Management of Complex Knee Ligament Injuries

7/30/2019 Management of Complex Knee Ligament Injuries

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InstructionalCourse LecturesThe American Academy of Orthopaedic Surgeons

K ENNETH A. E GOL

EDITOR , VOL. 60

C OMMITTEEK ENNETH A. E GOL CHAIR

F REDERICK M. A ZA R M ARY I. OC ONNOR M ARK P AGNANOP AU L T ORNETTA II I

E X -O FFICIOD EMPSEY S. S PRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERYFOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academys Annual Meeting, will be available in February 2011 in Instructional Course Lectures, Volume 60.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8A. M .-5 P . M ., Central time).

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Management of Complex Knee Ligament Injuries

By Gregory C. Fanelli, MD, James P. Stannard, MD, Michael J. Stuart, MD, Peter B. MacDonald, MDRobert G. Marx, MD, MSc, FRCSC, Daniel B. Whelan, MD, Joel L. Boyd, MD, and Bruce A. Levy, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Initial Evaluation of Acute andChronic Multiligament Knee InjuriesInitial evaluation of a knee with multipleligament injuries beginswith a thoroughand complete neurovascular examina-tion, an assessment of the soft tissue,and determination of the instability pattern. Failure to recognize a vascularinjury can lead to catastrophic limbdysfunction and ultimately to amputa-tion. Injury to the tibial and/or peronealnerves can also have devastating conse-quences and is encountered in almost25% of dislocated knees 1 . The modiedSchenck classication2 , in which notonly ligamentous structures but alsoneurovascular injuryand the presence of periarticular fracture are taken intoaccount, is widely used to describe theseinjuries.

Vascular Assessment There are several algorithms for theassessment of vascular injury of thelower limb. Vascular assessment may include physical examination alone, useof the ankle-brachial index, arterialultrasound, and conventional and/orcomputed tomography angiography. A

palpable pulse may be present distal toa complete popliteal arterial occlusion,as a result of the presence of collateralow (Fig. 1). When a patient presentswith hard signs of ischemia, whichinclude a cool, pulseless, obviously dysvascular limb, immediate vascularsurgery consultation is warranted.When the level of the lesion (forexample, the popliteal artery in thesetting of a dislocated knee) is known,the vascular surgeon may opt forimmediate surgical exploration or pro-ceed with angiography. Typically, a sa-phenous vein bypass graft obtainedfrom the contralateral side is used toreestablish arterial ow, and concomi-tant prophylactic four-compartmentfasciotomies are done. When a patientpresents with soft signs of ischemia,including palpable but asymmetricpulses and asymmetric warmth and/orcolor of the limb, further assessment isneeded.

The ankle-brachial index is de-termined by obtaining the systolic bloodpressure of the affected limb at the levelof the ankle and comparing it with thesystolic blood pressure of the ipsilateral

arm at the level of the brachial artery (Fig. 2): ankle-brachial index = Dopplersystolic arterial pressure in injured limb(ankle)/Doppler systolic arterial pres-sure in uninjured limb (brachial).

Mills et al.3 showed that when theankle-brachial index is 0.9 there is norisk of a major arterial injury but,because delayed thrombus is a risk,serial pulse examination should be doneevery four to six hours for a period of twenty-four hours. When the ankle-brachial index is


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Neurologic Assessment Niall et al.1 reported the risk of peronealnerve injury with dislocation of the kneeto be approximately 25%. In their series,4.0 mm indicates a bular collateralligament and posterolateral cornerinjury. In the acute setting, uoroscopicstress examination with the patientunder anesthesia helps to conrmclinical and/or magnetic resonanceimaging ndings.

Magnetic resonance imaging isthe diagnostic imaging modality of choice after radiographs have beenobtained. Magnetic resonance imaging identies the ligament injury andits specic location and extent, bothof which are critical for surgicalplanning.

Indications for Emergency Surgical Treatment The indications for emergency surgicaltreatment include an open knee dislo-cation, an irreducible knee dislocation,and a compartment syndrome. Openknee dislocations require aggressiveirrigation and debridement and place-ment of antibiotic bead pouches and/ora wound vacuum-assisted closure device(VAC; Kinetic Concepts, San Antonio,Texas), and may warrant plastic surgery for soft-tissue coverage. The irreducibleknee dislocation is typically a postero-lateral dislocation in which the medialfemoral condyle buttonholes throughthe medial aspect of the capsule and/orthe medial collateral ligament, causing a classic puckering of the medial skin.Prompt reduction is imperative to avoidskin necrosis and typically requires anopen arthrotomy. In emergency casessuch as these, denitive ligament repairor reconstruction is usually performedin a staged fashion, once all debridementand/or wound considerations have beenaddressed and the soft tissues havehealed satisfactorily to allow additionalsurgery. Indications for the immediateplacement of joint-spanning externalxation include vascular injury requir-ing repair, an open knee dislocation, andthe inability to maintain tibiofemoral joint reduction by other means 7,8 .

Fig. 1Conventional arteriogram demonstrating collateralow to the distal part of the lower extremity despitecomplete popliteal artery occlusion.

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Combined Posterior Cruciate andAnterior Cruciate LigamentReconstructionThe principles of reconstruction ina knee with multiple ligament injuriesinclude identication and treatment of all torn ligaments with accurate tunnelplacement, anatomic graft insertionsites, utilization of strong graft material,secure graft xation, and an extensivepostoperative rehabilitation program 8-24 .

An Achilles tendon allograft is ourpreferred graft for single-bundle poste-rior cruciate ligament reconstructions,and we preferAchilles tendon and tibialisanterior allografts for double-bundleposterior cruciate ligament reconstruc-tions. We prefer either a tibialis anterioror a patellar tendon allograft for anteriorcruciate ligament reconstructions. Theallograft tissue is prepared, and arthro-scopic instruments are placed with theinow in the superolateral portal, thearthroscope in the inferolateral patellarportal, and instruments in the infero-medial patellar portal. An accessory extracapsular extra-articular posterome-dial safety incision is used to protect theneurovascular structures and to conrmthe accuracy of tibial tunnel placement.

Notch preparation is performedrst and consists of anterior cruciate andposterior cruciate ligament stump de-bridement, bone removal, and contour-ing of the medial and lateral walls androof of the intercondylar notch. Specially designed 90 curets and rasps placed

through the notch to the posterior aspectof the tibia are used to elevate the capsuleand clearly identify the tibial footprint of the posterior cruciate ligament.

