Thank you very much for the opportunity to present today. Actually, I take that back. I guess it's not today, is it really? So I'll start that again. Okay, don't worry about it. All right, thanks. I'd like to thank the organizers for the opportunity to be a part of this course and to give you this presentation. I was asked to present on multiple ligament reconstruction and in particular, how I approach it. I know that you have access to other talks that kind of get into the nitty gritty of some of the details of management and thought processes for specific areas of the knee. So I will try to keep this as more of a broad overview slash review of management. And then in particular, discuss my own approach at this point of my career. I have nothing to disclose related to this presentation. And here's the things we'll go through. So we'll briefly talk about the initial management, which obviously in these patients with multiple ligament injuries, particularly those that have knee dislocations, that it is important to stabilize the limb first and make sure that we have good control of the limb before we think about doing anything else. It's then important to be able to classify the injury itself and understand what all needs to be operated on. We'll go through the exam and the diagnostics to help us figure that out. And then I'll get into how I approach it. And finally, we'll talk about rehab. And then I have a slide at the end to just discuss some of the recent areas of focus in the research on multiligament reconstruction. So this is an old slide, but an important one. It still holds true. So the first thing when you see a multiple ligament injury, injured knee, is to think about whether this potentially could be a knee dislocation. Roughly 50% of knee dislocations come in reduced. They're not displaced. And so you can be fooled into thinking that it's a less of an injury than what it actually is. So anytime there's likelihood of multiple ligaments, you need to be thinking about a knee dislocation. Not every multiple ligament injury is a knee dislocation, but every knee dislocation, generally speaking, is a multiligament injury. And so it's important to work that up first, obviously, with the history and physical exam. If you have some suspicion that there is a dislocation or you know that there is a dislocation, then you need to obviously make sure to evaluate the vascular and the neurologic status. In particular, the vascular is an urgency, and so you need to evaluate that with pulses and Doppler. If you're not able to find the pulse, then you need to move on to a vascular consult or an arteriogram. If you can find a pulse and you know the knee was dislocated then it's likely valuable to still consider an arteriogram. If you can find a pulse and the knee is located, then you can observe, but you need to observe closely. So to specifically speak about vascular injury, important to remember that limb ischemia greater than eight hours, there is a very high risk for amputation. So time is of the essence, and in many cases, these patients have been out somewhere before they get to the emergency room, so there is not a lot of time to work with. So obviously, as we mentioned before, pulses, ABI should be evaluated, and then also follow the leg compartments very carefully for the risk of compartment syndrome. Many of these patients, especially known dislocations, should undergo inpatient monitoring. As we mentioned before, arteriography and or vascular consultation for significant vascular injuries should be initiated very quickly in order to reestablish blood flow to the leg. Nerve injury in those significant dislocations is also not uncommon, particularly the perineal nerve. It is the most common nerve injury. In dealing with that, if it is in from a neuro status, then you want to isolate and protect that throughout the case. Even if it's not in, you want to isolate it and protect it. But if it's out, then you explore it. If there is a possibility of repairing, especially if you have someone who has some expertise in that area, then you want to try to repair. The key thing is then to wait and to see what kind of function you get back. And then the last thing is the overall stability of the knee. Historically, many of these, especially true dislocations, have been placed into an X-Fix. That obviously stabilizes the leg and helps the soft tissues as well as the neurovascular structures. The challenge is that that often then results in a very stiff knee. And so an unstable and stiff knee is more challenging more challenging than a knee that is unstable and very flexible. And so my preferred approach in this case, if possible, if it can be managed, is to place the patient into a hinged knee brace and to stabilize them that way. In some cases, that's just not possible and an X-Fix is necessary, especially if there's associated fractures and things like that. But in an ideal world, the key is to try to keep the knee mobile while also keeping it stable. From a classification standpoint, important to remember that the direction of injury is defined by the tibia. And so it's important to identify which direction the tibia is going. Sometimes it's going in straight cardinal direction plane. In other cases, there's the rotational instability. So it's important to define that. That also helps to give you some sense of what structures are likely to be injured. And then from a knee dislocation standpoint, I wanna remind you of the KD classification as defined by one of my mentors, Bob Skink, and also built upon by him and another one of my mentors, his partner, Dan Washer. So it's important, again, to be able to identify which structures are injured and therefore which structures we're going to be dealing with when it comes to the surgery. So this is all pretty self-explanatory. Important to remember that we also add the modifiers of vascular and nerve injury. On exam, obviously it's important to do your typical exam findings. You're