Management of Chronic Fixed Posterior Tibial Subluxation in the Multiple Ligament Injured Knee

  • Jonathan-James T. EnoEmail author
  • Thomas L. Wickiewicz


Management of chronic tibial subluxation following a multiligamentous knee injury is an uncommon but challenging pathology that requires meticulous preoperative evaluation and planning to maximize patient satisfaction and postoperative outcomes. Knowledge of both ligamentous and osseous anatomy and their role in knee biomechanics is important to an anatomic reconstruction. This understanding is particularly crucial in the setting of chronic tibial subluxation in the multiligamentous knee injury, as an absence of the normal anatomic landmarks and ligamentous restraints may exist. Optimal reconstruction and outcomes in this setting require the surgeon to establish a careful balance between knee stability and range of motion. In order to achieve this balance, three sequential operative steps should be followed: First, excise all scar tissue to maximize uninhibited knee range of motion; second, reconstruct the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) to establish a central knee axis of motion; and finally, following possible reconstruction of the medial and lateral complexes, carefully maintain postoperative stability and range of motion with a functional knee brace. Close clinical and radiographic follow-up will aid to achieve an optimal postoperative result in this complex clinical situation. If the chronicity of the injury has progressed to the point of maladaptive osseous changes, success with operative intervention to restore stability and functionality is unlikely, and therefore nonoperative management or salvage procedures should be considered.