The arm of the PCL ACL guide isinserted through the inferomedial patel-lar portal to begin creation of the tibialtunnel for the posterior cruciate ligamentgraft. The tip of the guide is positioned atthe inferolateral aspect of the anatomicinsertion site of the posterior cruciateligament. The bullet portion of the guidecontacts the anteromedial surface of the proximal part of the tibia at a pointmidway between the posteromedial bor-der of the tibia and the anterior aspectof the tibial crest approximately 1 cmbelowthetibial tubercle. This will providean angle of graft orientation such that thegraft will turn two very smooth 45 angleson the posterior aspect of the tibia andwill not have an acute 90 -angle turn,which may cause pressure necrosis of thegraft. The tip of the guide in the posterioraspect of the tibia is conrmed with thesurgeons nger through the extracapsu-lar extra-articular posteromedial safety incision. Intraoperative anteroposteriorand lateral radiographs may also be used.The surgeons nger conrms the posi-tion of the guidewire through the pos-teromedial safety incision, providing a double safety check. The appropriately sized standard cannulated reamer is usedto create the tibial tunnel. The surgeonsnger through the extracapsular extra-articularposteromedial incisionmonitors

the position of the guidewire. The drillis advanced until it comes to the pos-terior cortex of the tibia. The chuck isdisengaged from the drill, and the tibialtunnel is completed by hand, whichprovides an additional margin of safety for completion of the tibial tunnel.

The femoral tunnels for single-bundle or double-bundlereconstructionof the posterior cruciate ligament canbe made from inside out. Inserting theappropriately sized double-bundleaimer through a low anterolateral pa-tellar arthroscopic portal creates thefemoral tunnel for the anterolateralbundle of the posterior cruciate liga-ment graft. The double-bundle aimer ispositioned directly on the femoralfootprint of the insertion site of theanterolateral bundle of the posteriorcruciate ligament graft. The appropri-ately sized guidewire is drilled throughthe aimer, through the bone, and outa small skin incision. The double-bundle aimer is removed, and an acornreamer is used to drill endoscopically from inside out the femoral tunnelfor the anterolateral bundle of the pos-terior cruciate ligament graft. Whenthesurgeon chooses to perform a double-bundle double-femoral-tunnel recon-struction of the posterior cruciateligament, the same process is repeatedfor the posteromedial bundle of theposterior cruciate ligament graft. Thereshould be at least 5 mm of bone betweenthe two drill holes.

The tunnels for anterior cruciateligament reconstruction are createdwithuse of the single-incision technique. Thetibial tunnel begins externally at a point1 cm proximal to the tibial tubercle ontheanteromedial surface of theproximalpart of the tibia to emerge through thecenter of the stump of the anteriorcruciate ligament tibial footprint. Thefemoral tunnel is positioned next to theover-the-top position on the medial wallof the lateral femoral condyle near theanatomic insertion site of the anteriorcruciate ligament. The anterior cruciateligament graft is positioned and isanchored on the femoral side; this isfollowed by tensioning and tibial xa-tion of the anterior cruciate ligamentgraft25 (Figs. 3, 4, and 5).

Fig. 2Measurement of the ankle-brachial index.

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Lateral-Sided ReconstructionThe lateral side of the knee is commonly injured as part of a multiligament kneedislocation complex. The modiedSchenck 2,26 classication of knee dislo-cations includes KD IIIL (injuries in-volving the anterior and posteriorcruciate ligaments as well as the lateralcomplex). KD IV is less common andmore severe, as this injury involves boththe medial and lateral sides as well asboth cruciate ligaments. The mechan-ism of this injury includes a strong varusand external rotation force that is high-energy 26 . The lateral side of the knee iscomplex anatomically and thereforedifcult to replicate with reconstructivetechniques.

The lateral side consists of staticand dynamic stabilizers. The staticstabilizers include the bular collateralligament and the popliteobular liga-ment as well as the posterolateral aspectof the capsule. The popliteus muscle andtendon act as both a static and a dy-namicstabilizer to controlposterolateralrotation of the knee. The bular col-lateral ligament acts as a primary re-straint to varus stress and a secondary restraint to posterolateral rotation of the tibia on the femur. The popliteo-bular ligament acts as a primary re-straint to external rotation of the tibiaon the femur at 30 of exion, as does

the popliteus muscle and tendon. Theposterolateral aspect of the capsule actsin a secondary supportive role to resistexternal rotation, hyperextension, andvarus moments 27-29 .

The challenge of anatomic re-constructions is to recreate the postero-lateral anatomy as closely as possible,usually with a combination of femoral,tibial, and bular drill holes and allografttissue. An alternative is to simplify the re-pair by performing a bular and femoral-based reconstruction alone 14,21,30-32 (Figs.6-A and 6-B). There are few studiescomparing types of reconstructions inthe literature, but, with other kneereconstructions, the more anatomicrestorations tend to produce the bestresults. A reconstruction described by LaPrade et al.33 is often mentioned asthe closest reproduction of normalanatomy and will be described later inthis paper.

The timing of surgery hasbeen oneof the most controversial aspects of kneedislocation management. Recent studieshave indicated that earlier reconstructionmay be better 34 , but the evidence is notstrong. The benetsof early surgery mustbe balanced against the risks of arthro-brosis and the risks of infection whereopenwounds persist from either external

Fig. 3

Double-bundle posterior cruciate ligament reconstruction with use of an Achilles tendon allograft(anterolateral bundle) and a tibialis anterior allograft (posteromedial bundle) as well as anterior cruciate ligament reconstruction with use of an Achilles tendon allograft.

Fig. 4Drawingdepictingxation,tunnel,andgraft positioningin a combinedreconstructionof theposteriorandanterior cruciate ligaments. Note the primary aperture-opening xation combined with cortical sus-pensoryback-upxation. (Reprinted, withpermission, from:FanelliGC.Rationaleand surgical techniquefor PCL and multiple knee ligament reconstruction. Warsaw, IN: Biomet Sports Medicine; 2008.)

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xation pin sites or wounds from soft-tissue injury (Fig. 7). The decision whento operate needs to be individualized.

