Diagnosis and Treatment of Multiligament Knee Injury: State of the Art Gilbert Moatshe,1,2,3 Jorge Chahla,2,4 Robert F Laprade,2,5 Lars Engebretsen1,3

Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine Publish Ahead of Print, published on March 8, 2017 as doi:10.1136/jisakos-2016-000072 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from Diagnosis and treatment of multiligament knee injury: state of the art Gilbert Moatshe,1,2,3 Jorge Chahla,2,4 Robert F LaPrade,2,5 Lars Engebretsen1,3

1Oslo University Hospital and Abstract diagnostic workup and treatment plan is mandatory University of Oslo, Oslo, Norway when dealing with these injuries. The purpose of 2 Multiligament knee injuries constitute a complex and Steadman Philippon Research this article is to review specific focused principles Institute, Vail, Colorado, USA challenging entity, not only because of the diagnosis 3OSTRC, The Norwegian School and reconstruction procedure itself, but also because of of multiligament knee injuries, classification, diag- of Sports Sciences, Oslo, Norway the rehabilitation programme after the index procedure. nosis, treatment options and rehabilitation guide- 4Hospital Britanico de Buenos A high level of suspicion and a comprehensive clinical lines for addressing these complex injuries. Key Aires, Buenos Aires, Argentina and radiographic examination are required to identify information and articles on these injuries can be 5The Steadman Clinic, Vail, Colorado, USA all injured structures. Concomitant meniscal, chondral found in box 1 and box 2 respectively. and nerve injuries are common in multiligament injuries Correspondence to necessitating a detailed evaluation. Stress radiographs Classification Dr Robert F LaPrade, The are valuable in evaluating patients preoperatively Schenck described the most widely used classifica- Steadman Philippon Research and postoperatively. The current literature supports tion system for the dislocated knee in 1994, which 13 Institute, 181 West Meadow surgical management of multiligament injuries, and is based on the anatomical patterns of the torn liga- Drive, Suite 1000, Vail, 3 6 CO 81657, USA; reconstructions are recommended because repair of ments (table 1). The advantage of this classifica- drlapr ade@sprivail.org ligaments has higher failure rates. Reconstruction tion is that it allows for identification of the torn of all injured ligaments in one stage is advocated (if ligaments and planning of treatment. In addition, it Received 9 November 2016 possible) in order to achieve early mobilisation and makes it possible to compare the different studies in Revised 8 January 2017 the literature using the same classification system of Accepted 15 January 2017 to avoid joint stiffness. Using biomechanically and clinically validated anatomic ligament reconstructions knee dislocations. improves outcomes. In the setting of multiligament knee reconstructions, several technical aspects that require Aetiology consideration are vital, such as the graft choice, the Multiligament knee injuries can be caused by sequence of ligaments reconstruction, tunnel position both high-energy trauma,7 such as motor vehicle and orientation to avoid tunnel interference and graft accidents and fall from heights, and low-energy tensioning order. This review article discusses the use of trauma,8 including sporting activities. In a cohort of stress radiographs in diagnosing ligament injuries and 85 patients with knee dislocations, Engebretsen et al reported that 51% were high-energy injuries, and

evaluating postoperative stability. Tunnel convergence http://jisakos.bmj.com/ and tensioning sequence are potential problems, and 47% were sports-related injuries.9 In a review of guidelines to address these are also discussed. Recovery 303 patients with knee dislocations, Moatshe et al10 after a multiligament reconstruction surgery typically reported equivalent rates of high- and low-energy requires 9 to 12 months of rehabilitation prior to trauma, with 50.3% and 49.7%, respectively. Miller returning to full activities. The purpose of this article et al reported on multiligament knee injuries in is to review the specific principles of multiligament obese individuals as a result of ultra-low velocity injuries, classification, diagnosis, treatment options and trauma.11 rehabilitation guidelines for addressing these complex on September 27, 2021 by guest. Protected copyright. injuries. Evaluation Multiligament knee injuries are not uncommon. Only 28% of PLC injuries occur in isolation.12 The clinician should have a high level of suspi- Introduction cion, and a detailed knee examination should The definition of a multiligament knee injury is be performed including assessment of the limb’s commonly recognised as a tear of at least two of the neurovascular status. PLC injuries are associated four major knee ligament structures: the anterior with both common peroneal nerve injuries and cruciate ligament (ACL), the posterior cruciate liga- vascular injuries (Moatshe et al,10). When both ment (PCL), the posteromedial corner (PMC) and cruciate ligaments are torn, the risk of vascular the posterolateral corner (PLC).1 2 The terms knee and neurological injuries is very high and vascular dislocation and multiligament knee injuries are often assessment is often needed.2 Magnetic resonance used interchangeably. Knee dislocations often result imaging (MRI) is performed to evaluate all the in multiligament knee injuries, but some multiliga- injured structures (figure 1). For both acute and ment knee injuries are not knee dislocations. A knee chronic injuries, stress radiographs are essential, dislocation is typically characterised by rupture of but can be difficult to carry out in the acute phase To cite: Moatshe G, both cruciate ligaments, with or without an asso- (tables 2 and 3, figures 2 and 3).13–15 Chahla J, LaPrade RF, et al. 2 3 J ISAKOS Published Online ciated grade III medial or lateral-sided injury. First: [please include Day However, knee dislocations with one of the cruciate Acute multiligament knee injuries Month Year]. doi:10.1136/ ligaments intact have been reported.4 5 Multiliga- For high-energy injuries, Advanced Trauma Life jisakos-2016-000072 ment injuries are heterogeneous, and a thorough Support principles apply. Foot pulses and skin

