Anatomic Multiligament Knee Reconstruction With a Medial Meniscal Repair in the Setting of a Valgus Hyperextension Injury

Abstract

Background:

Simultaneous anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial collateral ligament (MCL) tears represent a severe form of multiligament knee injury (MLKI). This combination of injuries often results from high-energy trauma and leads to gross instability, impaired joint biomechanics, and long-term degenerative changes if not addressed appropriately. Untreated or improperly treated MLKIs may result in chronic pain, instability, and early onset osteoarthritis.

Indications:

Combined ACL, PCL, and MCL reconstruction is indicated in patients with complete tears of all 3 ligaments confirmed on physical examination, stress radiography, and magnetic resonance imaging, typically presenting with marked instability in both the anterior-posterior plane and to valgus stress. Early surgical intervention is often recommended in active individuals and in cases of knee dislocation, where spontaneous reduction may obscure the extent of concomitant ligament tears.

Technique Description:

The technique described was used to surgically reconstruct the ACL, PCL, and MCL, and repair the medial meniscus. A central-third bone-patellar tendon-bone autograft was used for the arthroscopic ACL reconstruction, and a double bundle PCL reconstruction used Achilles and tibialis anterior tendon allografts. The medial meniscal repair was also performed arthroscopically. The MCL was reconstructed open using autografts of the semitendinosus and gracilis tendons.

Results:

Clinical outcomes after simultaneous reconstruction of the ACL, PCL, and MCL have demonstrated significant improvements in subjective stability, return to sports, and pain reduction. Patients with multiligament injuries treated within 3 weeks have been reported to have improved outcomes compared with those who delay surgery.

Discussion:

Anatomic reconstruction of concomitant ACL, PCL, and MCL tears is an effective technique for restoring knee stability and function in the setting of multiligament knee trauma. Early diagnosis and treatment are critical for optimal outcomes. Single-stage reconstruction allows for efficient restoration of native biomechanics while minimizing the risk of instability, osteoarthritis, and chronic pain.

Patient Consent Disclosure Statement:

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 presentation demonstrates an anatomic multiligament knee reconstruction with a medial meniscal repair in the setting of a valgus hyperextension injury.

Background

Simultaneous tears of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial collateral ligament (MCL) represent a rare but severe form of multiligament knee trauma. These injuries are typically sustained during high-energy events and result in profound instability and loss of normal knee biomechanics. ⁸ If not addressed appropriately, patients are at a higher risk for chronic pain, functional limitations, and early degenerative joint disease. ⁴

The complexity of this injury pattern poses unique challenges in diagnosis, surgical planning, and rehabilitation. Anatomic, single-stage reconstruction of all 3 ligaments offers to restore knee stability and function, particularly in young, active patients.^3,5 Appropriate graft selection, tunnel positioning, and sequential fixation are essential to optimize the outcomes and avoid complications such as tunnel convergence or graft failure. ⁹

Indications

The patient depicted here is a 19-year-old man who presented to our clinic with left knee pain and instability. He reported that pain began after an altercation 7 days prior when he was kicked in the left knee, causing a valgus hyperextension injury.

Examination of the patient's left knee revealed significant swelling and ecchymoses around the medial aspect. The patient's range of motion in the left knee ranged from 0 cm of heel height to 90° of flexion, compared with 2 cm of heel height and 130° of flexion on the right knee. The left knee demonstrated a grade 2+ Lachman test and increased anterior tibial translation, with a grade 3+ posterior drawer.

PCL stress radiographs revealed 16.1 mm of increased posterior tibial translation in the left knee compared with the right, a discrepancy consistent with a PCL tear combined with a severe medial-sided knee injury. Valgus stress radiographs demonstrated a 6.6-mm increase in medial compartment gapping on the left knee compared with the right, a difference typical in a severe MCL injury.

Magnetic resonance imaging revealed ACL, PCL, MCL, posterior oblique ligament (POL), and medial patellofemoral ligament tears, a medial meniscal tear, lateral femoral condyle and posteromedial tibial bone bruising, and a nondisplaced impaction fracture of the anterior lateral tibial plateau.

The final diagnosis included an acute ACL tear, acute grade 3 PCL, MCL, and POL tears, and a posterior horn medial meniscal tear. The patient elected to undergo anatomic left knee arthroscopic ACL and double-bundle PCL reconstructions, an open MCL reconstruction, and an arthroscopic all-inside medial meniscal repair. A double-bundle PCL reconstruction was selected over a single-bundle reconstruction as biomechanical studies have reported that double-bundle reconstruction restores posterior translation and rotational stability to near-native kinematics. ⁶ In all cases, ligament reconstructions were selected over ligament repairs, given that reconstruction provides a lower likelihood of retear in adolescents and repairs are not recommended for complete midsubstance grade 3 tears, such as the ones observed in this patient. Before surgery, the patient completed 1 month of preoperative rehabilitation to improve the knee range of motion.