all aware of what those are, but in particular for multiligament injury, it's important to assess the external rotation and internal rotation asymmetry, and then to perform, and related to that, the dial test, which is done at both 30 degrees and 90 degrees, as you can see in the image on the right. Obviously, we're looking for any asymmetry. If there is asymmetry, then that suggests that there is some injury to that side, and 30 and 90 degrees, as you all know, impacts the posterolateral corner versus the PCL or both. Stress radiographs are something that have been used historically. It's not used all of the time. In many cases, it's pretty obvious what's going on. As you can see in these pictures, doing the stress radiographs sometimes can be uncomfortable for patients, but if there is a question of what's going on, then reminding yourself that using a stress radiograph can be very helpful, especially in those more subtle ones that you're not sure exactly how much injury occurred and or opening there is. If you do see opening on stress radiographs, then that's going to make you more likely to fix or approach those areas. Obviously, MRI is the mainstay, and we're looking at all of the four key ligaments in the knee as well as any other injury to cartilage, meniscus, or other stabilizing structures, including patellar, quad tendons, and the medial and lateral retinaculum. In some cases, particularly those KD5s, then you'll think about using a CT to understand the fracture pattern. Getting into my surgical approach, obviously, the first thing is in the acute setting to understand the vascular injury. That's the first priority, and getting blood flow reestablished to the limb. Also, if there's any kind of open fracture or dislocation, then we need to think about urgency to the operating room, getting that all cleaned out. And as I mentioned before, this is high-risk for compartment syndrome, so that needs to be carefully monitored and, if found, addressed in a timely manner. In terms of the timing of repair of any of the structures, particularly the posteromedial and posterolateral structures, there is some controversy in terms of the efficacy of repair. I think most of us surgeons doing multiligament reconstructions feel that if we can get some repair of tissues, it's useful, whether that's done at the definitive procedure or whether that's done in an initial setting before you get adequate motion back to the knee. There's some controversy there. Most of the time, if we're going to repair, we feel that it's ideal to do that within the first two to four weeks. Sometimes that matches up with minimal swelling and good range of motion so that you can do the definitive treatment. Sometimes it does not, and you have to use your better judgment about whether it's of value than to go in and do some repair and potentially come back later to do a complete reconstruction. The challenge is that if there is a repair and then you have to do a reconstruction later, if there's much time in between those, it is easier for those soft tissue structures that you've repaired to get stretched out. As far as definitive treatment, I've kind of already alluded to it, but we want to have minimal swelling and good range of motion. That doesn't mean necessarily full range of motion and no swelling, but it should be well-controlled so that after surgery, we can get the knee moving and have as minimal swelling as possible. There's discussion always about should this be staged and should you do parts of it, especially the multi-ligaments that involve three or four ligaments? Should we do collaterals and the central pivot separately? For me, my ideal preference is to do them all at once, if possible. I have found that it's rare that I'm needing to do it in a staged manner. The challenge is that if the knee is not in the most mechanically optimal environment and you have some structures that are in and healing, but some that are not in, then there is significant stress on those structures that are in and healing, and the reconstruction can also stretch out. I like to highlight this picture. This is from another one of my mentors that I trained with, Mark Miller. I don't use all of this hardware or metal hardware in any way anymore. However, I think it really highlights in these complex multi-ligament injuries, the number of places where you're putting hardware and how you need to be careful that the hardware is staying, or that the tunnels in particular are staying separate from other tunnels. We'll talk through that briefly here. So I like to start obviously with an examination under anesthesia. That's the best source for understanding the status of the ligaments. And you can see in the images on the right that obviously those are areas where the ligaments have been injured because we have drive-through signs in both the medial and lateral departments. Actually, before I start the exam under anesthesia, especially if it's a true multi-ligament of two or more ligaments, then I will often make an egress incision. So if I know I'm going to make a medial or lateral incision, I will make that approach and then get down to the capsule and make a small rent in the capsule so that we can have extravasation of scope fluid through the capsule and through that incision rather than that scope fluid ending up in the compartments because in most cases, the capsule is disrupted. And if the surgery goes on for a long time, you can have arthroscopic fluid that's then extravasating into the compartments, either proximally or distally, and you can end up with compartment syndrome from the surgery itself. So I like to do an egress incision in these multi-ligament reconstructions. If possible, I like to use no tourniquet. Obviously that does make it a little more complicated and if it's bleeding, then it can make it take longer. And so you have to weigh that against getting everything done. If you do prefer to use a tourniquet, then my preference is to