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Surgical Treatment of Combined ACL Medial- and Lateral-Sided Injuries: Acute and Chronic

  • Eric D. Wicks
  • Steven B. CohenEmail author
Chapter

Abstract

History and clinical examination are essential in the assessment of a patient with a multiligamentous knee injury. These injuries are complex and can be associated with serious limb-threatening vascular and neurologic damage. The appropriate diagnostic imaging is guided by thorough history and physical examination to enable an accurate diagnosis. A systematic approach first concerned with identifying and addressing tibiofemoral alignment and vascular injury is critical. Further classification of combined injuries in the setting of anterior cruciate ligament (ACL) tears is necessary to guide treatment options and decrease the failure of ACL reconstructions. Anterior cruciate ligament tears with lower grade medial collateral ligament (MCL) injures can be treated with bracing and delayed ACL reconstruction. Higher grade and tibial-sided MCL injuries accompanied by posteromedial corner disruption require repair or reconstruction of the medial structures to protect against chronic valgus instability. Acute combined ACL and lateral-sided injuries are best treated by addressing the lateral collateral ligament (LCL) and posterolateral corner (PLC) injures surgically in conjunction with ACL reconstruction. Chronic ACL and PLC injuries along with acute midsubstance LCL and higher grade PLC disruption have led to poor outcomes without anatomic reconstruction. The orthopedic surgeon must consider acuity, comorbid conditions, pre-injury physical demands, current structural damage, vascular and soft tissue status to determine the appropriate timing, technique, and extent of surgical intervention.

Keywords

Multiligament knee injury Multiligamentous Knee dislocation Combined knee ligament injury ACL MCL PMC LCL PLC Posteromedial corner Posterolateral corner 

