Mechanisms of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Pathoanatomy and Applied Anatomy
Medial Side Knee Anatomy
Lateral Side Knee Anatomy
Posterior Anatomy of the Knee
Management of Adverse Outcomes and Unexpected Complications
Authors’ Preferred Treatment
Central Pivot (ACL/PCL) Injury
ACL, PCL, and Medial-Side Injury
ACL, PCL, and Lateral-Sided Injury
ACL, PCL, Medial, and Lateral-Sided Injury
Other Injury Patterns
Outcomes, Controversies, and Future Directions
Operative Versus Nonoperative Management
Early Versus Delayed Surgical Management
Repair Versus Reconstruction
Autograft Versus Allograft Reconstruction
An appended uppercase C indicates circulatory injury, an N denotes neurologic damage. For example, KD III-MC implies tearing of both cruciate ligaments and the medial collateral ligament, with an associated popliteal artery injury.
PCL, posterior cruciate ligament.
(From Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19(3):457–477, with permission).
PLI, posterolateral instability; PFL, popliteofibular ligament; FCL, fibular collateral ligament.
(From Fanelli GC, Feldmann DD. Management of combined anterior cruciate ligament/posterior cruciate ligament/posterolateral complex injuries of the knee. Oper Tech Sports Med. 1999;7(3):144)
PLC, posterolateral corner; FCL, fibular collateral ligament; PFL, popliteofibular ligament; IT, Iliotibial.
(From Levy BA, Boyd JL, Stuart MJ. Surgical treatment of acute and chronic anterior and posterior cruciate ligament and lateral side injuries of the knee. Sports Med Arthrosc. 19(2):111, with permission)
In the setting of a central pivot (ACL/PCL) injury (KD II) in the absence of collateral ligament disruption, our current practice is to allow the patient to rehabilitate the knee, reduce the swelling, reestablish full range of motion and quadriceps strength, and then perform a delayed ACL/PCL reconstruction. Similar to an isolated ACL injury,183,216 the rate of arthrofibrosis has been shown to be higher if patients undergo acute surgical reconstruction.138,214 We, therefore, in this particular ligamentous injury, allow the patient to completely rehabilitate the knee preoperatively, which normally takes about 6 to 8 weeks from the time of injury and then perform delayed ACL/PCL reconstructions, using the techniques described previously. Our preferred technique in this situation is all inside ACL and all inside PCL reconstructions that have the benefit of sockets instead of full tunnels that may minimize difficulties in the setting of future revisions should they become necessary. Rehabilitation follows our standard rehabilitation protocol as outlined previously.
The ACL/PCL/medial-sided injury (KD-IIIM) is managed in numerous ways and is highly dependent on the extent of disruption to the medial-sided structures as well as the specific location of the medial-sided disruption.
In the setting of a distal MCL tear where the MCL is resting superficial to the pes tendons (the so-called “Stener lesion” of the knee), we feel that the rate of healing for this MCL avulsion is extremely poor. In that case, we recommend combined MCL repair of the distal avulsion and early ACL/PCL reconstruction at approximately 2 to 3 weeks from the time of injury. Waiting longer than 2 to 3 weeks makes it more difficult to discern the anatomical structures on the medial side of the knee for appropriate repair. Performing surgery before the 2- to 3-week period increases the risk of arthrofibrosis as noted previously. Our current repair technique involves ensuring 3-point fixation of the MCL. Since the femoral side is still intact, we need two distal points of fixation. We place suture anchors at the proximal tibial superficial MCL attachment site and pass the sutures through the tissue but wait to tighten them until we have completed the distal avulsion repair. The distal MCL repair is performed using a modified locking Krackow stitch weaving up and down the anterior and posterior borders of the ligament creating a small slit in the distal portion of the native ligament. With the knee flexed to 30º, we secure the MCL distally with a suture post and spiked ligament washer construct as described previously. Finally, the superficial MCL sutures at the tibial joint line are tied down with the knee in full extension. If necessary, the posterior oblique ligament and PL capsule are imbricated with a horizontal mattress suture technique to the native MCL ligament. This is also done with the leg in full extension to avoid capturing the knee.
In the setting of an ACL/PCL/MCL disruption where there is midsubstance stretch of the MCL as seen on the MRI, repairing the ligament is typically not very effective and we recommend ACL/PCL/MCL reconstructions. This is performed at approximately 6 to 8 weeks postinjury once the soft tissues have settled down and the knee is rehabilitated. Our preferred MCL reconstruction technique uses an Achilles tendon allograft with bone block as described previously.
In the setting of an ACL/PCL/MCL disruption with proximal (femoral) MCL avulsion, oftentimes the MCL may heal without surgery. Similarly to a combined ACL and MCL injury with femoral avulsion, we allow the patient to rehabilitate the knee, regain range of motion, and then test the medial-sided structures for integrity after 6 to 8 weeks. If the MCL has healed, we perform delayed ACL and PCL reconstructions. However, if the MCL has not healed, we will perform ACL/PCL/MCL reconstructions accordingly. Alternatively, in certain patients, we will treat femoral MCL avulsions similar to a distal avulsion, using a spiked washer/suture post construct to repair the avulsed MCL at the MCL femoral attachment site. The same principles of timing and surgery as noted previously apply.