Another controversial issue iswhether to repair or reconstruct theposterolateral corner. Recent work by both Stannard et al. 34 and Levy et al.35

indicates that reconstruction is probably better than repair. When surgery isperformed within the rst three weeksafter the injury, a combination of repairand reconstruction can be done andshould provide the best chance of pro-ducing a stable posterolateral corner.Stannard et al. recently reported a trialof repair versus reconstruction of theposterolateral corner in fty-sevenknees34 . Forty-four (77%) of the patientshad sustained multiple ligament injuriesof the knee, and the minimum duration

of follow-up was twenty-four months.The repair failure rate was 37%, com-pared with a reconstruction failure rateof 9%. Reconstruction was found tohave a signicant advantage over re-pair in terms of stability on clinicalexamination.

In the study by Levy et al.35 ,patients with multiligament knee injuries treated by a single surgeon wereidentied in a prospective database.Between February 2004 and May 2005,patients underwent repair of medial andlateral-sided injuries, followed by de-layed cruciate ligament reconstructions.Between May 2005 and February 2007,patients underwent single-stage multi-ligament knee reconstruction. Forty-veknees (forty-two patients) with a mini-mum of two years of follow-up were

identied. Four of ten repairs of thebular collateral ligament and postero-lateral corner and one of eighteenreconstructions of the bular collateralligament and posterolateral corner failed(p = 0.04). Although neither of thesestudies34,35 was randomized, the ndingsof the two were quite similar, with bothshowing the rate of failure of repairs of the bular collateral ligament and pos-terolateral corner to be signicantly higher than the rate of failure of re-constructions of those structures.

Numerous surgical techniques totreat posterolateral corner injury havebeen described, with varying clinicaloutcomes 14,36-38 . Stannard et al. useda modied two-tailed technique thatreconstructs the popliteobular liga-ment and bular collateral ligamentthrough transtibial and transbularbone tunnels and around a single screw on the lateral femoral condyle 36 . Twenty-two knees were followed for a minimumof two years, and the mean range of motion at the time of follow-up was133 . The mean Lysholm knee score was90 points for the entire group, 92 pointsfor the knees with multiligament injuries, and 88 points for those with anisolated posterolateral corner recon-struction. There were two failures (13%)in the group with multiligament kneeinjuries, compared with no failures inthe group with an isolated posterolateralcorner reconstruction.

Strobel et al. evaluated the clinicaloutcomes after single-stage anteriorcruciate ligament, posterior cruciateligament, and posterolateral corner re-construction in seventeen patients withchronic knee injuries and a minimumduration of follow-up of twenty-fourmonths 37 . The posterolateral cornerwas reconstructed with a graft passedthrough the proximal part of the bula,with both graft limbs inserting at anisometric point on the femur. At thenal evaluation, performed with theInternational Knee DocumentationCommittee (IKDC) score, the result wasgraded as nearly normal for ve of theseventeen patients, as abnormal for ten,and as grossly abnormal for two. Themean postoperative subjective IKDCscore was 71.8 19.3 points.

Fig. 5Postoperative radiograph made after reconstruction of the anterior cru-ciate ligament, posterior cruciate ligament, and posterolateral corner.

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The LaPrade technique 33 has beenpopularized as a stable and anatomically complete reconstruction utilizing a two-tailed graft (usually an Achilles tendonallograft) and reconstructing the bularcollateral ligament, the popliteobularligament, and thepopliteus tendon. Thistechnique requires four tunnels: twoin the femur (for the insertion of thebular collateral ligament and the pop-liteus tendon), one in the bula, and onein the proximal part of the tibia. TheAchilles tendon can be split into twoseparate grafts and bone blocks. Bothbone blocks are inset into the femoraltunnels and secured with interferencescrews, replicating the insertions of thebular collateral ligament and popliteustendon, respectively. The bular col-lateral ligament graft then runs fromanterior to posterior through the tun-nel in the bula and subsequently into

the tibia. The popliteus portion thenruns from the femur into the tibialtunnel to join the other graft. A largebioabsorbable screw is then placedfrom anterior to posterior with the twograft limbs under tension at 30 of exion and slight internal rotation.Excessive internal rotation force canconstrain the knee excessively. Al-though the procedure is technically challenging, the results of this recon-struction appear to be good.

When the posterolateral corner istorn, thereare usuallyotherknee ligamentinjuries. Therefore, when the posterolat-eral corner is being repaired the lateralcollateral ligament and the popliteobularligament complexes should be repaired aswell. Allograft tissue is recommended forposterolateral corner reconstruction sothat autogenous grafts can be used torepair the other ligaments and donor site

morbidity is kept to a minimum. Nu-merous surgical techniques are available,but varus and posterolateral rotatory stability is best restored by the techniquewith which the surgeon is most familiar.

Reconstruction of the MedialCollateral Ligament andPosteromedial CornerCombined injuriesof theanteriorcruciateligament, posterior cruciate ligament, andmedial collateral ligament/posteromedialcorner are classied as Type III according to the modied Schenck anatomic classi-cation scheme. The anatomic structureson the medial side are arranged in threedistinct layers: Layer 1 is the sartorius andsartorius fascia; Layer 2 is the supercialmedial collateral ligament, posterior ob-lique ligament, and semimembranosus;and Layer 3 is the deep medial collateralligament (the meniscofemoral and me-niscotibial ligaments) and the poster-omedial aspect of the capsule. The gracilisand semitendinosus tendons are foundbetween Layers 1 and 2. These layers arenot always separate since Layers 1 and 2blend anteriorly, whereas Layers 2 and 3blend posteriorly.

LaPrade et al.39 described theclinically relevant medial knee anatomy.There are three osseous prominences onthe medial aspect of the distal part of thefemur: the medial epicondyle, the ad-ductor tubercle, and the gastrocnemiustubercle. The femoral origin of thesupercial medial collateral ligamentis approximately 3 mm proximal and5 mm posterior to the epicondyle, whilethe tibial insertion is approximately 6 cm distal to the joint line. The deepmedial collateral ligament inserts along the tibial plateau margin, just distal tothe articular cartilage. The femoralorigin of the posterior oblique ligamentis approximately 8 mm distal and 6 mmposterior to the adductor tubercle.These anatomic sites correspond to theradiographic landmarks described by Wijdicks et al.40 . The combination of recognition of osseous prominences andradiographic identication helps toguide the surgeon to the proper liga-ment origin and insertion sites during repair or reconstruction. In a study of cadaver knees, Stannard et al. 41 found

Fig. 6-A Fig. 6-Aand 6-B Pictorial representationsof bular andfemoral-basedreconstructions of thebular

collateral ligament(FCL) and posterolateralcorner. PFL = popliteobularligament. (Copyrightedandused with permission of Mayo Foundation for MedicalEducation and Research, all rights reserved.)

