10-year followup to assess (1) knee stability; (2) return to preinjury level of function; (3) development of arthrosis; and (4) range of motion (ROM) loss. METHODS: This study was a retrospective review of 127 combined PCL, ACL, and medial and/or lateral side reconstructions performed by a single surgeon (GCF) between 1990 and 2008. Of these, 44 were available for clinical and functional evaluation (35%) at a minimum 5-year followup. Inclusion criteria were combined PCL/ACL plus medial and/or lateral side reconstruction. Evaluation methods included arthrometer measurements, stress radiography, knee ligament rating and activity scales (Lysholm and Tegner), plain radiographs with osteoarthritic assessment, and physical examination. RESULTS: Of the 44 patients, there were nine ACL/PCL medial, 22 ACL/PCL lateral, and 13 ACL/PCL mediolateral reconstructions. Followup was at a minimum of 5 years (mean, 10 years; range, 5-22 years). The mean age at the time of injury was 31 years with a range of 13 to 65 years. The mean arthrometer-measured side-to-side differences were as follows: PCL screen, 1.9 mm; corrected posterior, 2.4 mm; corrected anterior, 0.8 mm; and anterior displacement at 30° of knee flexion, 1.7 mm. Stress radiographic measurements at 90° of knee flexion revealed a mean side-to-side difference of 1.9 mm. Mean Lysholm, and Tegner scores were 84 of 100 and 4.1 of 9, respectively. Ninety-three percent (41 of 44) of patients returned to their preinjury level of activity or one Tegner grade lower. Ten of the 44 knees (23%) developed degenerative joint disease. The mean flexion loss was 12.5°, and flexion contractures were not seen in any of the patients. CONCLUSIONS: We found that a high proportion of patients treated for these severe injuries achieved static and functional stability, allowing the return to physically demanding work and recreational activities, but that nearly one-fourth of them will develop arthritis at a mean of 10 years. We cannot extrapolate our results to an elite athlete population, but our results probably apply well to working class populations. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Combined anterior cruciate ligament and posterolateral reconstruction of the knee using allograft tissue in chronic knee injuries.

Combined anterior cruciate ligament (ACL) and posterolateral injury of the knee can result in significant functional instability for the affected individual. Both components of the instability must be treated to maximize the probability of success for the surgical procedure. Higher failure rates of the ACL reconstruction have been reported when the posterolateral instability has been left untreated. The purpose of this article is to describe our surgical technique, and present the results of 34 chronic combined ACL posterolateral reconstructions in 34 knees using allograft tissue, and evaluating these patient outcomes with KT 1000 knee ligament arthrometer, Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scales. In addition, observations regarding patient demographics with combined ACL posterolateral instability, postoperative range of motion loss, postinjury degenerative joint disease, infection rate, return to function, and the use of radiated and nonirradiated allograft tissues will be presented.

Surgical treatment of combined PCL-ACL medial and lateral side injuries (global laxity): surgical technique and 2- to 18-year results.

The multiple ligament injured knee is a severe injury that may also involve neurovascular injuries, fractures, and other systemic injuries. Surgical treatment offers good functional results documented in the literature by physical examination, arthrometer testing, stress radiography, and knee ligament rating scales. Mechanical tensioning devices are helpful with cruciate ligament tensioning. Some low grade medial collateral ligament (MCL) complex injuries may be amenable to brace treatment, while high grade medial side injuries require combined surgical repair-reconstruction. Lateral posterolateral injuries are most successfully treated with combined surgical repair-reconstruction. Surgical timing in acute multiple ligament injured knee cases depends on the ligaments injured, injured extremity vascular status, skin condition of the extremity, degree of instability, and the patients overall health. Allograft tissue is preferred for these complex surgical procedures. Delayed reconstruction of 2 to 3 weeks may decrease the incidence of arthrofibrosis, and it is important to address all components of the instability. Currently, there is no conclusive evidence that double-bundle posterior cruciate ligament (PCL) reconstruction provides superior results to single-bundle PCL reconstruction in the multiple ligament injured knee. The purpose of this article is to discuss G.F.'s surgical technique for combined PCL and anterior cruciate ligament, medial, and lateral side reconstructions in acute and chronic multiple ligament injured knees with global laxity. This article will focus on recognizing and defining the instability pattern, the use of external fixation, surgical timing, graft selection and preparation, G.F.'s preferred surgical technique, mechanical graft tensioning, perioperative antibiotics, specialized operating teams, postoperative rehabilitation, and our results of treatment in these complex surgical cases.

