Complex Ligament Complex Ligament Injuries of The KneeInjuries of The Knee

H.Makhmalbaf MDH.Makhmalbaf MDConsultant Knee SurgeonConsultant Knee Surgeon

Assistant Professor OrthopaedicsAssistant Professor OrthopaedicsMashad University of Medical sciencesMashad University of Medical sciences

Surgical Management of Knee dislocations

• JBJS supp. 2005 Anikar Chhabra MD & Christopher Harner MD , University of Pittsburgh Medical Center Pittsburgh Pennsylvania

Evaluation & ManagementEvaluation & Management

• Characterize the pattern of injury• Determine the surgical approach• By ligament examination• After, survival of the limb is assured• And, the patient is stabilized

InvestigationsInvestigations: :

• Plain radiographs AP& LAT– Avulsion fx:– Fibular head, PCL, Segond’s sign– Depression

• CTscan, for fractures & avulsions • MRI

– Ligament injuries– Other soft tissue injuries– Bony injuries

Imaging

Postermedial repair

PM inj.& Subluxation

PCL MCL ACL injury

After repair

Final outcomeFinal outcome::

• Stable ,pain free, good ROM• Stiff knee• Unstable & pain free• Unstable & painful

Type of instabilityType of instability

• One plain• Rotational • Posteromedial • Posterolateral • Convert multidirectional to:• One plain instability

Anatomic classification of knee Anatomic classification of knee dislocationdislocation

• KDI ,single cruciate torn+ one corner• KDII ,ACL/PCL torn ,collaterals intact• KDIIIM ,ACL/PCL/MCL• KDIIIL ,ACL/PCL/LCL/PLC torn• KDIV ,ACL/PCL/MCL/LCL-PLC torn• KDV knee fracture dislocation

Knee dislocation managementKnee dislocation management

• Reduce • Splint & observe then operate• External fixation• Transfix pins• Vascular repair• Soft tissue condition?

PlanningPlanning

• Surgical & non surgical issues• Timing of surgery• Repair • Graft selection for reconstruction• Surgical techniques• Risks & benefits• Complications discussed with the patient

EUA & PositioningEUA & Positioning

• Position the patient• EUA• Determine ligaments injured• Arthroscopic assessment • Gravity inflow irrigation• Avoid extravasation & compartment syn.

Graft selection for multiple Graft selection for multiple ligament injuriesligament injuries

• Graft choice is based on the:• Extent of the injury• Timing of the surgery• Experience of the surgeon• Autograft

– Better graft incorporation &– Remodeling

• Allograft

ACL& PCL reconstructionACL& PCL reconstruction

• BPB allograft for ACL• Achilles tendon allograft for PCL• Or Hamstring tendon autograft• Tunnel preparation• Achilles tendon allograft or BPB for LCL • Pass PCL graft first then ACL• Fix in the femoral tunnel ,tibial at the end

Lateral side injuryLateral side injury

• Repair if fresh, or reconstruct • After fixation of ACL & PCL reconstructs• Lateral incision• Expose proneal nerve• LCL,Popliteofemoral lig. ,popliteus tendon• Joint capsule• Avulsion of biceps femoris & ITB

KDIIIL

Lateral side reconstruction

KDIIIM

Critical conceptsCritical concepts::

• The majority of the knees are treated surgically

• The goal of anatomic repair & reconst.• Approach with in 1st three weeks• Emergency surgery in: open, irreducible• Or with vascular injury or compartment syn

Order of fixation of ligamentsin repair or Reconstruction

• 1st FIX PCL in 90 flexion• Then ACL in extention• Then LCL in 30 FLEXION• Finally MCL in 30 flexion

Critical conceptsCritical concepts

• In open knee dislocations :• Wound management• Adequate soft tissue coverage• Dictate :• The timing of ligament reconstruction• Never be performed acutely

Irreducible DislocationsIrreducible Dislocations

• Uncommon but needs prompt,• Surgical reduction• To avoid NV damage• Delay definitive reconstruction• Allow complete knee imaging• Planning & stabilization of the patient• Emergent vascular repair

Critical conceptsCritical concepts

• Management & treatment of compartment syndrome

• Simple primary repair of injured soft tissue• Avoid additional incisions• Delay definitive ligament reconstructions• In vascular repair give enough time

ContraindicationsContraindications::

• Advanced age or sedentary lifestyle• An active infection• Intra-articular or periarticular fractures• Osteoarthritis• Debilitating or posttraumatic comorbidities

PitfallsPitfalls::

• Well planned skin incisions• MIS, use of Allograft & arthroscopy• Open technique for medial & lateral• Low intra-articular fluid pressure• To avoid compartment syndrome• Re check to make sure the compartments

are soft

Causes of failure in PLC injCauses of failure in PLC inj

• Frank R Noyes et al. Am J Sport Med. 2006 57 PLC operative procedures

• Untreated varus malalignment (10)• Failure to reconstruct all ruptured

ligaments , including cruciates (27)• Nonanatomical graft reconstruction (23 )

F. Noyes recommendationsAJSM 2006

• Anatomical graft reconstruction of one or more P Lateral ligaments

• Restoration of all cruciate ligaments• & correction of varus malalignment

Chronic inj.of the PLC of the Chronic inj.of the PLC of the knee (knee (Covey DC.JBJS 2001)

• More complex problem than acute• Scarring, secondary changes to other st.• Possible limb malalignment• The goals of operative treatment are:• Restoration of knee stability & kinematics• Return to preinjury activity level• Reduce chance OA ,

THANK YOUTehran 2007