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that use of radiographic landmarks,rather than palpating the osseous pro-minences, led to better reproduction of the isometry of the supercial medialcollateral ligament.

More than 10 mm of medial jointopening with the knee in full extensionis the hallmark nding in a knee witha combined injury involving the medialside and both cruciate ligaments. Stressexamination, with the patient underanesthesia, with the use of uoroscopy or radiography to compare joint spaceopening of the injured knee with that of the contralateral knee helps the surgeonto understand the extent of pathologicligament laxity. Magnetic resonanceimaging is a sensitive tool for identifying injured structures.

Once the soft tissues are satisfac-tory, acute surgery (performed one tothree weeks after the injury) is indicatedwhenthere is extensive medialdisruption,a displaced meniscal tear, or a so-calledStener lesion of the knee in which the

distal medial collateral ligament is ippedover the pes anserinus tendons. Delayedsurgical intervention (at more than threeweeks after the injury) may be necessary to allow the swelling to resolve and kneemotion to return. When the only medialdamage is a femoral medial collateralligament avulsion, healing may occur andonly the cruciate ligaments need to berepaired. When the anterior cruciateligament, posterior cruciate ligament, andmedial side need to be repaired, a single-stage procedure with anterior and poste-rior cruciate ligament reconstructionsalong with repair or reconstruction of themedial collateral ligament and poster-omedial corner, as indicated, is best.

In the acute setting, a femoral ortibial-sided avulsion of the medialcollateral ligament with good ligamentsubstance can be repaired to the ana-tomic origin with a suture post andligament washer. Figure 8 shows anexample of a tibial-sided disruption of the medial collateral ligament. The in-

tact ligament with excellent tissue sub-stance allows a secure repair without theneed for augmentation or reconstruc-tion. The deep meniscotibial ligamentcan be reattached with suture anchors.The repair should be tensioned with theknee at 30 of exion, a varus stress, andslight tibial external rotation. Injuries of the posterior oblique ligament and theposteromedial aspect of the capsule arealso repaired anatomically with sutureanchors and tensioning near full exten-sion. It is important to avoid overten-sioning in exion, as this may preventfull knee extension.

Numerous reconstruction tech-niques for treatment in the chronicsetting have been described 23,42-44 . Ourpreferred technique is to use an Achillestendon allograft with the bone plug xed in a femoral socket with an in-terference screw and the tendon securedto the tibia with a suture post/ligamentwasher construct. Figure 9 shows theAchilles tendon allograft after xation

Fig. 6-B

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of the femoral attachment. The pos-terior oblique ligament and postero-medial aspect of the capsule are repairedif necessary.

A detailed search of the literaturefrom 1978 through 2008 identied allstudies with outcome data on repair orreconstruction of the medial collateralligament in the setting of combinedligament injuries 8 . Only eight studiesmet the inclusion criteria: ve were onmedial collateral ligament repair, andthree were on medial collateral ligamentreconstruction. No prospective studiesdirectly compared medial collateral lig-ament repair or reconstruction withnonoperative treatment or comparedmedial collateral ligament reconstruc-tion with repair. The collective resultssuggest that either repair or reconstruc-tion in the knee with multiple ligamentinjuries yields satisfactory outcomes.Owens et al.45 reported on eleven kneeswith injuries to the anterior cruciateligament, posterior cruciate ligament,and medial collateral ligament, with themedial collateral ligament repaired only if it was avulsed, and all were stable tovalgus stress at the time of nal follow-up. One of us (G.C.F.) and colleagues 22

reported on nine knees with injuries tothe anterior cruciate ligament, posteriorcruciate ligament, and medial collateralligament, and all were stable to valgus

stress, including seven that were treatedsurgically. In a study by Hayashi et al.46

in which seven reconstructions of theanterior cruciate ligament, posteriorcruciate ligament, and medial collateral

ligament were performed with use of a semitendinosus autograft, the averageLysholm score was 95.1 points. Stannardet al.41 reported on seventy-three dis-located knees with posteromedial corner

Fig. 7Clinical photograph of a knee dislocation requiring spanning external xation with substantial soft-tissue injury.

Fig. 8A tibial-sided disruption of the medial collateral ligamentwith excellent tissue substancethat is amenable to directrepair.

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injuries. Forty-eight underwent auto-graft or allograft reconstruction of themedial collateral ligament, and twenty-four had a medial collateral ligamentrepair. On the basis of a 20% failure ratein the repair group compared with a 4%failure rate in the reconstruction group,Stannard concluded that medial collat-eral ligament repair is inferior to re-construction in a knee with multipleligament injuries.

It is important to make an accu-rate, anatomic diagnosis with the use of physical examination, imaging studies,and bilateral comparison stress radio-graphs. The surgeon needs to determinethe safe and appropriate timing of surgery and then proceed with recon-struction of the anterior and posteriorcruciate ligaments along with repair orreconstruction of the medial collateralligament, posterior oblique ligament,and posteromedial aspect of the capsule.

Postoperative RehabilitationThe knee should be kept in full ex-tension for a minimum of three weeks,and the patient should remain non-weight-bearing for six weeks47 . Pro-gressive range-of-motion exercises startthree weeks after the operation. Thebrace should be unlocked at the end of the third week, and use of the crutchesis discontinued once the patient canbear full weight. Progressive closed-kinetic-chain strength training andcontinued motion exercises are per-formed. Use of the brace should be

discontinued after the tenth week. Thepatient can return to sports and stren-uous labor after the ninth postoperativemonth as long as sufcient strength,proprioceptive skills, and motion havereturned 11,48 . A loss of 10 to 15 of terminal exion might be expectedafter these complex knee ligamentreconstructions.

Fracture-DislocationsFracture-dislocations of the knee aresevere injuries that have frequently beenassociated with poor outcomes 49-54 . Themost common fracture around the kneeassociated with a multiligament kneeinjury is a tibial plateau fracture. It isdifcult to treat patients who haveinstability of both the bone (a fracture)and ligaments of the knee. Recon-structing ligaments is a challenge whenone is trying to anchor a reconstructionin fractured bone. The risk of failure of early reconstruction of the posterolat-eral corner with use of the modiedtwo-tailed technique is higher in pa-tients with a tibial plateau fracture thanit is in patients who do not have afracture 34,36 .