Copyright 2017 by International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from Box 1 Key information Table 1 Explaining Schenck’s knee dislocation classification KD I Injury to single cruciate + collaterals ►► Multiligament injuries are complex and challenging. KD II Injury to ACL and PCL with intact collaterals ►► Detailed evaluation with physical examination, MRI, stress radiographs and angiography if ankle–brachial index <0.9 KD III M Injury to ACL, PCL, MCL KD III L Injury to ACL, PCL, FCL ►► Concomitant injuries including meniscal, chondral, nerve and vascular injuries are common. KD IV Injury to ACL, PCL, MCL, FCL ►► Surgical treatment of all injured structures in the same KD V Dislocation + fracture setting is recommended. Additional caps of “C” and “N” are utilized for associated injuries. “C” indicates an arterial injury. “N” indicates a neural injury, such as the tibial or, more commonly, ►► A well-crafted rehabilitation protocol is important to ensure the peroneal nerve. ACL, anterior cruciate ligament; FCL, fibular collateral ligament; good functional outcomes. KD, Knee Dislocation Classification I–V; MCL, media collateral ligament. ►► Good functional outcomes can be achieved with surgical treatment.

colour should be monitored and compared with the uninjured side. An ankle–brachial index (ABI) <0.9 warrants an angiography (figure 4).16 17 Knee dislocations are associated with injuries to the popliteal artery (23%–32%).7 18 Injury to the common peroneal nerve occurs in 14%–40% of knee dislocations.19 20 Ultra-low velocity knee dislocations in the obese patients are associated both with nerve and vascular injuries, and also with higher complication rates after surgical treat- Figure 1 MRI showing a PCL tear on the sagittal plane (A) and a sMCL ment.11 21 injury seen in the coronal plane (B). A detailed evaluation of the patient; ABI is useful as an adjunct to physical examination to assess and the images are mandatory to diagnose all the injured structures. PCL, for vascular injuries. Physical examination with the presence of posterior cruciate ligament; sMCL, superficial medial collateral ligament. a normal vascular examination (normal and symmetrical pulses, capillary refill, normal neurological examination) is reported to be reliable to screen patients with knee dislocations for ‘selec- Chronic multiligament knee injuries tive’ arteriography.22 Some protocols recommend an ABI cut-off Some multiligament knee injuries are missed in the acute phase, of <0.8,23 and others recommend <0.9 to perform arteriog- or concurrent ligament injuries are not acknowledged, in a multi- raphy.22 24 Stannard et al developed a protocol for monitoring trauma patient. A thorough patient history, clinical examination vascular injuries in knee dislocations.25 Patients with vascular supplemented with stress radiography and MRI are mandatory injuries are treated with acute revascularisation, and the knee is to identify all injured structures. Concomitant cartilage and http://jisakos.bmj.com/ protected in an external fixator to protect the revascularisation meniscal injuries should be diagnosed and treated concurrently. graft and to maintain knee reduction.23 26 The external fixator is In addition, long axis radiographs of the lower extremity should usually removed at 2–6 weeks and the knee is placed in a hinged be obtained to assess alignment, especially for chronic multi- brace to avoid pin infections and joint stiffness. ligament knee injuries. Varus malalignment is defined as being

Box 2 Key articles on September 27, 2021 by guest. Protected copyright. Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthros- copy. 2009;25:430–438. Levy BA, Fanelli GC, Whelan DB, et al. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17:197–206. James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res. 2014;472:2644–2657. 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;30:718–727. 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;472:2621–2629. Schenck R. Classification of knee dislocations. Operative Techniques in Sports Medicine. 2003;11:193–198. Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc. 2011;19:167–173. Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17:1013–1026. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14:33–38. Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: operative technique and clinical outcomes. J Bone Joint Surg Am. 2011;93:1773–1780.