Single compared to double-bundle PCL reconstruction using allograft tissue.

This study compares the results of arthroscopic transtibial tunnel single-bundle and double-bundle posterior cruciate ligament (PCL) reconstructions using allograft tissue in PCL-based multiple ligament injured knees. Ninety consecutive PCL reconstructions are evaluated: 45 single-bundle and 45 double-bundle reconstructions. All PCL reconstructions were performed using the arthroscopically assisted transtibial tunnel PCL reconstruction technique using fresh frozen allograft tissue from the same tissue bank. Achilles tendon allograft was used for the anterolateral bundle; tibialis anterior allograft was used for the posteromedial bundle. The knees were evaluated postoperatively, comparing the single-bundle results to the double-bundle results, with KT-1000 arthrometer (Medmetric Corporation, San Diego, CA) testing, three different knee ligament rating scales, and Telos stress radiography (Austin Associates, Fallston, MD). Both the single-bundle and the double-bundle PCL reconstruction surgical techniques using allograft tissue provide successful results in the PCL-based multiple ligament injured knee when evaluated with stress radiography, arthrometer measurements, and knee ligament rating scales.

Combined PCL-ACL lateral and medial side injuries: treatment and results.

The multiple ligament-injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurologic status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends on the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.

Rehabilitation after multiple-ligament reconstruction of the knee.

Diagnosis and management of multiple-ligament knee injuries has evolved over the years, and now treatment often includes surgical intervention. Rehabilitation after multiple-knee ligament reconstruction requires a precarious balance between restoring range of motion and function to the knee without compromising the static stability and integrity of the grafted tissues. It is imperative that the patient is aware of the time commitment, restrictions, and the fact that the entire rehabilitation process will likely take a full year before returning to unrestricted activity. The purpose of this study is to define the current approach to postsurgical management after posterior cruciate ligament-based multiple knee-ligament reconstruction.

Current concepts review: the posterior cruciate ligament.

Injuries to the posterior cruciate ligament (PCL) and methods of treatment of the injured PCL have historically been surrounded by controversy in the orthopedic community. The infrequent occurrence of PCL injuries and PCL-based, multiple ligament knee injuries has led to limitations in clinical studies and a subsequent lag in basic science and clinical research compared with that for other ligamentous injuries. In recent years, new studies have elucidated the biomechanical function and complex anatomy of the PCL leading to an increased interest in research, understanding, and treatment of these complex injuries. In addition to improved understanding of knee ligament structure and biomechanics, technical advancements in allograft tissue, surgical instrumentation, and graft tensioning and fixation methods and improved surgical techniques and postoperative rehabilitation methods have enhanced the results in PCL reconstruction and PCL-based, multiple ligament knee surgical outcomes.

Arthroscopic double-bundle posterior cruciate ligament reconstruction surgical technique.

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and back-up graft fixation, and use the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single-bundle and double-bundle arthroscopic transtibial tunnel PCL reconstruction based on stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.

Double bundle posterior cruciate ligament reconstruction: surgical technique and results.

The keys to successful posterior cruciate ligament reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and back-up graft fixation, and use the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single and double-bundle arthroscopic transtibial tunnel posterior cruciate ligament reconstruction based upon stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.

Postoperative rehabilitation of the posterior cruciate ligament.

Diagnosis and management of posterior cruciate ligament injuries has evolved, and now the treatment often includes surgical intervention. The purpose of this paper is to define the current approach to postsurgical management after the posterior cruciate ligament reconstruction, review conservative management, and discuss surgical outcomes using a specified program.

Evaluation and treatment of the multiligament-injured knee.