Knee fracture-dislocations occurmore frequently than generally thoughtand are particularly challenging to di-agnose. It is difcult to determine thestability of the knee in a patient witha tibial plateau fracture. These patientsalso frequently have multiple injuriesthat divert the attention of treating teams away from the knee injury. As

identied with magnetic resonance im-aging, the prevalence of concomitantligament injuries with tibial plateaufractures has been reported to be as low as 33% and as high as 90%55-58 . Whilemany of these injuries do not representfracture-dislocations, in Stannards se-ries of 103 consecutive tibial plateaufractures, more than half of the patientshad multiple ligament injuries and26% had a fracture-dislocation 55 .Magnetic resonance imaging is animportant adjunct to an examinationunder anesthesia for the successfuldiagnosis of fracture-dislocations of the knee.

There are very few publishedstudies dedicated to the topic of fracture-dislocation of the knee. The publishedresults show a high prevalence of pooroutcomes, with pain, instability, andarthrobrosis being the most commoncomplications 49-54 . Conservative treat-ment is associated with poor results,and most authors have recommendedsurgical treatment for patients withfracture-dislocation. Delamarter et al.reported that 40% of their patients witha fracture-dislocation had a poor out-come after nonoperative treatment com-pared with a 16% rate of poor resultsin those who had had an operation 59 .Stannard et al. developed a staged treat-ment protocol for fracture-dislocations,in which the treatment of the fracture isseparated from that for the dislocation,and it has yielded good functional out-comesin most patients 60 . Outcome scoresafter use of this staged protocol havebeenencouraging in patients with these com-plex injuries.

The initial phase of treatmentfor a patient with a fracture-dislocationof the knee is on the day of injury. Themechanism of injury, radiographicndings, and examination of the skin leadto a suspicion of a fracture-dislocation.The fracture is gently reduced withtraction, and a careful vascular exami-nation is performed. If the knee remainsreduced, the extremity should be immo-bilized with a splint or knee-immobilizerand magnetic resonance imaging shouldbe performed. In most cases, the skinand soft-tissue injury are so severe thatsurgical treatment should be delayed for

Fig. 9A reconstruction of the medial collateral ligament with an Achillestendonallograftafterxation of thebone block in thefemoral socket.

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at least three to seven days. Once thecondition of the soft tissues around theknee is satisfactory, the second phase of treatment can begin.

Phase two is surgical stabiliza-tion of the fracture and any avulsionsof major ligaments. Locked plates arefrequently necessary to stabilize the com-plex fractures associated with fracture-dislocations. Preoperative planning iscritical, both for successful treatment of the fracture and to ensure that the im-plants do not block future tunnels thatwillbenecessary for reconstructionof theinjured ligament. A knee-immobilizershould be applied after stabilization of the fracture, and one must be certain thatthe knee stays reduced.

Phase three is the early recon-structive phase of the protocol. If thecondition of the patient and the softtissues allow it, we advance to this phaseduring week three or four following theinjury. Allograft ligament reconstruc-tion is the mainstay of this phase. Thereare no denitive data in the literatureregarding the timing or staging of ligament reconstructions in patientsfollowing knee dislocations. On thebasis of the ndings in the seriesevaluated by Stannard et al.34,36 , recon-struction of the anterior cruciate liga-ment and posterolateral corner shouldbe delayed for approximately fourmonths to allow early healing of thetibial plateau before tunnels are drilledthrough the tibia. Those authors re-ported a failure rate of >30% whenposterolateral corner reconstructionshad been performed during phase threecompared with a failure rate of 8% whenthe same posterolateral corner recon-struction technique had beenperformedin patients without a tibial plateaufracture 34,36 . A hinged external xator isplaced at the end of the surgery in phasethree, providing a stable environmentfor early ligament healing. Gentle mo-tion is initiated on postoperative day one if the condition of the soft tissueallows it.

Phase four is the late reconstruc-tive phase. The patient should have atleast 80 of knee exion before starting phase four. The hinged external xatoris removed, and the anterior cruciate

ligament and posterolateral corner arereconstructed if the knee remains un-stable. Again, allograft tissue is normally used for the reconstructions. Early motion aftersurgery is used to minimizearthrobrosis.

In series evaluated by Stannardet al.60 , good functional outcomes wereachieved in patients in whom a fracture-dislocation had been treated with thisstaged protocol. In a series of fty patients witha total of fty-four fracture-dislocations, the nal Lysholm kneescore averaged 86 points (range, 50 to100 points). According to the nal ob- jective IKDC scores, there were thirty-two normal or nearly normal knees andseventeen abnormal knees. However,while good function was achieved,patients required an average of foursurgical procedures to complete theirtreatment.

ComplicationsComplications are frequent after kneedislocations and fracture-dislocations.Complications include a wide variety of conditions including wound-healing,vascular, and neurologic problems. Themost common complications remainpain, arthrobrosis, and ligament in-stability despite reconstruction. Pain isa difcult complication to quantify ob- jectively, but many patients have prob-lems with chronic pain following theseinjuries. The prevalence of chronicpain has ranged from 25% to 68% 61 .Arthrobrosis remains a substantialsource of pain and disability following knee dislocations. The prevalence hasranged from5% to 71% in the publishedliterature, with a mean of 29% of patientshaving arthrobrosis requiring surgicaltreatment 61 . The prevalence of persistentinstability was 100% after nonoperativetreatment, and it ranged from 18% to100% after surgical treatment, with a meanof 42% of patients having instability inat least one plane 61 .

Results of Treatment of Knee DislocationsOutcomes after knee dislocation aredifcult to quantify in large part becausethe injuries are heterogeneous 62 . A kneedislocation can range from a three-

ligament noncontact injury that reducedspontaneously to one sustained in ahigh-speed motor-vehicle accident andis associated with severe neurologic andvascular injuries. Nevertheless, the dataon the outcomes of these injuries aresummarized below.

Levy et al.8 performed a systematicreview of 413 articles on this topic. They evaluated studies that compared surgicaltreatment with nonoperative treat-ment 63-66 , studies that compared repairwith reconstruction 34,67 , and studiesthat compared early and late surgicaltreatment 21,68-71 .