2 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from Table 2 Evaluation of posterior knee instability Grade Clinical finding with posterior Kneeling stress radiographs drawer test I 0–5 mm PTT 0–7 mm PTT → normal or partial tear II 5–10 mm PTT 8–11 mm PTT → Complete PCL tear III >10 mm PTT → posterior sag ≥ 12 mm PTT → Combined ligament injury Clinical test findings and the corresponding stress radiograph values in evaluating posterior knee instability. PCL, posterior cruciate ligament; PTT, posterior tibial translation.

Table 3 Evaluation of varus and valgus instability using stress Figure 3 Valgus stress radiographs to evaluate the medial and radiographs posteromedial side of the knee are important and should be incorporated Varus stress test Valgus stress test in the evaluation, especially in chronic cases. In this case there is a 3.4 mm <2.7 mm → Normal or partial tear <3.2 mm → Normal or partial tear increase in medial compartment gapping on the right (A) compared with 2.7 mm → Isolated FCL tear 3.2 mm → Complete sMCL tear the left (B) knee, indication a complete sMCL tear. Overall, a 3.2 mm side to ≥4 mm: → Complete PLC injury ≥9.8 mm → Complete tear of all medial side difference of gapping represents a complete sMCL tear, and a 9.8 mm structures difference represents injury to all medial structures. sMCL, superficial Side-to-side differences between the injured and the noninjured knee using stress medial collateral ligament. radiograph to evaluate varus and valgus knee instability. FCL, fibular collateral ligament; PLC, posterolateral corner; sMCL, superficial medial collateral ligament.

Figure 4 A photograph demonstrating measurement of systolic blood pressure on the injured limb (ankle) using a Doppler probe (A) and systolic blood pressure on the uninjured upper limb (brachial) (B). The ankle brachial index (ABI) is calculated by taking the ratio of the Doppler systolic http://jisakos.bmj.com/ Figure 2 Kneeling stress radiographs for evaluation posterior laxity blood pressure in the injured limb (ankle) to the systolic arterial blood are an important part of the evaluation. In this patient, there was a pressure in the uninjured upper limb (brachial). ABI = Doppler systolic 10 mm increase in posterior tibial translation on the left compared with blood pressure in the injured limb/systolic blood pressure in the uninjured the right knee. To compare the posterior tibial translation, a point is upper limb. identified along the posterior tibial cortex 15 cm distal to the joint line. A line is then drawn from this point parallel to the posterior cortex, through the femoral condyles. The most posterior point of Blumensaat’s line is injuries, 38% had sufficient improvement after proximal tibia marked. A perpendicular line is drawn from the most posterior point of on September 27, 2021 by guest. Protected copyright. osteotomy that subsequent PLC reconstruction was not neces- the Blumensaat´s line to intersect the first line drawn parallel to the tibial sary.27 cortex. This distance is compared with the contralateral side to give a side-to-side difference. A posterior translation side-to-side difference of Concomitant injuries 0 to 6 mm are usually due to partial PCL tear or in patients who are too High incidences of meniscal and focal cartilage injuries are sore to put sufficient weight on the knee; an 8 mm to 11 mm side-to-side reported in multiligament knee injuries. In a review of 303 difference is associated with a complete isolated PCL tear; ≥12 mm is patients at a level I trauma centre (Moatshe et al,10), reported usually observed in patients with complete PCL tear with another ligament meniscal injuries were found in 37.3% of the patients and carti- injury, usually the PLC or PMC, but can also be seen in patients with lage injuries in 28.3%. Richter et al reported lower incidence decreased sagittal plane tibial slope. PCL, posterior cruciate ligament; PLC, (15%) of meniscal injuries in association with knee disloca- posterolateral corner; PMC, posteromedial corner. tions;28 however, Krych et al reported higher rates of meniscal and chondral lesions associated with knee dislocation in 121 present when a line from the centre of the femoral head to the patients (122 knees) with 76% of overall patients having a centre of the ankle joint (the mechanical axis) falls medial to meniscal or chondral injury; 55% presented with meniscal tears the apex of the medial tibial eminence on a long-leg alignment while 48% presented with a chondral injury.29 Common pero- radiograph (figure 5). When varus mal-alignment is present in a neal nerve injuries are frequently associated with lateral-sided patient with a chronic PLC injury, a corrective osteotomy should injuries. Moatshe et al.10 reported common peroneal nerve inju- be considered prior to reconstruction. Reconstruction grafts ries and vascular injuries in 19% and 5% of the 303 patients in the PLC do not tolerate varus mal-alignment, and this will with knee dislocations, respectively. Medina et al19 reported a potentially lead to graft stretching and reconstruction failure. frequency of 25% and 18% for nerve and vascular injuries in Arthur et al reported on 21 patients with chronic combined PLC knee dislocations, respectively, in a recent systematic review.

Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 3 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from

Figure 6 Image showing a left knee with multiligament knee injury involving the posterolateral corner. There is increased risk of common peroneal nerve injury with posterolateral corner injuries. CPN: common peroneal nerve.