In the setting of a very extensive medial-sided disruption where there is injury to the proximal, distal, and midsubstance areas of the MCL, as well as injury to the PMC structures (medial head of the gastrocnemius, posterior oblique ligament, semimembranosus tendon, and pes tendons), we typically perform a staged reconstruction. Stage 1 consists of MCL repair with allograft augmentation followed by second-stage ACL and PCL reconstructions at approximately 6 to 8 weeks from injury. Because of the extensive medial-sided disruption in this particular setting, we typically prefer to address the medial-sided structures prior to 2 weeks from injury to avoid scarring that would prevent us from dissecting out the anatomical structures individually and repairing them back to their native sites in an appropriate fashion.
Therefore, as noted previously, timing, fixation, and whether or not we stage ACL/PCL/medial-sided repair and/or reconstructions depends on the extent of the injury as well as the specific location of the medial-sided disruption.
As with ACL/PCL/medial-sided injuries, decision making with ACL/PCL/lateral-sided injuries (KD-IIIL) also depends on the specific location of the lateral-sided injury and the extent of the lateral-sided disruption.
Distally based avulsions of the lateral side of the knee have actually demonstrated reasonable success with repair. Shelbourne et al.182 have described the “en mass” repair techniques for such injuries that focus on repairing the PL capsule to the tibia as well as the FCL and biceps tendons to the fibula. In their study of 21 patients followed for a minimum of 2 years, the authors noted good objective and subjective success, using this technique. More recently, Geeslin and LaPrade59 described repair techniques for distal, midsubstance, and proximal avulsions of the FCL. Our preferred technique for distally based avulsions depends not just on the extent of the injury but also on the quality of the tissues and the age of the patient. For example, in the case of an ACL/PCL/lateral-sided injury with a distal avulsion where the capsule is detached from the tibia, the meniscus is separated from the capsule, and the biceps and FCL are torn off the fibula, we recommend early repair augmented with a graft when the quality of the tissue is not good. In young patients, we have found that the tissue quality is typically very good and if we can operate within 10 to 14 days prior to significant scarring, the anatomical structures can often all be identified, located, and repaired back to their native anatomical insertion sites. If after completion of fixation, the construct does not appear to be solid or the tissue is not strong, then we augment the repair with a reconstruction, using either hamstring tendon allograft or autograft tissue as described previously with our reconstruction technique.
In the case of an ACL/PCL/lateral-sided injury with midsubstance injury as noted on the MR image, we will typically let the patient rehabilitate the knee and perform delayed ACL/PCL/lateral-sided reconstructions at approximately 6 to 8 weeks from injury. In this case, being able to dissect out the anatomical structures is less critical as we are bypassing all these structures with our graft construct. This approach allows any swelling to subside and the patient to reestablish full range of motion, thereby decreasing the ultimate risk of arthrofibrosis.
In the setting of ACL/PCL/lateral-sided injuries with proximal avulsions, we have found poor success rates with repair alone for the avulsed popliteus tendon and FCL.115 Therefore, in this setting, similar to the midsubstance MCL injuries, we prefer ACL/PCL/lateral-sided reconstructions in a delayed fashion at approximately 6 to 8 weeks from the time of injury for the reasons noted previously.
In the setting of global instability with ACL/PCL/medial/lateral-sided injuries (KD-IV), all of the same principles we just described for medial and lateral-sided injuries apply here as well. For example, if there is extensive medial-sided disruption and a distally based avulsion of the lateral-sided structures, then we perform a staged procedure. We fix the medial-sided structures acutely, augmenting with graft if the tissues are not acceptable, followed by immediate repair of the distally avulsed tissues, again augmenting with graft if necessary. We then allow the patient to rehabilitate the knee and then perform second-stage ACL and PCL reconstructions in a delayed fashion. However, if there is significant intrasubstance signal change of both the medial and lateral sides of the knee, we allow the patient to rehabilitate the knee, regain range of motion, and perform a multiligament knee reconstruction of the ACL, PCL, MCL/PMC, and FCL/PLC approximately 3 to 6 weeks from injury once the swelling has subsided and the patient has reestablished a reasonable range of motion.
As a general rule, we prefer to treat all fractures first, restoring bony anatomy and allowing the bone to heal, and then perform delayed ligament reconstructions later. Having said that, there are times when there are fractures of the proximal tibia with bony avulsions of the collateral ligament at which point we would address all these bony avulsions (ligament repairs) at the time of the fracture fixation.
Although there are other combinations of ligamentous injuries, for example, ACL/medial side, ACL/medial/lateral side, or PCL/lateral side, all of the principles outlined previously pertain to any other combinations of injuries. For example, a PCL/lateral-sided injury would be treated in the same way as an ACL/PCL/lateral-sided injury. Similarly, an ACL/medial-side injury would be treated with the same principles as the ACL/PCL/medial-side injury.