Of the four studies that com-pared operative and nonoperativetreatment 63-66 , one was a meta-analysis of investigations published prior to 2000 63 .In three studies in which the Lysholmscore was used to record postoperativeoutcomes, surgical treatment resulted inhigher mean scores 63-65 , with one of thedifferencesbeingsignicant 64 . The surgicalgroup also had higher IKDC scores 64,66 .Return to work and to sports activitieswere also better overall in the surgically treated group.

Two studies that compared surgi-cal repair with reconstruction wereidentied 34,67 . Direct repair of cruciateligaments resulted in inferior motion,a higher rate of positive posterior sag signs, and a lower rate of return to thepreinjury activity level67 . The rate of failure after repair of the posterolateralcorner was also found to be higher thanthat after reconstruction 34 .

In general, three weeks was themost consistent time point up to whichsurgery was describedas early. Overall,the patients who had had early surgery had improved outcomes for severalparameters 21,68-71 . However, there is po-tential for substantial bias with respectto the timing of surgery because thereason for early or late surgery may berelated to prognosis (such as otherinjuries or the status of the soft tissuesaround the knee).

An excellent prospective cohortstudy with a minimum of two years of follow-up after reconstruction for treat-ment of knee dislocationswas carried outby Engebretsen et al.72 . Inclusion criteriawere injury to both the anterior and

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the posterior cruciate ligament as well asan injury to the medial and/or lateralside. Patients were treated with surgicalreconstruction within twoweeks after theinjury, when that was not contraindi-cated by other injuries. The authors usedboth autograft and allograft tissue, witha trend toward using autograft later inthe study enrollment period. Of 121patients who were initially eligible,eighty-ve patients had sufcient follow-up. Approximately half of the patientsin this cohort sustained what wasconsidered high-energy knee disloca-tions. The median Lysholm score forthe patients who were followed was 83points, and the median Tegner scorewas 5 points. The authors found thatinjuries resulting from high-energy trauma and those involving all fourmajor ligaments resulted in worse out-comes than did those resulting fromlow-energy trauma and those involving three ligaments.

Despite some excellent case seriesas well as comparative studies and theprospective cohort study by Engebretsenet al.72 , we are not aware of any random-ized controlled trials to assist us withoutcome assessment after knee disloca-tion.These injuries are complex and noteasily amenable to randomized trialsfor many reasons 62 . Additional researchis needed to identify prognostic factorsand treatment algorithms to improve

outcomes after these rare and devastat-ing injuries.

OverviewRecent advances in surgical techniques,including anatomic reconstructions, formanagement of knees with multipleligament injuries have led to improvedpatient outcomes. Current recommen-dations include measurement of theankle-brachial index in each patient,early surgical management (earlier thanthree weeks postinjury), the use of autograft or allograft tissue, recon-struction as opposed to repair alone of the bular collateral ligament and pos-terolateral corner structures, recon-struction of the anterior and posteriorcruciate ligaments, and repair and/orreconstruction of the medial collateralligament and posteromedial corner,depending on the injury pattern andquality of tissue. Future research in-cluding the establishment of multicenterworking groups and the collection of prospective data may hold the key toidentifying optimal treatment protocolsfor these complex injuries.

Gregory C. Fanelli, MDDepartment of Orthopaedic Surgery, GeisingerMedical Center, 115 Woodbine Lane, Danville,PA 17822-5212

James P. Stannard, MDDepartmentof Orthopaedic Surgery, University of Missouri, 1 Hospital Drive, Columbia,MO 65212

Michael J. Stuart, MDBruce A. Levy, MDDepartment of Orthopedic Surgery (M.J.S. and B.A.L.) and SportsMedicine Center (M.J.S.), Mayo Clinic,200 First Avenue S.W.,Rochester, MN 55906

Peter B. MacDonald, MDPan Am Clinic, 75 Poseidon Bay, Winnipeg,MB R3M 3E4, Canada

Robert G. Marx, MD, MSc, FRCSCHospital for Special Surgery,535 East 70th Street, New York, NY 10021

Daniel B. Whelan, MDUniversity of Toronto, 55 Queen Street East,Suite 800, Toronto, ON M5C 1R6, Canada

Joel L. Boyd, MDTRIA Orthopaedic Center,8100 Northland Drive,Minneapolis, MN 55431

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. Thisarticle, as well as other lectures presented atthe Academys Annual Meeting, will be

available in February 2011 in Instructional Course Lectures,Volume 60. The completevolume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M. ,Central time).

References

1. Niall DM, Nutton RW, Keating JF. Palsy of thecommon peroneal nerve after traumatic dislocationof the knee. J Bone Joint Surg Br. 2005;87:664-7.

2. Wascher DC. High-velocity knee dislocation withvascular injury. Treatment principles. ClinSports Med.2000;19:457-77.

3. Mills WJ, Barei DP, McNair P. The value of the

ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma.2004;56:1261-5.

4. Levy BA, Zlowodzki MP, Graves M, Cole PA.Screening for extremity arterial injury with the arterialpressure index. Am J Emerg Med. 2005;23:689-95.

5. Redmond JM, Levy BA, Dajani KA, Cass JR, ColePA. Detecting vascular injury in lower-extremity ortho-pedic trauma: the role of CT angiography. Orthope-dics. 2008;31:761-7.

6. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB.The reproducibility and repeatability of varus stressradiographs in the assessment of isolated bular collateral ligament and grade-III posterolateral kneeinjuries. An in vitro biomechanical study. J Bone JointSurg Am. 2008;90:2069-76.

7. Levy BA, Krych AJ, Shah JP, Morgan JA, Stuart MJ.Staged protocol for initial management of thedislocated knee. Knee Surg Sports Traumatol Ar-throsc. 2010 Jul 16 [Epub ahead of print].

8. Levy BA, Dajani KA, Whelan DB, Stannard JP,Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, MarxRG. Decision making in the multiligament-injuredknee: an evidence-based systematic review. Arthros-copy. 2009;25:430-8.

9. Fanelli GC, editor. The multiple ligament injuredknee: a practical guide to management. New York:Springer; 2004.

10. Fanelli GC, editor. Posterior cruciate ligamentinjuries: a practical guide to management. New York:Springer; 2001.

11. Edson CJ. Postoperative rehabilitation of themultiligament-reconstructed knee. Sports Med Ar-throsc. 2001;9:247-54.

12. Fanelli GC. Double-bundle compared with single-bundle posterior cruciate ligament reconstruction.Orthop Today. 2008;28:58.