Surgical versus nonsurgical management Surgical treatment of the torn ligaments in multiligament injured knees improves patient-reported outcomes.28 32 33 In a meta-analysis including 132 knees treated surgically and 74 treated nonsurgically, Dedmond et al reported improved motion and Lysholm scores in the surgical treatment group.32 The surgical group had significantly better range of motion (123° in the surgical group vs 108° in the nonsurgical group) and Lysholm scores (85.2 in the surgical group vs 66.5 in the nonsurgical group). Richter et al27 reported on 89 patients with traumatic knee dislocations with a mean follow-up of 8.2 years. Sixty-three patients were treated with surgical repair or reconstruction, while 26 patients were treated nonsurgically. The authors reported significantly improved outcomes in the surgical group compared with the nonsurgical group. Functional rehabilitation after surgery was

reported to be the most important positive prognostic factor. In http://jisakos.bmj.com/ addition, patients who were 40 years of age or younger and who had low velocity sports injuries had better scores.28 In a literature review by Peskun and Whelan,33 evaluating outcomes in 855 patients from 31 studies treated surgically, and 61 patients from four studies treated nonsurgically, functional outcomes, Figure 5 In chronic cases, long-leg radiographs are recommended contracture, instability, and return to activity favoured surgical to evaluate alignment. Patients with chronic PLC injuries and varus treatment. In summary, the literature supports surgical treat- malalignment should be treated with an osteotomy to correct mal- ment, and postoperative functional rehabilitation of multiliga- on September 27, 2021 by guest. Protected copyright. alignment prior to PLC reconstruction. Untreated mal-alignment will likely ment knee injuries. It is in rare occasions such as advanced age, cause the grafts to stretch over time and fail. PLC: posterolateral corner. immobility and comorbidities that nonsurgical treatment can be considered.

Becker et al reported peroneal nerve injury in 25% of knees and Repair versus reconstruction arterial injury in 21% in a series of 106 patients.30 Moatshe et Earlier studies have reported poor outcomes after repair of al10 reported that the odds of having a peroneal nerve injury isolated ACL injuries.34–36 Mariani et al evaluated outcomes in were 42 times higher among patients with injury than those a cohort of patients with multiligament injuries; 52 patients without, while the odds of having a popliteal artery injury were treated with repair of the ligaments versus 28 treated with 9.2 times higher in patients with a posterolateral corner injury reconstructions.37 All patients had bicruciate ligament injuries, (figure 6). and they were divided into three groups; direct ACL/PCL repair Medial-sided injuries are usually the most common injuries (group 1), ACL reconstruction and PCL repair (group 2) and in multiligament knee injury patterns. Moatshe et al10 reported ACL and PCL reconstruction (group 3). Patients with repair of that medial-sided injuries constituted 52% of the injuries in cruciate ligaments had higher rates of flexion deficit >6°, higher 303 patients with multiligament knee injuries. In their series, rates of posterior instability and lower rates of return to prein- lateral-sided injuries constituted 28% and bicruciate injuries jury activity levels. High reoperation rates have been reported constituted only 5%. In a review by Robertson et al,31 medi- in patients with posterolateral injuries treated with repair.38 39 al-sided and lateral-sided injuries were reported in 41% and Anatomic reconstruction of the injured structures using biome- 28%, respectively. In contrast, Becker et al reported that later- chanically validated techniques has been reported to yield al-sided injuries were the most common (43%) in a series of 106 improved outcomes (figure 7).40–42 In the setting of multiligament patients.30 injuries, reconstruction of the torn ligaments is recommended.

4 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from sufficient bone stock between the grafts for fixation and graft incorporation. Few studies have evaluated the risk of tunnel convergence and optimal angulation of the tunnels. Moatshe et al reported a 66.7% tunnel convergence rate between the posterior oblique ligament (POL) tunnel and the PCL tunnel in the tibia when the POL tunnel was aimed at Gerdy´s tubercle. They recommended that the POL tunnels be aimed to a point 15 mm medial to Gerdy´s tubercle to reduce risk of convergence with the PCL, and that the superficial medial collateral ligament (sMCL) tunnel be aimed 30° distally to avoid convergence with the PCL.50 On the lateral femoral side, Moatshe et al (in press, 2016) performed a 3D imaging study varying the angles of the FCL and popliteus tunnels. A 35°–40° angulation in the axial plane and 0° in the coronal plane were safe and avoided tunnel convergence. On the medial side, aiming the sMCL tunnel 40° in the axial and coronal planes and the POL tunnel 20° in the axial and coronal planes was safe to avoid convergence with the double-bundle PCL tunnels (figure 8). In a laboratory study, Carmada et al reported a high risk of tunnel convergence between the ACL and the FCL (69%–75% depending on the length of the tunnel) and recommended aiming the FCL tunnel 0° in the coronal plane and 20° - 40° in the axial plane.51 Gelber et al evaluated tunnel Figure 7 An intraoperative arthroscopy image showing double-bundle convergence and optimal angulation of the tunnels on the medial PCL reconstruction. Anatomic reconstruction of all the torn ligaments using femur condyle. They found that angulations of 30° in the axial biomechanically and clinically validated techniques is recommended. ALB, plane and coronal plane reduced the risk of convergence with anterolateral bundle; PMB, posteromedial bundle; MFC, medial femoral the PCL tunnels.52 However, the diameter of their PCL tunnels condyle. were smaller than those used by Moatshe et al.

