Knee Multiligament Reconstruction: ACL / PCL / MCL

Abstract

Background:

Multiligament knee injury (MLKI) is a rare, complex injury that requires surgical intervention. However, there is a lack of consensus regarding optimal timing, staging, and graft choice for ligament reconstruction.

Indications:

Delayed, single-stage reconstruction offers the advantage of attaining improved preoperative range of motion and potential healing of extra-articular ligaments and may be necessary in the setting of multitrauma.

Technique Description:

A hamstring graft was harvested and diagnostic arthroscopy performed. Three posterior portals were made for posterior cruciate ligament (PCL) reconstruction. Femoral and tibial pins were placed for both PCL and anterior cruciate ligament (ACL) tunnels, positions confirmed with fluoroscopy, and tunnels drilled over the pins. The Achilles allograft was shuttled through the femoral and tibial PCL tunnels in anterograde fashion and fixed with a metal interference screw on the femoral side. The hamstring autograft was passed through the ACL tunnels and suspended on the femoral side. Tibial fixation of both grafts was achieved with biocomposite interference. Medial collateral ligament reconstruction was performed through the medial incision from hamstring harvesting. The semitendinosis allograft was passed and fixed with screws and spiked washers. Fluoroscopy confirmed that screw trajectory did not interfere with the ACL or PCL tunnels.

Results:

Bagherifard et al reported a study of 41 consecutive patients with MLKI who underwent single-stage reconstruction with autograft and/or allograft. Mean postoperative Lysholm and International Knee Documentation Committee (IKDC) scores were 86.9 and 70, respectively, and only 7 patients experienced restricted range of motion. Billieres et al reported a study of 23 patients with MLKIs who underwent single-stage reconstruction with allograft only. Mean postoperative Lysholm and IKDC scores were 77.3 and 67.2, respectively, and 19 patients returned to sport. Goyal et al reported a study of 27 patients with MLKI who underwent single-stage reconstruction greater than 6 weeks after injury. At 2 years, there were significant improvements in Visual Analog Scale, IKDC, and Lysholm scores, and no patients had residual laxity of the knee joint.

Discussion/Conclusion:

Single-stage reconstruction of MLKIs is an effective intervention that has been supported in literature; however, further studies are necessary to determine optimal surgical timing and graft type.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video will discuss multiligament knee injuries (MLKIs) and present a case of a knee dislocation resulting in injury to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial collateral ligament (MCL).

We will provide a patient case through which we will discuss the evaluation of and workup and treatment algorithm for these injuries, as well as demonstrate surgical techniques for reconstruction and our postoperative protocol.

Our case presentation is of a 28-year-old man who presented to our clinic with right knee pain and instability after jumping out of a moving car. He was treated initially at an outside hospital, where his knee was found to be reduced. His examination in clinic demonstrated intact skin, a large effusion, and range of motion from 5° to 90° of flexion, limited by pain. He had a positive Lachman and posterior drawer test, as well as instability with valgus stress. The lateral knee structures appeared competent and he had a normal neurovascular examination.

Plain radiographs demonstrated a reduced knee with no acute osseous injury.

Stress radiographs were performed to determine the degree of PCL insufficiency, which was suspected on clinical examination. Using a line that is parallel to the posterior cortex of the tibia, we measure the distance from the posterior aspect of the tibial plateau to the posterior aspect of the femoral condyles. There was an 8-mm difference between his injured and normal sides, demonstrating that this was most likely a complete or a high-grade partial tear of the PCL.

A magnetic resonance imaging of his knee confirmed what appeared to be a complete rupture of the ACL and the PCL.

Here is a representative coronal cut elucidating a complete femoral-sided avulsion of the MCL. The remainder of the knee appeared normal.

The patient was 3 weeks out from his injury and was able to achieve 90° of flexion; therefore, we concluded that we could proceed with reconstruction of all ligaments in a single-stage procedure. For the ACL reconstruction, we used a hamstring autograft. Some surgeons prefer to avoid hamstring autograft in patients with MCL injuries, and this is certainly reasonable. A cadaveric study by Kremen et al simulated hamstring harvest in ACL reconstruction with partial MCL injury and found that there was increased valgus motion. This is a different scenario than our case in which we perform a robust reconstruction of the MCL. We have not had issues with persistent medial laxity with hamstring use in these circumstances, so we elected to use that graft for this patient as we would be making a medially based incision for the MCL reconstruction, regardless. An Achilles allograft with a bone plug was used for the PCL reconstruction, and a semitendinosus allograft was used for the MCL. For PCL reconstruction, we have transitioned to using a transtibial technique as opposed to an inlay because it avoids a posterior incision and the technical challenges associated with arthroscopic inlay.

We begin with an examination under anesthesia, which shows that the patient has a positive Lachman examination, a positive posterior drawer sign, and significant opening medially with valgus stress.

Finally, a Slocum test is performed, which compares a standard anterior drawer test with the tibia in neutral rotation to an anterior drawer with the tibia in external rotation. Equal or greater laxity with external rotation suggests a posteromedial knee injury.

We prep and drape the patient in the supine position, with a bracketed leg positioner to assist with maintaining different degrees of flexion throughout the case. We began first with harvesting the hamstring tendons in the standard fashion, which resulted in a 10-mm quadrupled graft. With our longitudinal incision over the anteromedial tibia, we had exposure to the superficial MCL and confirmed that it was intact. The 2 allografts were also prepared on the back-table while we started our arthroscopic portion of the case.

