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Surgical Treatment of Combined PCL-ACL Medial and Lateral Side Injuries (Global Laxity): Acute and Chronic

  • Gregory C. FanelliEmail author
Chapter

Abstract

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 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 upon 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 2–3 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 PCL reconstruction provides superior results to single-bundle PCL reconstruction in the multiple ligament injured knee. The purpose of this chapter is to discuss my surgical technique for combined posterior and anterior cruciate ligament, medial, and lateral side reconstructions in acute and chronic multiple ligament injured knees with global laxity. This chapter will focus on recognizing and defining the instability pattern, the use of external fixation, surgical timing, graft selection and preparation, the author’s preferred surgical technique, mechanical graft tensioning, perioperative antibiotics, specialized operating teams, postoperative rehabilitation, and our results of treatment in these complex surgical cases.

Keywords

Multiple ligament knee injury Mechanical graft tensioner Allograft Transtibial PCL reconstruction Inside-to-outside PCL femoral tunnels 

References

  1. 1.
    Fanelli GC. Surgical treatment of combined PCL ACL medial and lateral side injuries (global laxity): acute and chronic. In: Fanelli GC, editor. The multiple ligament injured knee. A practical guide to management. 2nd ed. New York: Springer; 2013. p. 281–301.CrossRefGoogle Scholar
  2. 2.
    Fanelli GC, Beck JD, Edson CJ. Double bundle posterior cruciate ligament reconstruction. Surgical technique and results. Sports Med Arthrosc Rev. 2010;18(4):242–8.CrossRefGoogle Scholar
  3. 3.
    Fanelli GC, Beck JD, Edson CJ. Combined PCL ACL lateral and medial side injuries: treatment and results. Sports Med Arthrosc Rev. 2011;19(2):120–30.CrossRefGoogle Scholar
  4. 4.
    Fanelli GC, Boyd J. How I manage PCL injuries. Oper Tech Sports Med. 2009;17(3):175–93.CrossRefGoogle Scholar
  5. 5.
    Fanelli GC, Beck JD, Edson CJ. How I manage the multiple ligament injured (dislocated) knee. Oper Techn Sports Med. 2010;18(4):198–210.CrossRefGoogle Scholar
  6. 6.
    Fanelli GC. Rationale and surgical technique for PCL and multiple knee ligament reconstruction. 3rd ed. Warsaw, Indiana: Biomet Sports Med; 2012.Google Scholar
  7. 7.
    Fanelli GC, Gianotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy. 1996;12(1):5–14.CrossRefGoogle Scholar
  8. 8.
    Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2–10 year follow-up. Arthroscopy. 2002;18(7):703–14.CrossRefGoogle Scholar
  9. 9.
    Fanelli GC, Feldmann DD. Management of combined anterior cruciate ligament/posterior cruciate ligament/posterolateral complex injuries of the knee. Oper Techn Sports Med. 1999;7(3):143–9.CrossRefGoogle Scholar
  10. 10.
    Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy. 2005;21(4):471–86.CrossRefGoogle Scholar
  11. 11.
    Fanelli GC, et al. Treatment of combined anterior cruciate-posterior cruciate ligament-medial-lateral side knee injuries. J Knee Surg. 2005;18(3):240–8.CrossRefGoogle Scholar
  12. 12.
    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
  13. 13.
    Fanelli GC, Harris JD. Late MCL (medial collateral ligament) reconstruction. Tech Knee Surg. 2007;6(2):99–105.CrossRefGoogle Scholar
  14. 14.
    Fanelli GC, Edson CJ, Reinheimer KN, Garofalo R. Posterior cruciate ligament and posterolateral corner reconstruction. Sports Med Arthrosc Rev. 2007;15(4):168–75.CrossRefGoogle Scholar
  15. 15.