Repair of the collaterals is usually reserved for bony avulsion Tensioning sequence injuries.43 The tensioning sequence in multiligament injuries is a topic of debate. Different tensioning sequences have been reported in the Timing of surgery literature. Some authors advocate for starting with the PCL to Timing of surgery during multiligament injuries is a topic of restore the central pivot and tibial step-off, followed by the ACL debate. In addition, there is still no consensus on the point of in extension to ensure the knee can be fully extended, postero- http://jisakos.bmj.com/ demarcation between acute and chronic. Some authors have used lateral corner and the posteromedial corner last.53 54 A biome- 3 weeks as the critical time to better identify and treat the struc- chanical study by Wentorf et al reported that in a posterolateral 9 37 44 45 tures before scarring and tissue necrosis affect outcomes. corner deficient knee, tension during fixation of the ACL graft This is also particularly important in the case of bony avulsion increased external tibial rotation of the tibia.49 Therefore, there injuries. However, some authors have used 6 weeks to demarcate between acute and chronic.40 Better outcomes are reported in acute compared with chronic treatment in studies that directly compared timing of treatment. Levy et al reported no difference on September 27, 2021 by guest. Protected copyright. in range of motion after acute and chronic surgery in a systematic review of literature that included five studies46 Moatshe et al. (unpublished data, 2016) reported on 303 patients with knee dislocations, and the percentage of patients developing arthro- fibrosis was 15.2% and 3.8% in the acutely treated and the chronic injuries, respectively. The authors preferred acute treatment of the injured structures to facilitate early rehabilitation.40 In addition, staging the reconstruction can potentially alter joint kinematics, and increase the risk of graft failure.47–49 In high energy trauma, surgery may be delayed because of injuries to the soft tissue about the knee and concomitant injuries to other vital organs. However, stiffness in these patients may be easier to treat than recurrent instability.

Surgical principles Figure 8 Reconstruction of the sMCL on a right knee. The AT is an Avoiding tunnel convergence important landmark to locate the adductor tubercle which is just distal to Reconstructing several reconstruction tunnels in the distal femur the adductor tendon insertion. The attachment site of the MCL is 12 mm and proximal tibia pose a risk of tunnel convergence because of distal and 8 mm anterior to the adductor tubercle. To avoid convergence limited bone mass in these areas. Tunnel convergence increases with the PCL tunnels, the sMCL and popliteus tunnels should be aimed the risk of reconstruction graft failure because of the potential anteriorly and proximally. AT, adductor tendon; PCL, posterior cruciate damage to reconstruction grafts, fixation devices and not having ligament; sMCL, superficial medial collateral ligament.

Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 5 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from are authors that advocate for fixing the posterolateral corner prior to the ACL to avoid external tibial rotation. Markolf et al reported in a biomechanical study that the PCL should be fixed prior to the ACL to best restore graft forces.55 Kim et al retro- spectively reviewed 25 patients with multiligament injuries, 14 with the PCL tensioned first and 11 with simultaneous tension and fixing the ACL first. Posterior stress radiographs, Lysholm score, International Knee Documentation Committee (IKDC) scores favoured fixing the ACL first.56 The optimal tensioning sequence can be best evaluated with well-designed biomechanical studies.57 The authors preferred tensioning sequence which fixes the anterolateral bundle of the PCL at 90° to restore the normal tibial step-off, the posteromedial bundle of the PCL in extension, the FCL at 20°−30° of knee flexion and a slight valgus force, followed by the rest of the PLC structures at 60° of flexion and neutral rotation, the ACL near full extension and finally the posteromedial corner. Figure 9 A diagram of a left knee illustrating the superficial medial Surgical technique collateral: ligament (sMCL) and posterior oblique ligament (POL) A thorough preoperative assessment to aid patient selection reconstruction grafts. ME: medial epicondyle. Reprinted with permission and planning of treatment is important (box 3). The surgical of SAGE Publications, Inc, from Coobs BR, Wijdicks CA, Armitage BM, technique uses both allografts and autografts depending on the Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF. An in ligaments injured. Anatomic ligament reconstructions that are vitro analysis of an anatomic medial knee reconstruction. Am J Sports Med. biomechanically and clinically validated are performed. An open 2010;38:339–347 surgical approach is performed prior to arthroscopy to allow for improved soft tissue visualisation and to limit fluid extravasation into the surgical site. On the medial side, a skin incision is performed proximally between the adductor tubercle and the patella and extended 8 cm distally from the joint line to the medial part of the tibia. The semitendinosus and gracilis tendons are harvested and fixed at the superficial MCL attachment site, 6 cm distal to the joint line with two suture anchors.58 A femoral reconstruction tunnel is reamed at the anatomic attachment of the MCL, and the grafts are passed under the sartorius fascia

