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Special Considerations for Multiple-Ligament Knee Injuries

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Sports Injuries

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Abstract

While high level of evidence studies on multiligament knee injuries are limited, a growing body of level III and IV clinical studies are available to guide treatment of these severe injuries. Early recognition and treatment is crucial for management of acute injuries, with immediate attention being directed toward ruling out or addressing vascular injuries. A thorough physical exam that delineates which structures are injured directs the need for more objective stress radiographs or other imaging modalities. The mechanical axis must be determined in patients with chronic injuries due to the high risk of failure of soft tissue grafts in patients with malalignment. An anatomic reconstruction of combined ligamentous injuries with early postoperative range of motion is recommended for best functional results. A multidisciplinary approach is necessary for the extensive rehabilitation following surgical treatment and should include the orthopedic surgeon, physical therapist, and athletic trainer if applicable.

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References

  • American Medical Association (1966) Standard nomenclature of athletic injuries. American Medical Association, Chicago, pp 99–100

    Google Scholar 

  • Arthur A, LaPrade RF, Agel J (2007) Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med 35:1844–1850. doi:10.1177/0363546507304717

    Article  PubMed  Google Scholar 

  • Benjaminse A, Gokeler A, Van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36:267–288. doi:10.2519/jospt.2006.2011

    Article  PubMed  Google Scholar 

  • Coobs BR, Wijdicks CA, Armitage BM et al (2010) An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 38:339–347. doi:10.1177/0363546509347996

    Article  PubMed  Google Scholar 

  • Dedmond BT, Almekinders LC (2001) Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg 14:33–38

    PubMed  CAS  Google Scholar 

  • Engebretsen L, Risberg MA, Robertson B et al (2009) Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc 17:1013–1026. doi:10.1007/s00167-009-0869-y

    Article  PubMed  Google Scholar 

  • Fanelli GC, Edson CJ (1995) Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy 11:526–529

    Article  PubMed  CAS  Google Scholar 

  • Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy 18:703–714. doi:10.1053/jars.2002.35142

    Article  PubMed  Google Scholar 

  • Fanelli GC, Stannard JP, Stuart MJ et al (2010) Management of complex knee ligament injuries. J Bone Joint Surg Am 92:2235–2246

    PubMed  Google Scholar 

  • Gabriel MT, Wong EK, Woo SL-Y et al (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22:85–89. doi:10.1016/S0736-0266(03)00133-5

    Article  PubMed  Google Scholar 

  • Geeslin AG, LaPrade RF (2010) Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am J Sports Med 38:2502–2508. doi:10.1177/0363546510376232

    Article  PubMed  Google Scholar 

  • Geeslin AG, LaPrade RF (2011) Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: a prospective case series and surgical technique. J Bone Joint Surg Am 93:1672–1683. doi:10.2106/JBJS.J.01639

    Article  PubMed  Google Scholar 

  • Green NE, Allen BL (1977) Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am 59:236–239

    PubMed  Google Scholar 

  • Griffith CJ, LaPrade RF, Johansen S et al (2009) Medial knee injury: Part 1, static function of the individual components of the main medial knee structures. Am J Sports Med 37:1762–1770. doi:10.1177/0363546509333852

    Article  PubMed  Google Scholar 

  • Grood ES, Stowers SF, Noyes FR (1988) Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am 70:88–97

    PubMed  CAS  Google Scholar 

  • Harner C, Waltrip R, Bennett C et al (2004) Surgical management of knee dislocations. J Bone Joint Surg Am 86:262–273

    PubMed  Google Scholar 

  • Hughston JC, Norwood LA (1980) The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee. Clin Orthop Relat Res 142:82–87

    Google Scholar 

  • Indelicato PA, Bittar ES (1985) A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases. Clin Orthop Relat Res 198:77–80

    PubMed  Google Scholar 

  • Jackman T, LaPrade RF, Pontinen T, Lender PA (2008) Intraobserver and interobserver reliability of the kneeling technique of stress radiography for the evaluation of posterior knee laxity. Am J Sports Med 36:1571–1576. doi:10.1177/0363546508315897