The patient underwent surgery 29 days after his initial examination. Examination under anesthesia was consistent with clinical findings of a severe multiligament injury with a grade 3+ pivot shift, posterior drawer, and valgus stress test at 30°, and a grade 2+ Lachman and valgus stress testing in extension. In contrast to clinical findings, this examination showed that the patient's patella was no longer subluxing.

Technique Description

An anteromedial incision was made starting over the vastus medialis oblique muscle belly and extending 8 cm distal to the joint line. After dissection, the semitendinosus and gracilis tendons were identified. The superficial MCL (sMCL) was also identified and was completely torn at the tibial attachment. Adhesions were removed from the tendons, which were then harvested with an open-ended hamstring graft harvester with the distal attachments left intact. A spinal needle was placed at the joint line, and a ruler was then used to measure 6 cm distal to the joint line, where 2 Q-fix anchors (Smith & Nephew) were placed at the distal tibial attachment of the sMCL.

Then, the femoral side of the medial knee was dissected to identify the adductor magnus tendon, which allowed for the identification of the adductor tubercle. A ruler was used to measure 12.6 mm distal and 8.3 mm anterior to the adductor tubercle to identify the medial epicondyle. Just posterior and proximal to this, the sMCL attachment site was identified. A Beath pin was placed at the sMCL femoral attachment, and the attachment was overreamed with a 7-mm reamer, and a passing stitch was placed.

The semitendinosus and gracilis tendon grafts were then passed under the remaining sartorius fascia and whipstitched at the end, such that 3 cm would fit into the reconstruction tunnel.

Next, the knee was dissected to identify the POL, which appeared taut and thickened with scar tissue. Given that the POL had healed in, no repair was deemed necessary.

The dissection continued anteriorly to identify the central third of the patellar tendon, which was then harvested with a 10 × 20 mm bone block off the patella and a 10 × 25 mm bone block off the tibial tubercle. The patellar tendon graft was prepared for ACL reconstruction and was sized to fit through 10-mm tunnels with 2 passing sutures in each bone block.

Next, the PCL anterolateral bundle (ALB) was prepared from an Achilles tendon allograft with an 11 × 20–mm bone plug and a distal tubularized graft. The PCL posteromedial bundle (PMB) was prepared from a tibialis anterior allograft, and it was whipstitched on each end with No. 2 nonabsorbable sutures.

While grafts were being prepared, the medial and lateral arthroscopic portals were created, and the joint was insufflated with normal saline.

There was some softening of the lateral tibial plateau and mild fissuring due to the impaction fracture and bone bruising.

The medial compartment demonstrated a drive-through sign, and there was a tear in the medial meniscus. The edges of the meniscal tears were rasped in preparation for a repair later in the procedure.

Both the ACL and PCL were identified and completely torn off the femur. The attachment sites of the PCL ALB and PMB on the femur were identified. After identification, 11 mm and 7 mm diameter closed-socket tunnels were reamed 25 mm deep at the femur attachment sites for the ALB and PMB, respectively.

Next, the ACL femoral attachment site was identified inferior to the lateral intercondylar ridge. A bur hole was made at this location to serve as a guide for the beath pin. The knee was maximally flexed, and the beath pin was drilled anterolaterally out of the thigh and overreamed with a 10-mm diameter low-profile reamer, maintaining a 1-mm backwall. The ACL femoral tunnel depth was 25 mm.

The remaining PCL was then visualized as it was bunched up posteriorly and significantly scarred. A posteromedial portal was made, and the remaining tissue over the bundle ridge was debrided. The shaver and coagulator were faced anteriorly to avoid the posterior neurovascular structures.

The shiny white fibers of the posterior horn of the medial meniscus were identified and used as a landmark of the PCL facet during PCL tunnel drilling to avoid an iatrogenic medial meniscal root tear. ⁶ A PCL guide was used to drill a guide pin starting 6 cm distal to the joint line, and exited just superior to the champagne glass drop-off at the bundle ridge. This was positioned as close to the midline on the anteromedial tibia as possible, due to the need for another reconstruction graft tunnel. An intraoperative lateral radiograph was obtained to confirm that the guide pin was placed at the correct location in the PCL facet.

The ACL tibial tunnel pin was then reamed directly adjacent to the anterior horn of the lateral meniscus, and due to the length of the BTB autograft, the tunnel guide was placed as far distally as possible on the anteromedial tibia.

Next, a single FastFix Flex (Smith & Nephew) suture was used to perform an all-inside direct repair of the medial meniscal tear, which had been previously rasped.