and the graft ends are whipstitched so that 30 mm will fit into http://jisakos.bmj.com/ the femoral tunnel (figure 9).59 On the posterolateral side, a technique described by LaPrade et al60 is performed using a split Achilles graft (figure 10). The fibular, tibial and femoral tunnels are reamed and passing sutures are placed. After drilling the tunnels for the collateral ligament reconstruction grafts, attention is turned to the intra-articular injuries. An anatomic double-bundle PCL41 61 and single-bundle ACL reconstructions

are performed. The concomitant meniscal and chondral lesions on September 27, 2021 by guest. Protected copyright. Figure 10 An illustration of the right knee demonstrating the are addressed prior to graft fixation and tensioning. Graft posterolateral knee reconstruction procedure. A, posterior view; B, tensioning is performed as described above. Tips and tricks, and lateral view. PLT, popliteus tendon; FCL, fibular collateral ligament; PFL, some potential pitfalls when performing this type of surgery can popliteofibular ligament. Reprinted with permission of SAGE Publications, be found in box 4 and box 5 respectively. Inc, from LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An Analysis of an Anatomical Posterolateral Knee Reconstruction: An Rehabilitation In Vitro Biomechanical Study and Development of a Surgical Technique. Am Multiligament knee injuries are complex and challenging pathol- J Sports Med. 2004;32:1405–1414. ogies to rehabilitate due to the extensive soft tissue damage and the different injury patterns that can occur. An appropriate diagnosis and treatment of all the damaged structures is vital for a successful outcome. Reconstruction of all injured ligaments and repair of soft tissue structures such as the meniscus Box 3 Key issues of patient selection or cartilage are recommended to aid in early mobilisation and to avoid joint stiffness or graft failure. Postoperative recovery ►► Injury to>1 major knee ligament (ACL, PCL, MCL, FCL or PCL) after a multiligament reconstruction procedure typically requires ►► Active patients without major comorbidities 9–12 months of rehabilitation prior to returning to full activities. ►► Detailed assessment of all injuries This allows proper time for the grafts to incorporate and to heal ►► Aim for surgical treatment of all injured structures in the in order to prevent reconstruction graft failure. A well-crafted acute setting rehabilitation plan after a multiligament reconstruction should ►► Obese patients have higher complication rates focus on graft protection and functional outcomes including ►► Delay ligament surgery in patients with vascular injuries regaining motion, strength and function. A dynamic PCL brace

6 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from (Ossur PCL Rebound brace, Foothill Ranch, CA, USA) or a Jack Box 4 Tips and tricks PCL brace (Albrecht GmbH, DE, USA) is used in the rehabilitation period (9–12 months) to protect the reconstruction. It is ► Patient positioning: The patient should be positioned to ► also recommended to use a brace on the first year of returning allow full flexion and extension of the knee. to activities. Full range of motion is especially vital to long-term ► Graft preparation: Ensure availability of grafts and correct ► outcomes, and patients should aim to obtain 0–90° of knee graft length. Tightly spacing the whipstitch sutures protects flexion within the first 2 weeks after surgery. Once a muscular the grafts from laceration when securing with an interfer- strength foundation with good dynamic neuromuscular control ence screw. has been established, patients can progress to their functional ► Steps during surgery: Start with the collateral ligament ► sport specific exercises. injuries. Fluid extravasation from arthroscopy can impair Initial management should focus on supportive measures such visualisation and identification of structures. as pain control, inflammation/effusion control (cryotherapy, ► Tunnel positioning: All the tunnels should be placed at the ► elevation and compression of the affected limb), range of motion anatomic footprint of the ligaments being reconstructed. All re-establishment, patellar mobilisation, restoring appropriate the tunnels’ positions and orientations should be planned muscle activation patterns and progressive gait training. Soft in detail to avoid tunnel convergence. Aiming the femoral tissue healing involves a predictable series of phases (inflam- FCL and popliteus tunnels anteriorly reduces the risk of mation, proliferative and remodelling phases) that should be convergence with the ACL tunnel and the risk of violating addressed at a proper time to promote physiological healing the intercondylar notch. The centre of the popliteus tunnel is responses, minimise negative changes and facilitate the prolif- 18.5 mm anterior to the centre of the FCL tunnel, and there eration and alignment of collagen fibres.62 Patellar mobilisation is an 8–9 mm bone bridge between the tunnels. The femoral should be a primary initial focus of the rehabilitation, as hypo- tunnels for the posteromedial corner should be aimed mobility of the proximal pole of the patella can interfere with anteriorly and proximally to avoid convergence with the PCL the extensor mechanism leading to loss of range of motion and a tunnels. The femoral PCL tunnels should be divergent. quadricep lag.62 Conversely, flexion can be affected by a dimin- ► Acorn reamers: These reamers allow the surgeon to add ► ished patellar inferior glide. With regards to weight bearing, to fine adjustments to the tibial tunnel paths. The edges of the date there is no randomised clinical trial assessing the effective- tunnels should be smooth to prevent the bone edges from ness of early weight bearing after a multiligament reconstruc- damaging the grafts. tion, and therefore protected weight bearing is carried out for ► Fixation: The sequence of graft fixation affects the tibiofem- ► the first 6 weeks after which partial weight bearing is allowed. oral orientation and the graft forces. The PCL is tensioned Periodisation is the division of a training or rehabilitation first, followed by the PLC, then the ACL and finally the PMC. programme into smaller phases (periods) as a means of creating ► Postoperative rehabilitation: Early protected range of motion ► more manageable segments. In a multiligament knee reconstruc- is important. Periodisation, progressive weight bearing, tion rehabilitation programme, the phases are constituted by quadriceps activation and patella mobility. Rehabilitation muscular endurance, strength and power and can be developed takes 9–12 months. Use brace during activities the first year