    Article  PubMed  Google Scholar 

  • Jansson KS, Costello KE, O’Brien L et al (2012) A historical perspective of PCL bracing. Knee Surg Sports Traumatol Arthrosc 21:1064–1070. doi:10.1007/s00167-012-2048-9

    Article  PubMed  Google Scholar 

  • Johnson ME, Foster L, DeLee JC (2008) Neurologic and vascular injuries associated with knee ligament injuries. Am J Sports Med 36:2448–2462. doi:10.1177/0363546508325669

    Article  PubMed  Google Scholar 

  • Kopf S, Kauert R, Halfpaap J et al (2012) A new quantitative method for pivot shift grading. Knee Surg Sports Traumatol Arthrosc 20:718–723. doi:10.1007/s00167-012-1903-z

    Article  PubMed  CAS  Google Scholar 

  • LaPrade RF (1997) Arthroscopic evaluation of the lateral compartment of knees with grade 3 posterolateral knee complex injuries. Am J Sports Med 25:596–602

    Article  PubMed  CAS  Google Scholar 

  • LaPrade RF, Wijdicks CA (2012a) The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther 42:221–233. doi:10.2519/jospt.2012.3624

    Article  PubMed  Google Scholar 

  • LaPrade RF, Wijdicks CA (2012b) Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res 470:806–814. doi:10.1007/s11999-011-2061-1

    Article  PubMed  PubMed Central  Google Scholar 

  • LaPrade RF, Hamilton CD, Engebretsen L (1997) Treatment of acute and chronic combined anterior cruciate ligament and posterolateral knee ligament injuries. Sports Med Arthrosc Rev 5:91–99

    Article  Google Scholar 

  • LaPrade RF, Resig S, Wentorf F, Lewis JL (1999) The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force. A biomechanical analysis. Am J Sports Med 27:469–475

    PubMed  CAS  Google Scholar 

  • LaPrade RF, Gilbert TJ, Bollom TS et al (2000) The magnetic resonance imaging appearance of individual structures of the posterolateral knee. A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med 28:191–199

    PubMed  CAS  Google Scholar 

  • LaPrade RF, Muench C, Wentorf F, Lewis JL (2002) The effect of injury to the posterolateral structures of the knee on force in a posterior cruciate ligament graft: a biomechanical study. Am J Sports Med 30:233–238

    PubMed  Google Scholar 

  • LaPrade RF, Ly TV, Wentorf FA, Engebretsen L (2003) The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med 31:854–860

    PubMed  Google Scholar 

  • LaPrade RF, Johansen S, Wentorf FA et al (2004) An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med 32:1405–1414. doi:10.1177/0363546503262687

    Article  PubMed  Google Scholar 

  • LaPrade RF, Engebretsen L, Johansen S et al (2008a) The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability: a biomechanical study. Am J Sports Med 36:956–960. doi:10.1177/0363546507312380

    Article  PubMed  Google Scholar 

  • LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB (2008b) The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg Am 90:2069–2076. doi:10.2106/JBJS.G.00979

    Article  PubMed  Google Scholar 

  • LaPrade RF, Ly TV, Griffith C (2008c) The external rotation recurvatum test revisited: reevaluation of the sagittal plane tibiofemoral relationship. Am J Sports Med 36:709–712. doi:10.1177/0363546507311096

    Article  PubMed  Google Scholar 

  • LaPrade RF, Bernhardson AS, Griffith CJ et al (2010) Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med 38:330–338. doi:10.1177/0363546509349347

    Article  PubMed  Google Scholar 

  • LaPrade RF, Johansen S, Engebretsen L (2011) Outcomes of an anatomic posterolateral knee reconstruction: surgical technique. J Bone Joint Surg Am 93(Suppl 1):10–20. doi:10.2106/JBJS.J.01243