The PCL tibial tunnel was then reamed with a 12-mm reamer to 70% of its length, and the remaining portion was completed by hand, with a large curette protecting the neurovascular structures. A gore Smoother (Smith & Nephew) was then placed in the tibial tunnel and passed out the anterolateral arthroscopic portal to help with graft passage and remove any bony spicules present.

The PCL allografts were then ready for insertion. First, the PMB graft was passed into its femoral tunnel and secured with a 7 × 20–mm bioabsorbable screw. Then, the bone plug of the ALB was passed into its femoral tunnel, cortical side up, and fixed in place with a 7 × 20–mm titanium screw. Both the ALB and PMB grafts were passed through the tibial tunnels with a large gore smoother. Allografts were utilized for the PCL double-bundle reconstruction as opposed to quadricep and hamstring tendon autografts to minimize harvesting autografts from the contralateral knee.

The tibial guide pin for the ACL reconstruction graft was then overreamed with a 10-mm reamer. The ACL autograft was then pulled through the tibial tunnel and into the femoral tunnel until the bone block was in the appropriate position. The graft was then fixed to the femur with a 7 × 20–mm titanium screw. The patellar tendon BTB autograft was selected for ACL reconstruction to promote bone ingrowth and healing and a lower risk of graft rerupture.

Returning to the PCL, the bundles were individually fixed on the tibia with 6.5-mm titanium screws and an 18-mm spike washer. The ALB was first fixed at 90° of flexion with an anterior reduction force and the foot in neutral rotation. Then, the PMB was similarly fixed in full extension. The PCL was tensioned and fixed before the ACL to reduce the risk of posterior translation when the knee is in extension. After PCL fixation, the patient's posterior drawer test was eliminated.

The ACL graft was then fixed in the tibial tunnel with the knee in full extension. A trough technique was utilized due to graft tunnel mismatch, and 2 Richard staples were used to fix the ACL autograft, eliminating the positive Lachman test.

Lastly, the MCL graft was fixed in its femoral tunnel, with the knee at 20° of flexion and a slight varus reduction force. The final MCL graft fixation was for the proximal tibial MCL attachment by placing a Q-Fix anchor (Smith & Nephew) 15 mm distal to the joint line on the tibia and then sewing the graft to reconstitute the proximal tibial attachment of the sMCL.

The deep and superficial tissues were closed, and a sterile dressing was placed with a knee immobilizer in full extension.

Results and Discussion

This complex procedure is not without potential complications that can affect both short- and long-term patient outcomes. Arthrofibrosis remains the most frequently reported complication of MLKI reconstruction and is especially prevalent with MCL injuries and when reconstruction is performed within the first 3 weeks after injury. ¹⁰ Early mobilization protocols and appropriate rehabilitation can reduce this risk, although more severe cases may require surgical lysis of adhesion or manipulation under anesthesia.

Graft failure is another complication typically involving the ACL or PCL. This often results from improper tunnel placement, poor graft selection, or premature return to activity. ⁸

Persistent instability despite reconstruction is another complication that may result from improper graft placement, biological graft failure, or inadequate rehabilitation. ⁹

Finally, tunnel convergence is particularly concerning in complex reconstructions, as it can compromise graft integrity and lead to failure. To avoid convergence of the sMCL and PCL tibial tunnels, the sMCL tunnel should be directed transversely across the tibia and 30° distally. ⁹ Additionally, femoral tunnel convergence of the PCL and sMCL can be avoided by aiming the PCL tunnel 40° proximally and 40° anteriorly while directing the sMCL tunnel 20° proximally and 20° anteriorly. ⁷

The patient began physical therapy on postoperative day 1 to work on quadriceps activation, edema control, and knee motion. He remained nonweightbearing on his left lower extremity for 6 weeks. For the first 2 weeks after surgery, knee flexion was limited to 90° and then increased as tolerated. The patient transitioned to a dynamic PCL brace and wore it at all times except when showering and changing clothes for the first 6 months of recovery.

Plain films were ordered and received on postoperative day 1 in the clinic. They demonstrated no evidence of fractures or soft-tissue abnormalities. Hardware was intact and nondisplaced.

A study by Fine et al ² reported return to sport outcomes of youth athletes after multiligament knee injuries and operative reconstruction or repair of at least 1 of these ligaments. The results of this study showed that 27 of the 30 patients included in the study were able to fully return to sports after their multiligament injury, and 13 were able to return to their preinjury level of play or higher. ²

Even with the technical demands, early operative intervention in the acute setting has demonstrated superior outcomes in both subjective knee function and objective stability when compared with delayed surgery.^1,4 Despite these findings, there is generally no consensus on the optimal timing for MLKR surgery. ¹ Future studies—including prospective randomized control trials and matched cohort studies—are needed to better understand the outcomes for acute and delayed surgical reconstruction of these injuries.