based on the patient’s expectations and return to activity time- http://jisakos.bmj.com/ of returning to activities. line. The length of each phase depends on the time frame of the rehabilitation programme, but it should be no shorter than 6 weeks. With range of motion (ROM) restored, the treatment emphasis shifts to the development of a muscular endurance Box 5 Major pitfalls base. A transition in training emphasis to the development of muscular strength can then be made before muscular power is ►► Patient positioning: Incorrect positioning of the patient may developed. Three to four sessions a week are appropriate while limit knee motion and the space available for the surgeon to 63

still providing adequate recovery between sessions. on September 27, 2021 by guest. Protected copyright. work effectively. Given the numerous variables (age, BMI, sport, concurrent ►► Graft preparation: Oversizing the grafts can complicate injuries, etc) that can interact in the decision to allow a patient the passage of grafts in the tunnels. Care must be taken to to return to sport, the rehabilitation process and return to sport ensure availability of graft for all torn ligaments. timeline should be tailored to each patient. A systematic review of ►► Tunnel convergence: With many tunnels being created in 264 studies by Barber-Westin and Noyes reported that the return both the femur and tibia, the risk of tunnel convergence to play decision was based on subjective nonspecific criteria such is high. Tunnel convergence will potentially damage the as ‘regained full functional stability’, ‘normal knee function on grafts, fixation devices, create too short tunnels or leave not clinical examination’, ‘satisfactory stability’ or ‘nearly full ROM enough bone stock for graft fixation and integration. The and muscle strength’.64 Few studies described objective criteria PCL femoral tunnels should be divergent. such as time from surgery, muscle strength, ROM and effusion, ►► Meniscal root injuries: Malposition of the PCL tibial tunnel which were the most frequently used.64 can potentially injure the posterior root of the medial meniscus. Malposition of the ACL tibial tunnels can potentially injure the anterior horn of the lateral meniscus. Subjective and objective outcomes Poor outcomes are reported for nonsurgical management of ►► Neurovascular complications: There is increased risk of neurovascular injuries when creating tibial femoral tunnels. multiligament knee injuries, therefore this section will focus on The guide pin should be visualised and advancement of the outcomes after surgical management. Preoperative and post- guide pin should be prevented during reaming. operative stability and functional scores are usually compared to evaluate patient outcomes (box 6). Unfortunately, most ►► Fixation: The sequence of graft fixation can theoretically alter tibiofemoral orientation and thus knee kinematics, studies on multiligament knee injuries have small cohorts and increasing the risk of graft failure and osteoarthritis. the follow-up is generally short. Good functional outcomes are reported in short to medium follow-up after surgical treatment

Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 7 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from trauma,9 repair of medial side injury,69 age >30 years70 (Moatshe Box 6 Validated outcome measures and classifications et al,71), concomitant cartilage injury,72 combined medial and lateral meniscal tears.72 ►► Stress radiographs to evaluate knee stability ►► Tegner Activity Score ►► Lysholm Score Conclusions and future perspectives ►► International Knee Documentation Committee (IKDC) Multiligament knee injuries are complex and a high level of ►► Use Schenck´s Knee Dislocation Classification (KD I-V) (table 1) suspicion is required when treating these patients. Some of the concurrent ligament and meniscal injuries may be missed initially, and this necessitates a detailed history and clinical of multiligament injuries.9 46 In a follow-up of 85 patients with examination, supplemented with MRI and stress radiographs. knee dislocations at 2–9 years, Engebretsen et al reported Failure to treat all injured structures can lead to changes in knee improved patient reported outcomes with a mean Lysholm of kinematics and hence poorer outcomes and an increased risk of 83, median Tegner Activity score of 5 and mean IKDC 2000 graft failure. Treating all the injured structures in the acute phase subjective score of 64. However, 87% of the patients in the is recommended in order to facilitate early rehabilitation and cohort had radiological osteoarthritis in the injured knee based better restoration of knee function. Good functional outcomes on Kellgren-Lawrence classification.9 Moatshe et al (unpub- can be achieved after surgical treatment of these injuries, but lished data, 2016) reported a mean Lysholm score of 84, Tegner post-traumatic osteoarthritis is common. score of 4 and subjective IKDC 73 in a follow-up of 65 patients There is still no consensus on the optimal tensioning sequence with multiligament knee injuries at a minimum follow-up of 10 of the grafts during multiligament knee injury surgery. Biome- years. Forty-two per cent of the cohort had radiological osteoar- chanical studies are necessary to evaluate the effects of the thritis in the injured knee compared with only 6% in the unin- different tensioning orders to the knee kinematics. This will jured knee. Geeslin et al40 reported on 29 patients (30 knees), 8 potentially pave the way for multicentre clinical studies to eval- knees had isolated posterolateral corner injuries and 22 knees uate this in clinical settings. In addition, several reconstruction had combined ligament injuries involving the posterolateral grafts are often needed during this type of surgery, posing a corner. At a mean follow-up of 2.4 years, Cincinnati and IKDC problem in areas where allografts are not available. Optimal subjective outcome scores improved from 21.9 to 81.4 and 29.1 reconstruction in the setting where allografts are not available is to 81.5, respectively. Side-to-side varus gapping on stress radio- an area that needs further research (box 7). graphs improved from 6.2 mm preoperatively to 0.1 mm postoperatively.40 Postoperative stress radiographs are an important objective method of evaluating stability (figure 11). Box 7 Future perspectives Good functional outcomes have also been reported by other authors.40 41 65–68 Despite good functional scores, several studies ►► The effect of tensioning force during multiligament recon- report relatively high prevalence of radiographic osteoarthritis structions ranging from 23% to 87%.9 65 68 Certain factors have been ►► The optimal tensioning sequence during multiligament reported to correlate with poor outcomes including high-energy reconstructions http://jisakos.bmj.com/ ►► Long-term follow-up outcomes after multiligament knee injuries ►► Optimal treatment protocol for ultra-low velocity multiligament injuries in obese patients ►► Multiligament injuries: optimal treatment and outcomes in the adolescent population on September 27, 2021 by guest. Protected copyright.

Contributors All the authors (GM, JC, RFL, LE) have contributed fully at all phases of this manuscript. All the the authors have read and approved the final version of the manuscript being submitted. Competing interests None declared. Provenance and peer review Commissioned; externally peer reviewed.

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Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072 9 State of the Art J ISAKOS: first published as 10.1136/jisakos-2016-000072 on 8 March 2017. Downloaded from 67 Fanelli GC, Edson CJ. Surgical treatment of conbined PCL-ACL medial and lateral 70 Levy NM, Krych AJ, Hevesi M, et al. Does age predict outcome after multiligament side injuries (Global Laxity): Surgical Technique and 2- to 18-Year Results. J Knee knee reconstruction for the dislocated knee? 2- to 22-year follow-up. Knee Surg Surg 2012;25:307–16. Sports Traumatol Arthrosc 2015;23:3003–7. 68 Fanelli GC, Sousa PL, Edson CJ. Long-term followup of surgically treated knee 71 Moatshe G, Dornan GJ, Ludvigsen TC, et al. High prevalence of knee osteoarthritis dislocations: stability restored, but arthritis is common. Clin Orthop Relat Res at a minimum 10-year follow-up after knee dislocation surgery. Knee Surg Sports 2014;472:2712–7. Traumatol Arthrosc 2017, In Press. 69 King AH, Krych AJ, Prince MR, et al. Surgical Outcomes of medial versus 72 King AH, Krych AJ, Prince MR, et al. Are meniscal tears and articular cartilage lateral Multiligament-Injured, Dislocated Knees. Arthroscopy 2016;32: injury predictive of inferior patient outcome after surgical reconstruction for 1814–9. the dislocated knee? Knee Surg Sports Traumatol Arthrosc 2015;23:3008–11. http://jisakos.bmj.com/ on September 27, 2021 by guest. Protected copyright.

10 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072