We are viewing here from the anterolateral portal looking into the notch. We see that the ACL and PCL are completely torn.

This is a view of the medial compartment. Note the “drive-through” sign, with significant separation between the medial femoral condyle and the medial plateau, due to the torn MCL and medial capsular tissues. There was no medial meniscus tear in this patient. As this was a femoral-sided MCL injury, we see the expected finding of the medial meniscus maintaining its tibial-sided attachments and remaining along the plateau once a valgus stress is applied.

Conversely, in tibial-sided MCL injuries, we generally see the opposite, the medial meniscus stays proximal when a valgus stress is applied, exposing the underlying plateau.

After clearing out the notch in preparation for cruciate reconstructions, use of posterior portals and a transseptal portal can help to assess and treat posterior meniscocapsular pathology and to plan for the PCL tibial tunnel. Here are some images of what it looks like to make the posterior portals, looking with the scope from the notch to each respective side. Notice how the 70° arthroscope improves visualization.

With the posterolateral and posteromedial portals made, a transseptal portal can be created by viewing from the posteromedial portal, and bringing the shaver through the posterolateral portal, up to the thin veil of the septum. The shaver can then safely, under direct visualization, excise the septum. We place soft cannulas in the posterior portals once they are made.

Here we are viewing from the posteromedial portal. We were able to clear off the PCL insertion site with a radiofrequency device brought through the posterolateral portal. The PCL aiming guide, set at about 60°, is placed through the anteromedial portal and then hooked about 1 to 1.5 cm over the posterior plateau. Viewing from this portal allows us to ensure that we are far enough off the posterior plateau, so the guide pin pierces the posterior tibia through the anatomical footprint.

We then move the camera back to the anterolateral portal to establish the remainder of the guide pins. The pin for the PCL femoral tunnel is placed with the appropriate targeting guide, with the pin entering high in the notch, about 8 mm off the articular cartilage of the medial femoral condyle.

The ACL tibial and femoral pins are placed in the usual manner as they are in a standard ACL reconstruction.

Here is a tour of the notch from the anterolateral portal with the 4 guide pins in place, showing the PCL femoral pin, the ACL femoral pin, the ACL tibial pin, and the PCL tibial pin.

Once all 4 pins are placed, we use intraoperative fluoroscopy to confirm appropriate positioning prior to drilling the tunnels.

We use a curette to prevent advancement of the tibial PCL pin during drilling and use direct visualization given that this is a high-risk zone.

The tunnels are then drilled over their respective pins. The ACL femoral tunnel is shown here, confirming no breach of the back wall. Passing sutures are then shuttled through the tunnels in the usual manner.

A rasp can be used to gently round the edges of the PCL tunnel apertures over which the PCL graft will be pulled to dissipate the focal pressure on the graft as it makes relatively sharp turns. This can be done on the femoral and tibial sides.

The PCL graft is shuttled through the femoral and tibial tunnels in an antegrade fashion, with the soft tissue end of the Achilles allograft leading, and the bone plug is secured into the femoral tunnel. We use a metal interference screw for fixation on the femoral side.

Suspensory fixation is used for the femoral side of the hamstring autograft ACL reconstruction. Once both grafts are passed and secured on their femoral sides, we tensioned the PCL with the knee in 90° of flexion. For this patient, we used a biocomposite interference screw for tibial tunnel fixation, with an addition of a staple for back-up fixation.

The knee was then taken into full extension, and the tibial side of the ACL graft is tensioned and then secured with a biocomposite sheath and interference screw.

Finally, we perform our medial-sided reconstruction. We used 2 smaller medial incisions for this patient: one proximally over the femoral condyle, and then distally we used our incision that we had made for the hamstring harvest, as this gave us access to the distal superficial MCL insertion. The proximal MCL tissue was of poor quality, so a direct repair alone was not possible. We created a tunnel along the superficial MCL, working from distal to proximal, toward the femoral MCL insertion, and then passed the semitendinosus allograft tendon through.

We used screws and spiked washer technique for MCL fixation. Guide pins for these screws are placed, and then we use fluoroscopy to ensure our screw trajectory does not interfere with our ACL or PCL tunnels.

The allograft is looped around the femoral screw and held in place with the washer, while the tails of the graft are tied around the tibial screw post, which is then secured. We imbricate the posterior oblique ligament in our closure, as well as incorporate what could be salvaged of the MCL remnant.

After final fixation, the knee was stable to valgus stress, and there was excellent anterior, posterior, and rotatory stability of the tibia.

Postoperatively, we advise patients 50% weightbearing on the affected side with a hinged knee brace allowing 0°-90° of motion for 6 weeks. Passive range of motion is highly encouraged in the early period. Full weightbearing and motion is allowed at about 6 weeks, with progression of closed chain exercises and linear-motion exercises. We typically perform formal functional testing prior to any return to sport, which is typically around 9 months postoperatively depending on the patient and injury.

Outcome data for single-stage reconstruction have demonstrated satisfactory Lysholm and International Knee Documentation Committee scores, with most patients returning to previous activity levels at greater than 2 years of follow-up. Optimal surgical timing is still uncertain as outcomes are similar between acute and delayed reconstruction.

Thank you for watching.