13. Fanelli GC, Edson CJ. Arthroscopically assistedcombined anterior and posterior cruciate ligamentreconstruction in the multiple ligament injured knee:2- to 10-year follow-up. Arthroscopy. 2002;18:703-14.

14. Fanelli GC, Edson CJ. Combined posterior cruci-ate ligament-posterolateral reconstructions withAchilles tendon allograft and biceps femoris tendontenodesis: 2- to 10-year follow-up. Arthroscopy.2004;20:339-45.15. Fanelli GC,Edson CJ,OrcuttDR, HarrisJD,Zijerdi D.Treatment of combined anterior cruciate-posterior cruciate ligament-medial-lateral side knee injuries.J Knee Surg. 2005;18:240-8.

16. Fanelli GC, Edson CJ, Reinheimer KN. Evaluationand treatment of the multiligament-injured knee. Instr Course Lect. 2009;58:389-95.

17. Fanelli GC, Edson CJ, Reinheimer KN. Posterior cruciate ligament reconstruction: transtibial tunnelsurgical technique. Orthop Today. 2007;27(2):40-6.

18. Fanelli GC, Edson CJ, Reinheimer KN, Beck J.Arthroscopic single-bundle versus double-bundleposterior cruciate ligament reconstruction. Arthros-copy. 2008;24:e26.

2245




13/13

19. Fanelli GC, Edson CJ, Reinheimer KN, Garofalo R.Posterior cruciate ligament and posterolateral corner reconstruction. Sports Med Arthrosc. 2007;15:168-75.

20. Fanelli GC, Feldmann DD. Management of combined anterior cruciate ligament/posterior cruci-ate ligament/posterolateral complex injuries of the

knee. Oper Tech Sports Med. 1999;7:143-9.21. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopi-cally assistedcombined anterior and posterior cruciateligament reconstruction. Arthroscopy. 1996;12:5-14.

22. Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, andresults. Arthroscopy. 2005;21:471-86.

23. Fanelli GC, Tomaszewski DJ. Allograft use in thetreatment of the multiple ligament injured knee.Sports Med Arthrosc. 2007;15:139-48.

24. Levy BA, Fanelli GC, Whelan DB, Stannard JP,MacDonald PA, Boyd JL, Marx RG, Stuart MJ; KneeDislocation Study Group. Controversies in thetreatment of knee dislocations and multiligamentreconstruction. J Am Acad Orthop Surg. 2009;17:197-206.

25. Fanelli GC. Rationale and surgical technique for PCL and multiple knee ligament reconstruction.Surgical technique guide. Warsaw, IN: Biomet SportsMedicine; 2008.

26. SchenckRC Jr,KovachIS, Agarwal A, BrummettR,Ward RA, Lanctot D, Athanasiou KA. Cruciate injury patterns in knee hyperextension: a cadaveric model.Arthroscopy. 1999;15:489-95.

27. Baker CL Jr, Norwood LA, Hughston JC. Acuteposterolateral rotatory instability of the knee. J BoneJoint Surg Am. 1983;65:614-8.

28. LaPrade RF, Wentorf FA, Fritts H, Gundry C,Hightower CD. A prospective magnetic resonanceimaging study of the incidence of posterolateral andmultiple ligament injuries in acute knee injuriespresenting with a hemarthrosis. Arthroscopy. 2007;23:1341-7.

29. Sanchez AR 2nd, Sugalski MT, LaPrade RF.Anatomy and biomechanics of the lateral side of theknee. Sports Med Arthrosc. 2006;14:2-11.

30. Nau T, Chevalier Y, Hagemeister N, Deguise JA,Duval N. Comparison of 2 surgical techniques of posterolateral corner reconstruction of the knee. Am JSports Med. 2005;33:1838-45.

31. Schechinger SJ, Levy BA, Dajani KA, Shah JP,Herrera DA, Marx RG. Achilles tendon allograft re-construction of the bular collateral ligament andposterolateral corner. Arthroscopy. 2009;25:232-42.

32. Sekiya JK, Kurtz CA. Posterolateral corner re-construction of the knee: surgical technique utilizinga bid Achilles tendon allograft and a double femoraltunnel. Arthroscopy. 2005;21:1400.

33. LaPradeRF, JohansenS, WentorfFA, Engebretsen

L, Esterberg JL, Tso A. An analysis of an anatomicalposterolateral knee reconstruction: an in vitro bio-mechanical study and development of a surgical tech-nique. Am J Sports Med. 2004;32:1405-14.

34. Stannard JP, Brown SL, Farris RC, McGwin G Jr,Volgas DA. The posterolateral corner of the knee:repair versus reconstruction. Am J Sports Med. 2005;33:881-8.

35. Levy BA, Dajan KA, Morgan JA, Shah JP, DahmDL, Stuart MJ. Repair versus reconstruction of thebular collateral ligament and posterolateral corner inthe multiligament-injured knee. Am J Sports Med.2010;38:804-9.

36. Stannard JP, Brown SL, Robinson JT, McGwin GJr, Volgas DA. Reconstruction of the posterolateralcorner of the knee. Arthroscopy. 2005;21:1051-9.

37. Strobel MJ, Schulz MS, Peterson WJ, EichhornHJ. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner recon-struction with autogenous hamstring grafts in chronicinstabilities. Arthroscopy. 2006;22:182-92.

38. Yoon KH, Bae DK, Ha JH, Park SW. Anatomic

reconstructive surgery for posterolateral instability of the knee. Arthroscopy. 2006;22:159-65.

39. LaPrade RF, Engebretsen AH, Ly TV, Johansen S,Wentorf FA,EngebretsenL. Theanatomy of themedialpart of the knee. J Bone Joint Surg Am. 2007;89:2000-10.

40. Wijdicks CA, Grifth CJ, LaPrade RF, Johansen S,Sunderland A, Arendt EA, Engebretsen L. Radio-graphic identication of the primary medial kneestructures. J Bone Joint Surg Am. 2009;91:521-9.

41. Stannard JP, Volgas DA, Azbell CH. Posteromedialcorner injury in knee dislocations. Read at the 35thAnnual Meeting of the American Orthopaedic Society for Sports Medicine; 2009 Jul 9-12; Keystone, CO.