Tibial subluxation Chronic Multiligamentous knee injury 


  1. 1.
    Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Jt Surg Am. 1980;62(2):259–70.CrossRefGoogle Scholar
  2. 2.
    Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy. 2005;21(4):471–86.CrossRefGoogle Scholar
  3. 3.
    Anderson AF, Snyder RB, Lipscomb Jr AB. Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med. 2001;29(3):272–9.CrossRefGoogle Scholar
  4. 4.
    Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997;25(6):786–95.CrossRefGoogle Scholar
  5. 5.
    Almekinders LC, de Castro D. Fixed tibial subluxation after successful anterior cruciate ligament reconstruction. Am J Sports Med. 2001;29(3):280–3.CrossRefGoogle Scholar
  6. 6.
    Almekinders LC, Pandarinath R, Rahusen FT. Knee stability following anterior cruciate ligament rupture and surgery. The contribution of irreducible tibial subluxation. J Bone Jt Surg Am. 2004;86-A(5):983–7.CrossRefGoogle Scholar
  7. 7.
    Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Jt Surg Am. 1987;69(2):233–42.CrossRefGoogle Scholar
  8. 8.
    Grood ES, Stowers SF, Noyes FR. Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Jt Surg Am. 1988;70(1):88–97.CrossRefGoogle Scholar
  9. 9.
    Fox RJ, Harner CD, Sakane M, Carlin GJ, Woo SL. Determination of the in situ forces in the human posterior cruciate ligament using robotic technology. A cadaveric study. Am J Sports Med. 1998;26(3):395–401.CrossRefGoogle Scholar
  10. 10.
    Harner CD, Hoher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med. 1998;26(3):471–82.CrossRefGoogle Scholar
  11. 11.
    Ahmed AM, Burke DL. In-vitro measurement of static pressure distribution in synovial joints—part I: tibial surface of the knee. J Biomech Eng. 1983;105(3):216–25.CrossRefGoogle Scholar
  12. 12.
    Barton TM, Torg JS, Das M. Posterior cruciate ligament insufficiency. A review of the literature. Sports Med. 1984;1(6):419–30.CrossRefGoogle Scholar
  13. 13.
    Logan M, Williams A, Lavelle J, Gedroyc W, Freeman M. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med. 2004;32(8):1915–22.CrossRefGoogle Scholar
  14. 14.
    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
  15. 15.
    Ogata K, McCarthy JA. Measurements of length and tension patterns during reconstruction of the posterior cruciate ligament. Am J Sports Med. 1992;20(3):351–5.CrossRefGoogle Scholar
  16. 16.
    Renstrom P, Arms SW, Stanwyck TS, Johnson RJ, Pope MH. Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med. 1986;14(1):83–7.CrossRefGoogle Scholar
  17. 17.
    Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Fixed posterior subluxation in posterior cruciate ligament-deficient knees: diagnosis and treatment of a new clinical sign. Am J Sports Med. 2002;30(1):32–8.CrossRefGoogle Scholar
  18. 18.
    Race A, Amis AA. Loading of the two bundles of the posterior cruciate ligament: an analysis of bundle function in a-P drawer. J Biomech. 1996;29(7):873–9.CrossRefGoogle Scholar
  19. 19.
    Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Jt Surg Am. 2004;86-A(2):262–73.CrossRefGoogle Scholar
  20. 20.
    Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A. Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):739–49.CrossRefGoogle Scholar
  21. 21.
    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
  22. 22.
    Strauss EJ, Ishak C, Inzerillo C, et al. Effect of tibial positioning on the diagnosis of posterolateral rotatory instability in the posterior cruciate ligament-deficient knee. Br J Sports Med. 2007;41(8):481–5 (discussion 485).Google Scholar
  23. 23.
    Hirschmann MT, Zimmermann N, Rychen T, et al. Clinical and radiological outcomes after management of traumatic knee dislocation by open single stage complete reconstruction/repair. BMC Musculoskelet Disord. 2010;11:102.CrossRefGoogle Scholar
  24. 24.
    Hirschmann MT, Iranpour F, Muller W, Friederich NF. Surgical treatment of complex bicruciate knee ligament injuries in elite athletes: what long-term outcome can we expect? Am J Sports Med. 2010;38(6):1103–9.CrossRefGoogle Scholar
  25. 25.
    Martinek V, Steinbacher G, Friederich NF, Muller WE. Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved? Am J Knee Surg. 2000;13(2):74–82. Spring.Google Scholar
  26. 26.
    Almekinders LC, Chiavetta JB. Tibial subluxation in anterior cruciate ligament-deficient knees: implications for tibial tunnel placement. Arthroscopy. 2001;17(9):960–2.CrossRefGoogle Scholar
  27. 27.
    Mook WR, Miller MD, Diduch DR, Hertel J, Boachie-Adjei Y, Hart JM. Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Jt Surg Am. 2009;91(12):2946–57.CrossRefGoogle Scholar
  28. 28.
    Roman PD, Hopson CN, Zenni EJ Jr. Traumatic dislocation of the knee: a report of 30 cases and literature review. Orthop Rev. 1987;16(12):917–24.Google Scholar
  29. 29.
    Simonian PT, Wickiewicz TL, Hotchkiss RN, Warren RF. Chronic knee dislocation: reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med. 1998;26(4):591–6.CrossRefGoogle Scholar
  30. 30.
    Strobel MJ, Schulz MS, Petersen WJ, Eichhorn HJ. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy. 2006;22(2):182–92.CrossRefGoogle Scholar
  31. 31.
    Markolf KL, O’Neill G, Jackson SR, McAllister DR. Reconstruction of knees with combined cruciate deficiencies: a biomechanical study. J Bone Jt Surg Am. 2003;85-A(9):1768–74.CrossRefGoogle Scholar
  32. 32.
    Clancy WG Jr, Sutherland TB. Combined posterior cruciate ligament injuries. Clin Sports Med. 1994;13(3):629–47.Google Scholar
  33. 33.
    Sisto DJ, Warren RF. Complete knee dislocation. A follow-up study of operative treatment. Clin Orthop Relat Res. 1985;198:94–101.Google Scholar
  34. 34.
    Henshaw RM, Shapiro MS, Oppenheim WL. Delayed reduction of traumatic knee dislocation. A case report and literature review. Clin Orthop Relat Res. 1996;330:152–6.CrossRefGoogle Scholar
  35. 35.
    Richard DR. Unreduced dislocations. Trop Doct. 1973;3(3):119–22.CrossRefGoogle Scholar
  36. 36.
    Dee R. The case for arthrodesis of the knee. Orthop Clin North Am. 1979;10(1):249–61.PubMedGoogle Scholar
  37. 37.
    Frymoyer JW, Hoaglund FT. The role of arthrodesis in reconstruction of the knee. Clin Orthop Relat Res. 1974;101:82–92.Google Scholar
  38. 38.
    Green SA, Kolsnick R. Arthrodesis of the knee. Orthopedics. 1985;8(12):1514–8.PubMedGoogle Scholar
  39. 39.
    Siller TN, Hadjipavlou A. Knee arthrodesis: long-term results. Can J Surg. 1976;19(3):217–9.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Orthopaedic Surgery, Sports Medicine and Shoulder Service, Hospital for Special SurgeryNew YorkUSA

Personalised recommendations