References

  1. 1.
    Moatshe G, Dornan GJ, Loken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and injuries associated with knee dislocation: a prospective review of 303 patients. Orthop J Sports Med. 2017;5(5):2325967117706521.CrossRefGoogle Scholar
  2. 2.
    Peskun CJ, Levy BA, Fanelli GC, Stannard JP, Stuart MJ, MacDonald PB, et al. Diagnosis and management of knee dislocations. Phys Sportsmed. 2010;38(4):101–11.CrossRefGoogle Scholar
  3. 3.
    Werner BC, Gwathmey FW Jr, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med. 2014;42(2):358–63.CrossRefGoogle Scholar
  4. 4.
    Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy. 2005;21(4):471–86.CrossRefGoogle Scholar
  5. 5.
    Mack AW, Freedman BA, Shawen SB, Gajewski DA, Kalasinsky VF, Lewin-Smith MR. Wound complications following the use of FiberWire in lower-extremity traumatic amputations. A case series. J Bone Joint Surg Am. 2009;91(3):680–5.CrossRefGoogle Scholar
  6. 6.
    Twaddle BC, Bidwell TA, Chapman JR. Knee dislocations: where are the lesions? A prospective evaluation of surgical findings in 63 cases. J Orthop Trauma. 2003;17(3):198–202.CrossRefGoogle Scholar
  7. 7.
    Tardy N, Boisrenoult P, Teissier P, Steltzlen C, Beaufils P, Pujol N. Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):524–31.CrossRefGoogle Scholar
  8. 8.
    Schenck R. Classification of knee dislocations. Operative Tech Sports Med. 2003;11(3):193–8.CrossRefGoogle Scholar
  9. 9.
    Schenck RC, Burke R, Walker D. The dislocated knee. South Med J. 1992;85(Supplement):3S–62.CrossRefGoogle Scholar
  10. 10.
    Peskun CJ, Chahal J, Steinfeld ZY, Whelan DB. Risk factors for peroneal nerve injury and recovery in knee dislocation. Clin Orthop Relat Res. 2012;470(3):774–8.CrossRefGoogle Scholar
  11. 11.
    Bonnevialle P, Dubrana F, Galau B, Lustig S, Barbier O, Neyret P, et al. Common peroneal nerve palsy complicating knee dislocation and bicruciate ligaments tears. Orthop Traumatol Surg Res. 2010;96(1):64–9.CrossRefGoogle Scholar
  12. 12.
    Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87(5):664–7.CrossRefGoogle Scholar
  13. 13.
    Bui KL, Ilaslan H, Parker RD, Sundaram M. Knee dislocations: a magnetic resonance imaging study correlated with clinical and operative findings. Skeletal Radiol. 2008;37(7):653–61.CrossRefGoogle Scholar
  14. 14.
    Potter HG, Weinstein M, Allen AA, Wickiewicz TL, Helfet DL. Magnetic resonance imaging of the multiple-ligament injured knee. J Orthop Trauma. 2002;16(5):330–9.CrossRefGoogle Scholar
  15. 15.
    Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma. 2013;27(4):226–31.CrossRefGoogle Scholar
  16. 16.
    Levy NM, Krych AJ, Hevesi M, Reardon PJ, Pareek A, Stuart MJ, et al. Does age predict outcome after multiligament knee reconstruction for the dislocated knee? 2- to 22-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3003–7.CrossRefGoogle Scholar
  17. 17.
    Medina O, Arom GA, Yeranosian MG, Petrigliano FA, McAllister DR. Vascular and nerve injury after knee dislocation: a systematic review. Clin Orthop Relat Res. 2014;472(9):2621–9.CrossRefGoogle Scholar
  18. 18.
    Sanders TL, Johnson NR, Pareek A, Krych AJ, Marx RG, Stuart MJ, et al. Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1258–65.PubMedGoogle Scholar
  19. 19.
    Ridley TJ, McCarthy MA, Bollier MJ, Wolf BR, Amendola A. The incidence and clinical outcomes of peroneal nerve injuries associated with posterolateral corner injuries of the knee. Knee Surg Sports Traumatol Arthrosc. 2018;26(3):806–11.CrossRefGoogle Scholar
  20. 20.
    Jari S, Shelbourne KD. Nonoperative or delayed surgical treatment of combined cruciate ligaments and medial side knee injuries. Sports Med Arthrosc Rev. 2001;9(3):185–92.CrossRefGoogle Scholar
  21. 21.
    Tibor LM, Marchant MH Jr, Taylor DC, Hardaker WT Jr, Garrett WE Jr, Sekiya JK. Management of medial-sided knee injuries, part 2: posteromedial corner. Am J Sports Med. 2011;39(6):1332–40.CrossRefGoogle Scholar
  22. 22.
    Stannard JP. Medial and posteromedial instability of the knee: evaluation, treatment, and results. Sports Med Arthrosc Rev. 2010;18(4):263–8.CrossRefGoogle Scholar
  23. 23.
    Stannard JP, Black BS, Azbell C, Volgas DA. Posteromedial corner injury in knee dislocations. J Knee Surg. 2012;25(5):429–34.CrossRefGoogle Scholar
  24. 24.
    Torg JS, Conrad W, Kalen V. Clinical I diagnosis of anterior cruciate ligament instability in the athlete; 1976. p. 84–93.Google Scholar
  25. 25.
    Slocum DB, Larson RL, Rotatory instability of the knee. Its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg Am. 1968;50(2):211–25.CrossRefGoogle Scholar