42. Borden PS, Kantaras AT, Caborn DN. Medialcollateral ligament reconstruction with allograft usinga double-bundletechnique. Arthroscopy.2002;18:E19.

43. Kim SJ, Lee DH, Kim TE, Choi NH. Concomitantreconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee.J Bone Joint Surg Br. 2008;90:1323-7.

44. Lind M, Jakobsen BW, Lund B, Hansen MS,Abdallah O, Christiansen SE. Anatomical reconstruc-tion of the medial collateral ligament and postero-medial corner of the knee in patients with chronicmedial collateral ligament instability. Am J SportsMed. 2009;37:1116-22.

45. Owens BD, Neault M, Benson E, Busconi BD.Primary repair of knee dislocations: results in 25patients (28 knees) at a mean follow-up of four years.J Orthop Trauma. 2007;21:92-6.

46. Hayashi R, Kitamura N, Kondo E, Anaguchi Y,Tohyama H, Yasuda K. Simultaneous anterior andposterior cruciate ligament reconstruction in chronicknee instabilities: surgical concepts and clinicaloutcome. Knee Surg Sports Traumatol Arthrosc.2008;16:763-9.

47. Higgins L, Clatworthy M, Harner CD. Multiliga-ment injuries of the knee. In: Garrett WE Jr, Speer KP,Kirkendall DT, editors. Principles and practice of orthopedic sports medicine. Philadelphia: LippincottWilliams & Wilkins; 2000. p 805-17.

48. Fanelli GC. Posterior cruciate ligament rehabili-tation: how slow should we go? Arthroscopy. 2008;24:234-5.

49. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: failure of arthro-scopic treatment. Arthroscopy. 1993;9:446-50.

50. Dendrinos GK, Kontos S, Katsenis D, Dalas A.Treatment of high-energy tibial plateau fractures by

theIlizarovcircular xator. J Bone Joint Surg Br.1996;78:710-7.

51. Hohl M. Tibial condylar fractures. J Bone JointSurg Am. 1967;49:1455-67.

52. Mills WJ, Nork SE. Open reduction and internalxation of high-energy tibial plateau fractures. OrthopClin North Am. 2002;33:177-98, ix.

53. Moore TM. Fracture dislocation of the knee.Clin Orthop Relat Res. 1981;156:128-40.

54. Stokel EA, Sadasivan KK. Tibial plateau frac-tures: standardized evaluation of operative results.Orthopedics. 1991;14:263-70.

55. Stannard JP, Schmidt AH, Kregor PJ, editors.Surgical treatment of orthopaedic trauma. New York:Thieme; 2007.

56. Gardner MJ, Yacoubian S, Geller D, Suk M,Mintz D, Potter H, Helfet DL, Lorich DG. The inci-dence of soft tissue injury in operative tibial plateaufractures: a magnetic resonance imaging analysisof 103 patients. J Orthop Trauma. 2005;19:79-84.

57. Holt MD, Williams LA, Dent CM. MRI in the man-

agement of tibial plateau fractures. Injury. 1995;26:595-9.

58. Shepherd L, Abdollahi K, Lee J, Vangsness CT Jr.The prevalence of soft tissue injuries in nonoperativetibial plateau fractures as determined by magneticresonance imaging. J Orthop Trauma. 2002;16:628-31.

59. Delamarter RB, Hohl M, Hopp E Jr. Ligamentinjuries associated with tibial plateau fractures. ClinOrthop Relat Res. 1990;250:226-33.

60. Stannard J, Bankston L, Volgas DA, McGwin G Jr.Fracture dislocation of the knee: clinical outcomeswith a treatment protocol using a hinged externalxator. Read at the 31st Annual Meeting of theAmerican Orthopaedic Society for Sports Medicine;2005 Jul 14-17; Keystone, CO.

61. Stannard J, Schenck RC Jr, Fanelli G. Kneedislocations and fracture-dislocations. In: BucholzRW, Heckman JD, Court-Brown CM, Tornetta P 3rd,editors. Rockwood and Greens fractures in adults.7th ed. Philadelphia: Lippincott Williams & Wilkins;2009. p 1832-66.

62. Levy BA, Marx RG. Outcome after knee disloca-tion. Knee Surg Sports Traumatol Arthrosc. 2009;17:1011-2.

63. Dedmond BT, Almekinders LC. Operative versusnonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14:33-8.

64. Richter M, Bosch U, Wippermann B, Hofmann A,Krettek C. Comparison of surgical repair or recon-struction of the cruciate ligaments versus nonsurgicaltreatment in patients with traumatic knee disloca-tions. Am J Sports Med. 2002;30:718-27.

65. RosA, VillaA, Fahandezh H,de Jos e C,VaqueroJ.Resultsafter treatment of traumatic kneedislocations:a report of 26 cases. J Trauma. 2003;55:489-94.

66. Wong CH, Tan JL, Chang HC, Khin LW, Low CO.Knee dislocations-a retrospective study comparingoperative versus closed immobilization treatmentoutcomes. Knee Surg Sports Traumatol Arthrosc.2004;12:540-4.

67. Mariani PP, Santoriello P, Iannone S, Condello V,Adriani E. Comparison of surgical treatments for kneedislocation. Am J Knee Surg. 1999;12:214-21.

68. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH.Loss of motion after anterior cruciate ligamentreconstruction. Am J Sports Med. 1992;20:499-506.

69. Liow RY, McNicholas MJ, Keating JF, Nutton RW.Ligament repair and reconstruction in traumatic disloca-tion of the knee. J Bone Joint Surg Br. 2003;85:845-51.

70. Tzurbakis M, Diamantopoulos A, Xenakis T,Georgoulis A. Surgical treatment of multiple kneeligament injuries in 44 patients: 2-8 years follow-upresults. Knee Surg Sports Traumatol Arthrosc.2006;14:739-49.

71. Wascher DC, Becker JR, Dexter JG, Blevins FT.Reconstruction of the anterior and posterior cruciateligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts. Am J Sports Med.1999;27:189-96.

72. Engebretsen L, Risberg MA, Robertson B,Ludvigsen TC, Johansen S. Outcome after kneedislocations: a 2-9 years follow-up of 85 consecutivepatients.Knee SurgSports TraumatolArthrosc. 2009;17:1013-26.

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Management of Complex Knee Ligament Injuries