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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

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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- drlaprade@ 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 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072. Copyright © 2017 ISAKOS 1 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 angi- ography (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 dislo- cations.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 25 vascular injuries in knee dislocations. 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
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