    PubMed  Google Scholar 

  • Levy BA, Dajani KA, Whelan DB et al (2009) Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy 25:430–438. doi:10.1016/j.arthro.2009.01.008

    Article  PubMed  Google Scholar 

  • Levy BA, Dajani KA, Morgan JA et al (2010a) Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 38:804–809. doi:10.1177/0363546509352459

    Article  PubMed  Google Scholar 

  • Levy BA, Giuseffi SA, Bishop AT et al (2010b) Surgical treatment of peroneal nerve palsy after knee dislocation. Knee Surg Sports Traumatol Arthrosc 18:1583–1586. doi:10.1007/s00167-010-1204-3

    Article  PubMed  Google Scholar 

  • Medvecky MJ, Zazulak BT, Hewett TE (2007) A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-ligament injured athlete. Sports Med 37:169–187

    Article  PubMed  Google Scholar 

  • Miller MD, Osborne JR, Gordon WT et al (1998) The natural history of bone bruises. A prospective study of magnetic resonance imaging-detected trabecular microfractures in patients with isolated medial collateral ligament injuries. Am J Sports Med 26:15–19

    PubMed  CAS  Google Scholar 

  • Mills WJ, Barei DP, McNair P (2004) The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 56:1261–1265. doi:10.1097/01.TA.0000068995.63201.0B

    Article  PubMed  Google Scholar 

  • Mook WR, Miller MD, Diduch DR et al (2009) Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg Am 91:2946–2957. doi:10.2106/JBJS.H.01328

    Article  PubMed  Google Scholar 

  • Nielsen S, Helmig P (1986) The static stabilizing function of the popliteal tendon in the knee. An experimental study. Arch Orthop Trauma Surg 104:357–362. doi:10.1007/BF00454430

    Article  PubMed  CAS  Google Scholar 

  • Noyes FR, Barber-Westin SD (1996) Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med 24:415–426

    Article  PubMed  CAS  Google Scholar 

  • Noyes FR, Barber-Westin SD, Hewett TE (2000) High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 28:282–296

    PubMed  CAS  Google Scholar 

  • Odensten M, Hamberg P, Nordin M et al (1985) Surgical or conservative treatment of the acutely torn anterior cruciate ligament. A randomized study with short-term follow-up observations. Clin Orthop Relat Res 198:87–93

    PubMed  Google Scholar 

  • Peskun CJ, Whelan DB (2011) Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev 19:167–173. doi:10.1097/JSA.0b013e3182107d5f

    Article  Google Scholar 

  • Petersen W, Zantop T (2006) Partial rupture of the anterior cruciate ligament. Arthroscopy 22:1143–1145. doi:10.1016/j.arthro.2006.08.017

    Article  PubMed  Google Scholar 

  • Phisitkul P, Wolf BR, Amendola A (2006) Role of high tibial and distal femoral osteotomies in the treatment of lateral-posterolateral and medial instabilities of the knee. Sports Med Arthrosc Rev 14:96–104. doi:10.1097/01.jsa.0000212306.47323.83

    Article  Google Scholar 

  • Puddu G, Franco V (2009) Distal femoral osteotomy for genu valgus correction. Techn Knee Surg 8:257–264

    Article  Google Scholar 

  • Salzler MJ, Martin SD (2012) All-arthroscopic anatomic repair of an avulsed popliteus tendon in a multiple ligament-injured knee. Orthopedics 35:e973–e976. doi:10.3928/01477447-20120525-46

    Article  PubMed  Google Scholar 

  • Schenck RC (1994) The dislocated knee. Instr Course Lect 43:127–136

    PubMed  Google Scholar 

  • Schulz MS, Steenlage ES, Russe K, Strobel MJ (2007) Distribution of posterior tibial displacement in knees with posterior cruciate ligament tears. J Bone Joint Surg Am 89:332–338. doi:10.2106/JBJS.C.00834

    Article  PubMed  Google Scholar 

  • Sekiya JK, Whiddon DR, Zehms CT, Miller MD (2008) A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am 90:1621–1627. doi:10.2106/JBJS.G.01365