  26. 26.
    Duffy PS, Miyamoto RG. Management of medial collateral ligament injuries in the knee: an update and review. Phys Sportsmed. 2010;38(2):48–54.CrossRefGoogle Scholar
  27. 27.
    Craft JA, Kurzweil PR. Physical examination and imaging of medial collateral ligament and posteromedial corner of the knee. Sports Med Arthrosc Rev. 2015;23(2):e1–6.CrossRefGoogle Scholar
  28. 28.
    Allen BJ, Krych AJ, Engasser W, Levy BA, Stuart MJ, Collins MS, et al. Medial patellofemoral ligament tears in the setting of multiligament knee injuries rarely cause patellar instability. Am J Sports Med. 2015;43(6):1386–90.CrossRefGoogle Scholar
  29. 29.
    Hunter SC, Marascalco R, Hughston JC. Disruption of the vastus medialis obliquus with medial knee ligament injuries; 1983. p. 427–31.Google Scholar
  30. 30.
    Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30(5):718–27.CrossRefGoogle Scholar
  31. 31.
    Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma. 1997;11(7):525–9.CrossRefGoogle Scholar
  32. 32.
    Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am. 2008;90(6):1258–64.CrossRefGoogle Scholar
  33. 33.
    Laprade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. 2010;38(2):330–8.CrossRefGoogle Scholar
  34. 34.
    Chahal J, Al-Taki M, Pearce D, Leibenberg A, Whelan DB. Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1098–104.CrossRefGoogle Scholar
  35. 35.
    LaPrade RF, Gilbert TJ, Bollom TS, Wentorf F, Chaljub G. 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. 2000;28(2):191–9.CrossRefGoogle Scholar
  36. 36.
    Veillette CJ, Mehdian H, Schemitsch EH, McKee MD. Survivorship analysis and radiographic outcome following tantalum rod insertion for osteonecrosis of the femoral head. J Bone Joint Surg Am. 2006;88 Suppl 3(1):48–55.CrossRefGoogle Scholar
  37. 37.
    LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89(9):2000–10.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Ross SM, Joshi R, Frank CB. Establishment and comparison of fibroblast cell lines from the medial collateral and anterior cruciate ligaments of the rabbit. Vitro Cell Dev Biol. 1990;26(6):579–84.CrossRefGoogle Scholar
  39. 39.
    Yoshida M, Fujii K. Differences in cellular properties and responses to growth factors between human ACL and MCL cells. J Orthop Sci. 1999;4(4):293–8.CrossRefGoogle Scholar
  40. 40.
    Zhang J, Pan T, Im HJ, Fu FH, Wang JH. Differential properties of human ACL and MCL stem cells may be responsible for their differential healing capacity. BMC Med. 2011;9(1):68.CrossRefGoogle Scholar
  41. 41.
    Zhu J, Dong J, Marshall B, Linde MA, Smolinski P, Fu FH. Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):550–7.CrossRefGoogle Scholar
  42. 42.
    Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc Rev. 2006;14(2):58–66.CrossRefGoogle Scholar
  43. 43.
    Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc Rev. 2006;14(2):78–83.CrossRefGoogle Scholar
  44. 44.
    Holden DL, Eggert AW, Butler JE. The nonoperative treatment of grade I and 11 medial collateral ligament injuries to the knee; 1983. p. 340–4.Google Scholar
  45. 45.
    Zaffagnini S, Bonanzinga T, Marcheggiani Muccioli GM, Giordano G, Bruni D, Bignozzi S, et al. Does chronic medial collateral ligament laxity influence the outcome of anterior cruciate ligament reconstruction?: a prospective evaluation with a minimum three-year follow-up. J Bone Joint Surg Br. 2011;93(8):1060–4.CrossRefGoogle Scholar
  46. 46.
    Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2006;34(7):1134–40.CrossRefGoogle Scholar
  47. 47.
    Westermann RW, Spindler KP, Hettrich CM, Wolf BR. Outcomes following ACL and grade III MCL injuries. Orthop J Sports Med. 2017;5(3_suppl3):2325967117S0012.CrossRefGoogle Scholar
  48. 48.
    Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech. 2014;3(4):e505–8.CrossRefGoogle Scholar
  49. 49.
    Gilmer BB, Crall T, DeLong J, Kubo T, Mackay G, Jani SS. Biomechanical analysis of internal bracing for treatment of medial knee injuries. Orthopedics. 2016;39(3):e532–7.CrossRefGoogle Scholar
  50. 50.
    Koga H, Muneta T, Yagishita K, Ju YJ, Sekiya I. Surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):88–94.CrossRefGoogle Scholar
  51. 51.
    Hanley JM, Anthony CA, DeMik D, Glass N, Amendola A, Wolf BR, et al. Patient-reported outcomes after multiligament knee injury: MCL repair versus reconstruction. Orthop J Sports Med. 2017;5(3):2325967117694818.CrossRefGoogle Scholar
  52. 52.