A dislocated knee with tearing of both cruciate ligaments and one or both of the collateral ligaments is a severe injury that can result from high-or low-energy trauma. Vascular injuries (especially of the popliteal artery), nerve injuries, associated fractures, functional instability, and posttraumatic arthrosis all can occur with this injury complex. Most of these ligament injuries require surgical treatment, although some low-grade medial collateral ligament complex injuries can be treated with bracing. The timing of surgical treatment of acute multiple ligament injuries depends on the ligaments injured, the vascular status and skin condition of the injured extremity, the degree of knee instability, and the patient's overall health. It is important to correct all components of instability. Delaying reconstruction for 2 to 3 weeks may decrease the incidence of arthrofibrosis. Allograft tissue generally is preferred for these complex surgical procedures. Currently, there is no conclusive evidence that double-bundle posterior cruciate ligament reconstruction provides better results than single-bundle posterior cruciate ligament reconstruction in the knee with injuries to multiple ligaments.

Posterior cruciate ligament and posterolateral corner reconstruction.

The keys to successful posterior cruciate ligament reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft-tensioning device, use primary and backup graft fixation, and employ the appropriate postoperative rehabilitation program. Adherence to these technical points results in successful single and double bundle arthroscopic transtibial tunnel posterior cruciate ligament reconstruction documented with stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.

Conservative and postoperative rehabilitation of isolated and combined injuries of the medial collateral ligament.

Injuries to the medial collateral ligament (MCL) are very common and there seems to be a consensus supporting the conservative management of grade I and II tears. Grade III tears are also usually treated conservatively unless associated with injuries to the anterior cruciate ligament or posterior cruciate ligament. This article outlines rehabilitation programs for conservative treatment of MCL injuries, and postoperative programs after anterior cruciate ligament or multiple ligament reconstruction. In addition, the use of functional and prophylactic bracing for injuries of the MCL is reviewed.

The multiple-ligament injured knee: evaluation, treatment, and results.

The multiple-ligament injured knee is a complex problem in orthopaedic surgery. Most dislocated knees involve tears of the anterior and posterior cruciate ligaments (ACL/PCL) and at least 1 collateral ligament complex. Careful assessment of the extremity vascular status is essential because of the possibility of arterial and/or venous compromise. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and to formulate a treatment plan. Arthroscopically assisted combined ACL/PCL reconstruction is a reproducible procedure. Knee stability is improved postoperatively when evaluated using knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Acute medial collateral ligament (MCL) tears, when combined with ACL/PCL tears, may in certain cases be treated with bracing. Posterolateral corner injuries combined with ACL/PCL tears are best treated with primary repair as indicated, combined with reconstruction using a post of strong autograft (split biceps tendon, biceps tendon, semitendinosus) or allograft (Achilles tendon, bone-patellar tendon-bone) tissue. Surgical timing depends on the ligaments injured, the vascular status of the extremity, reduction stability, and the overall health of the patient. We prefer to use allograft tissue for reconstruction in these cases because of the strength of these large grafts and the absence of donor site morbidity.

Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up.

PURPOSE: This study presents the 2- to 10-year (24 to 120 month) results of 41 chronic arthroscopically assisted combined posterior cruciate ligament (PCL)-posterolateral reconstructions evaluated preoperatively and postoperatively using Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scales, KT-1000 arthrometer testing, stress radiography, and physical examination. TYPE OF STUDY: Case series. METHODS: This study population included 31 men and 10 women with 24 left and 17 right chronic PCL-posterolateral knee injuries with functional instability. The knees were assessed before and after surgery with arthrometer testing, 3 different knee ligament rating scales, stress radiography, and physical examination. PCL reconstructions were performed using the arthroscopically assisted single femoral tunnel-single bundle transtibial tunnel PCL reconstruction technique using fresh-frozen Achilles tendon allografts in all 41 cases. In all 41 cases, posterolateral instability reconstruction was performed with combined biceps femoris tendon tenodesis, and posterolateral capsular shift procedures. RESULTS: Postoperative physical examination revealed normal posterior drawer and tibial stepoff in 29 of 41 (70%) knees. Posterolateral stability was restored to normal in 11 of 41 (27%) knees, and tighter than normal knee was found in 29 of 41(71%) knees evaluated with the external rotation thigh foot angle test. A 30 degrees varus stress testing was normal in 40 of 41 (97%) knees, and grade 1 laxity in 1 of 41 (3%) knees. Postoperative KT-1000 arthrometer testing mean side to side difference measurements were 1.80 mm (PCL screen) and 2.11 mm (corrected posterior; P =.001). The postoperative stress radiographic mean side-to-side difference measurement measured at 90 degrees of knee flexion and 32 lb of posterior directed force applied to the proximal tibia using the Telos device was 2.26 mm (P =.001). Postoperative Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scale mean values were 91.7, 4.92, and 88.7, respectively (P =.001). All objective parameters showed a statistically significant improvement from preoperative status. CONCLUSIONS: Chronic combined PCL-posterolateral instabilities can be successfully treated with arthroscopic PCL reconstruction using fresh-frozen Achilles tendon allograft combined with posterolateral corner reconstruction using biceps tendon tenodesis combined with posterolateral capsular shift procedure. Statistically significant improvement is noted (P =.001) from the preoperative condition at 2 to 10 years' follow-up evaluation using objective parameters of knee ligament rating scales, arthrometer testing, stress radiography, and physical examination. LEVEL OF EVIDENCE: Level IV, case series (no historical or control group).

Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up.

PURPOSE: This study presents the 2- to 10-year results of 35 arthroscopically assisted combined anterior cruciate ligament and posterior cruciate ligament (ACL/PCL) reconstructions evaluated preoperative and postoperatively using Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scales, KT-1000 arthrometer testing, stress radiography, and physical examination. TYPE OF STUDY: Case series. METHODS: This study population included 26 men and 9 women with 19 acute and 16 chronic knee injuries. Ligament injuries included 19 ACL/PCL/posterolateral instabilities, 9 ACL/PCL/medial cruciate ligament (MCL) instabilities, 6 ACL/PCL/posterolateral/MCL instabilities, and 1 ACL/PCL instability. All knees had grade III preoperative ACL/PCL laxity and were assessed preoperatively and postoperatively with arthrometer testing, 3 different knee ligament rating scales, stress radiography, and physical examination. Arthroscopically assisted combined ACL/PCL reconstructions were performed using the single-incision endoscopic ACL technique and the single femoral tunnel-single bundle transtibial tunnel PCL technique. PCLs were reconstructed with allograft Achilles tendon (in 26 cases), autograft bone-patellar tendon-bone (BPTB) (in 7 cases), and autograft semitendinosus/gracilis (in 2 cases). ACLs were reconstructed with autograft BPTB (16 cases), allograft BPTB (12 cases), Achilles tendon allograft (6 cases), and autograft semitendinosus/gracilis (1 case). MCL injuries were treated with bracing or open reconstruction. Posterolateral instability was treated with biceps femoris tendon transfer, with or without primary repair, and posterolateral capsular shift procedures as indicated. RESULTS: Postoperative physical examination revealed normal posterior drawer/tibial step-off in 16 of 35 (46%) knees. Normal Lackman and pivot-shift test results were found in 33 of 35 (94%) knees. Posterolateral stability was restored to normal in 6 of 25 (24%) knees, and tighter than normal knee results were found in 19 of 25 (76%) knees evaluated with the external rotation thigh foot angle test. In this group, 30 degrees varus stress testing was normal in 22 of 25 (88%) knees, and grade 1 laxity was found in 3 of 25 (12%) knees. 30 degrees valgus stress testing was normal in 7 of 7 (100%) surgically treated MCL tears, and in 7 of 8 (87.5%) brace-treated knees. Postoperative KT-1000 arthrometer testing mean side-to-side difference measurements were 2.7 mm (PCL screen), 2.6 mm (corrected posterior), and 1.0 mm (corrected anterior) measurements, a statistically significant improvement from preoperative status (P =.001). Postoperative stress radiographic side-to-side difference measurements measured at 90 degrees of knee flexion and 32 lb posteriorly directed proximal force were 0 to 3 mm in 11 of 21 (52.3%) knees, 4 to 5 mm in 5 of 21 (23.8%), and 6 to 10 mm in 4 of 21 (19%) knees. Postoperative Lysholm, Tegner, and HSS knee ligament rating scale mean values were 91.2, 5.3, and 86.8, respectively, showing a statistically significant improvement from preoperative status (P =.001). CONCLUSIONS: Combined ACL/PCL instabilities can be successfully treated with arthroscopic reconstruction and the appropriate collateral ligament surgery. Statistically significant improvement is noted from the preoperative condition at 2- to 10-year follow-up using objective parameters of knee ligament rating scales, arthrometer testing, stress radiography, and physical examination. Postoperatively, these knees are not normal, but they are functionally stable. Continuing technical improvements will probably improve future results.