    Article  PubMed  Google Scholar 

  • Shelbourne KD, Nitz PA (1991) The O’Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med 19:474–477

    Article  PubMed  CAS  Google Scholar 

  • Spiridonov S, Slinkard N, LaPrade R (2011) Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral. J Bone Joint Surg Am 93:1773–1780

    Article  PubMed  Google Scholar 

  • Stannard JP, Brown SL, Farris RC et al (2005) The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med 33:881–888. doi:10.1177/0363546504271208

    Article  PubMed  Google Scholar 

  • Strauss EJ, Ishak C, Inzerillo C et al (2007) Effect of tibial positioning on the diagnosis of posterolateral rotatory instability in the posterior cruciate ligament-deficient knee. Br J Sports Med 41:481–485. doi:10.1136/bjsm.2006.030767 (discussion 485)

    Article  PubMed  PubMed Central  Google Scholar 

  • Terry GC, LaPrade RF (1996) The posterolateral aspect of the knee. Anatomy and surgical approach. Am J Sports Med 24:732–739

    Article  PubMed  CAS  Google Scholar 

  • The International Knee Documentations Committee (2000) 2000 IKDC knee forms. In: The American Academy for Sports Medicine. http://www.sportsmed.org/uploadedFiles/Content/Medical_Professionals/Research/Grants/IKDC_Forms/IKDC 2000 - Revised Subjective Scoring.pdf. Accessed 22 Jan 2013

  • Treiman GS, Yellin AE, Weaver FA et al (1992) Examination of the patient with a knee dislocation. The case for selective arteriography. Arch Surg 127:1056–1062, discussion 1062–3

    Article  PubMed  CAS  Google Scholar 

  • Wascher DC, Dvirnak PC, DeCoster TA (1997) Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma 11:525–529

    Article  PubMed  CAS  Google Scholar 

  • Wentorf FA, LaPrade RF, Lewis JL, Resig S (2002) The influence of the integrity of posterolateral structures on tibiofemoral orientation when an anterior cruciate ligament graft is tensioned. Am J Sports Med 30:796–799

    PubMed  Google Scholar 

  • Wiertsema SH, Van Hooff HJA, Migchelsen LAA, Steultjens MPM (2008) Reliability of the KT1000 arthrometer and the Lachman test in patients with an ACL rupture. Knee 15:107–110. doi:10.1016/j.knee.2008.01.003

    Article  PubMed  CAS  Google Scholar 

  • Wijdicks CA, Griffith CJ, Johansen S et al (2010) Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 92:1266–1280. doi:10.2106/JBJS.I.01229

    Article  PubMed  Google Scholar 

  • Wilkins SA (2011) Rehabilitation of the multiple ligament injured knee. Techn Knee Surg 10:2–10. doi:10.1097/BTK.0b013e31820d4a03

    Article  Google Scholar 

  • Wroble RR, Grood ES, Cummings JS et al (1993) The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee. Am J Sports Med 21:257–262 (discussion 263)

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, 81657, Vail, CO, USA

    Joel Huleatt & Robert LaPrade

  2. School of Medicine, Western Michigan University, 1903 Western Michigan Avenue, 49008, Kalamazoo, MI, USA

    Andrew Geeslin

Authors
  1. Joel Huleatt
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  2. Andrew Geeslin
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  3. Robert LaPrade
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Correspondence to Joel Huleatt .

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Editors and Affiliations

  1. Dept. Orthopedics & Traumatology, Hacettepe University Fac. Medicine, Ankara, Turkey

    Mahmut Nedim Doral

  2. Gothenburg, Sweden

    Jon Karlsson

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Huleatt, J., Geeslin, A., LaPrade, R. (2014). Special Considerations for Multiple-Ligament Knee Injuries. In: Doral, M., Karlsson, J. (eds) Sports Injuries. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-36801-1_112-2

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  • DOI: https://doi.org/10.1007/978-3-642-36801-1_112-2

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