    Robins AJ, Newman AP, Burks RT. Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries. The effect of medial collateral ligament rupture location. Am J Sports Med. 1993;21(1):20–5.CrossRefGoogle Scholar
  53. 53.
    Halinen J, Lindahl J, Hirvensalo E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am. 2009;91(6):1305–12.CrossRefGoogle Scholar
  54. 54.
    Zhang H, Sun Y, Han X, Wang Y, Wang L, Alquhali A, et al. Simultaneous reconstruction of the anterior cruciate ligament and medial collateral ligament in patients with chronic ACL-MCL lesions: a minimum 2-year follow-up study. Am J Sports Med. 2014;42(7):1675–81.CrossRefGoogle Scholar
  55. 55.
    Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012;470(3):806–14.CrossRefGoogle Scholar
  56. 56.
    Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;147:45–50.Google Scholar
  57. 57.
    Noyes FR, Huser LE, Levy MS. Rotational knee instability in ACL-deficient knees: role of the anterolateral ligament and iliotibial band as defined by tibiofemoral compartment translations and rotations. J Bone Joint Surg Am. 2017;99(4):305–14.CrossRefGoogle Scholar
  58. 58.
    LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee; 1997. p. 433–8.Google Scholar
  59. 59.
    LaPrade RF, Ly TV, Griffith C. The external rotation recurvatum test revisited: reevaluation of the sagittal plane tibiofemoral relationship. Am J Sports Med. 2008;36(4):709–12.CrossRefGoogle Scholar
  60. 60.
    Noyes FR, Stowers SF, Grood ES, Cummings J, VanGinkel LA. Posterior subluxations of the medial and lateral tibiofemoral compartments. An in vitro ligament sectioning study in cadaveric knees. Am J Sports Med. 1993;21(3):407–14.CrossRefGoogle Scholar
  61. 61.
    Pacheco RJ, Ayre CA, Bollen SR. Posterolateral corner injuries of the knee: a serious injury commonly missed. J Bone Joint Surg Br. 2011;93(2):194–7.CrossRefGoogle Scholar
  62. 62.
    Patel RM, Brophy RH. Anterolateral ligament of the knee: anatomy, function, imaging, and treatment. Am J Sports Med. 2018;46(1):217–23.CrossRefGoogle Scholar
  63. 63.
    Kraeutler MJ, Welton KL, Chahla J, LaPrade RF, McCarty EC. Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction. Am J Sports Med. 2018;46(5):1235–42.CrossRefGoogle Scholar
  64. 64.
    Kennedy MI, Claes S, Fuso FA, Williams BT, Goldsmith MT, Turnbull TL, et al. The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43(7):1606–15.CrossRefGoogle Scholar
  65. 65.
    Marwan Y, Kulkarni S, Addar A, Algarni N, Tamimi I, Boily M, et al. Anterolateral ligament injury in knee dislocations. Arthroscopy. 2018;34(6):1891–7.CrossRefGoogle Scholar
  66. 66.
    LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. 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. 2003;31(6):854–60.CrossRefGoogle Scholar
  67. 67.
    Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev. 2011;19(2):167–73.CrossRefGoogle Scholar
  68. 68.
    Kannus P. Nonoperative treatment of grade II and III sprains of the lateral ligament compartment of the knee; 1989. p. 83–8.Google Scholar
  69. 69.
    Krukhaug Y, Molster A, Rodt A, Strand T. Lateral ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc. 1998;6(1):21–5.CrossRefGoogle Scholar
  70. 70.
    Shelbourne KD, Haro MS, Gray T. Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side. Am J Sports Med. 2007;35(7):1105–16.CrossRefGoogle Scholar
  71. 71.
    Stannard JP, Brown SL, Farris RC, McGwin G Jr, Volgas DA. The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med. 2005;33(6):881–8.CrossRefGoogle Scholar
  72. 72.
    Geeslin AG, Moulton SG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, part 1: surgical treatment of acute injuries. Am J Sports Med. 2016;44(5):1336–42.CrossRefGoogle Scholar
  73. 73.
    Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med. 2010;38(4):804–9.CrossRefGoogle Scholar
  74. 74.
    Terry GC, LaPrade RF. The posterolateral aspect of the knee. Anatomy and surgical approach. Am J Sports Med. 1996;24(6):732–9.CrossRefGoogle Scholar
  75. 75.
    Schechinger SJ, Levy BA, Dajani KA, Shah JP, Herrera DA, Marx RG. Achilles tendon allograft reconstruction of the fibular collateral ligament and posterolateral corner. Arthroscopy. 2009;25(3):232–42.CrossRefGoogle Scholar
  76. 76.
    LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med. 2004;32(6):1405–14.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Orthopaedics, Rothman InstituteThomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Orthopedic Surgery, Rothman InstituteThomas Jefferson UniversityPhiladelphiaUSA

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