    Fanelli GC, Feldmann DD. Arthroscopically assisted combined anterior cruciate ligament/posterior cruciate ligament reconstruction. In: Fanelli GC, editor. Posterior cruciate ligament injuries: a practical guide to management. New York: Springer; 2001. p. 215–36.CrossRefGoogle Scholar
  16. 16.
    Fanelli GC, Combined ACL. PCL medial lateral side injuries of the knee. In: Fanelli GC, editor. The multiple ligament injured knee. A practical guide to management. New York: Springer; 2004. p. 111–31.CrossRefGoogle Scholar
  17. 17.
    Fanelli GC, Edson CJ, Reinheimer KN. Evaluation and treatment of the multiple ligament injured knee. Am Acad Orthop Surg Inst Course Lect. 2009;58:389–95.Google Scholar
  18. 18.
    Levy B, Dajani KA, Whalen DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG. Decision making in the multiple ligament injured knee: an evidence based systematic review. Arthroscopy. 2009;25(4):430–8.CrossRefGoogle Scholar
  19. 19.
    Fanelli GC, Stannard JP, Stuart MJ, MacDonald PB, Marx RG, Whelan DB, Boyd JL, Levy BA. Management of complex knee ligament injuries. J Bone Joint Surg. 2010;92-A(12):2235–46.Google Scholar
  20. 20.
    Levy B, Fanelli GC, Whalen D, Stannard J, MacDonald P, Boyd J, Marx R, Stuart M. Modern perspectives for the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17(4):197–206.CrossRefGoogle Scholar
  21. 21.
    Fanelli GC. Mechanical graft tensioning in multiple ligament knee surgery. In: Fanelli GC, editor. The multiple ligament injured knee. A practical guide to management. 2nd ed. New York: Springer; 2013. p. 323–30.CrossRefGoogle Scholar
  22. 22.
    Fanelli GC. Mechanical graft tensioning in posterior cruciate ligament reconstruction. In: Fanelli GC, editor. Posterior cruciate ligament injuries. A practical guide to management. 2nd ed. New York: Springer; 2015. p. 263–70.Google Scholar
  23. 23.
    Fanelli GC. Posterior cruciate ligament rehabilitation: how slow should we go? Arthroscopy. 2008;24(2):234–5.CrossRefGoogle Scholar
  24. 24.
    Edson CJ, Fanelli GC, Beck JD. Rehabilitation after multiple ligament reconstruction of the knee. Sports Med Arthrosc Rev. 2011;19(2):162–6.CrossRefGoogle Scholar
  25. 25.
    Edson CJ, Fanelli GC, Beck JD. Postoperative rehabilitation of the posterior cruciate ligament. Sports Med Arthrosc Rev. 2010;18(4):275–9.CrossRefGoogle Scholar
  26. 26.
    Edson CJ, Fanelli GC. Postoperative rehabilitation of the multiple ligament injured knee. In: Fanelli GC, editor. The multiple ligament injured knee. A practical guide to management. 2nd ed. New York: Springer; 2013. p. 437–42.CrossRefGoogle Scholar
  27. 27.
    Edson CJ. Rehabilitation following PCL reconstruction: scientific and theoretical basis. In: Fanelli GC, editor. Posterior cruciate ligament injuries. A practical guide to management. 2nd ed. New York: Springer; 2015. p. 311–20.Google Scholar
  28. 28.
    Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft tissue. J Knee Surg. 2012;25(1):59–64.CrossRefGoogle Scholar
  29. 29.
    Fanelli GC, Edson CJ. Surgical treatment of combined PCL, ACL, medial, and lateral side injuries (global laxity): surgical technique and 2 to 18 year results. J Knee Surg. 2012;25(4):307–16.CrossRefGoogle Scholar
  30. 30.
    Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically treated knee dislocations: stability restored, but arthritis is common. Clin Orthop Relat Res. 2014;472(9):2712–7.CrossRefGoogle Scholar

Recommended Reading

  1. 1.
    Fanelli GC, editor. The multiple ligament injured knee. A practical guide to management. 2nd ed. New York: Springer; 2013.Google Scholar
  2. 2.
    Fanelli GC, editor. Posterior cruciate ligament injuries: a practical guide to management. 2nd ed. New York: Springer; 2015.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryGeisinger Medical Center/Health SystemDanvilleUSA

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