use that at the start. And when we're focusing on the central pivot work, which is arthroscopic and then having it off for the open reconstructions in the medial and lateral sides of the knee. As far as approaching the reconstructions, I start with the central pivot and my preference is to drill the femur on the ACL or excuse me, for the ACL and the PCL first. And the reason is so that we don't have too much of the fluid extravasating out through the tibial tunnels. Again, I don't mind the egress, or actually I prefer the egress incision, but I don't want too much fluid to be coming out of the tibial tunnels because then sometimes visualization can be negatively impacted and can be difficult to find your footprints. So the tunnels, the way I prefer to drill the tunnels is the same way I would drill it if I was doing an isolated ACL or PCL, which is to use hyperflexion of the knee and then to use anteromedial and anterolateral portals, anteromedial being for the ACL and anterolateral being for the PCL. And sometimes that requires an accessory portal. And then I wanna place the tunnel in the center of the footprint and I do these surgeries just with a single bundle. And then I turn to the tibia and I start with the PCL on the tibia first because it's posterior and easier to then get back there and again, not have extravasation through that ACL tibia. In both the ACL and PCL, I like to leave as much remnant as possible. A key thing on the PCL is to make sure that you have the guide in and that you can see where the guide is and that you're getting low enough on the PCL footprint. It's easy to be too proximal or not posterior enough. If there's any question, you can use the x-ray to kind of guide you. I put both of them roughly in the center, obviously just medial of the tibial crest, but basically in the center. And so the PCL is distal and posterior to the ACL tunnel. I usually drill the ACL at 45 to 55 degrees and the PCL at 55 to 65 degrees, depending upon what I have chosen for the other one. Then as far as graft passage for the PCL graft, I have used a number of different graft options, but a graft option that I really like is the tripled peroneus longest allograft. I use suspensory fixation on the femur and then a full tunnel and an interference screw on the tibia. I fix the PCL first, tension it, and then fix that at 90 degrees, obviously pulling some anterior jaw so that you get that tension, but you do have to be careful that you don't over tension it. And if there's any question, again, use x-ray to make sure that in the sagittal plane to make sure that you're located. After the PCL is fixed, then I turn to the ACL graft. I think the ACL, I prefer to use an autograft is the one situation where I think it's valuable again, because of the lack of synovium that we see with isolated ACL in terms of healing. And so same rationale, prefer to use an autograft. I think you can use dealer's choice of any of the three common autografts at this point. Again, suspensory fixation on the femur and an interference screw on the tibia with a full tunnel through the tibia. In this case, tension and fix it roughly 10 degrees or sometimes even close to zero degrees of flexion. Once the central pivot is established, and I should stop here and just say, there's a lot of ways to do this. Many people will hold off on the tibial fixation for the ACL and PCL until they have their collateral grafts in place and ready to fix. That's certainly a reasonable approach. Most of the time, because I want to get the scope part done, I will just go ahead and fix the ACL and PCL, but then you obviously have to be more careful with your tunnels when you're drilling for any of your collateral work. So for the posterolateral corner, obviously important first to make your windows as shown in the image on the right, and then to find your peroneal nerve and dissect that out. We did a study several years ago that demonstrated that the peroneal nerve was reliably five to seven centimeters proximal to the fibular head. So if you can't find it, the fibular head, or it's torn, then follow the biceps proximally, and usually five to seven centimeters proximal to the fibular head is where the peroneal nerve crosses the biceps. In the case of both medial and lateral sides, I think it's helpful to repair as much of the tissues as possible, and then to augment with the reconstruction. So the reconstruction is critical, but if you can repair any of the tissues, that just helps to kind of reinforce. In the lateral side, most of the multiligaments will involve the entire posterolateral corner and not just the LCL. And so you can consider both LEPROD or RCRO techniques. For me, most of the time in a true multiligament, I'm gonna go with the LEPROD technique because I think that most of the posterolateral corner structures are involved, not just the LCL. I prefer to use two SEMIT allografts, and the shorter graft goes into the popliteal reconstruction. And so at the popliteal origin on the, or excuse me, insertion on the femur, and then around to the tibia. And then the longer graft is for both the LCL and the popliteal fibular ligament, where it's fixed on the femur, comes down to the anterior aspect of the fibula at the LCL footprint through the fibular head, and then around to the tibia to recapitulate the popliteal fibular ligament. For the drilling on the fibula, again, we did another study several years ago that was published on the 50-60 rule. So that's the amount of external rotation and then proximal angulation. And so the typical historical tunnels on the fibula are drilled in a straight A to P direction. If you really wanna get those, the graft at the footprint of the popliteal fibular ligament and of the LCL, then you need to change the orientation to follow the 50-60 rule. You have to be careful, however, when doing this that you don't drill too high and remount the superior aspect of the fibular head. With the femoral tunnels, if you aim proximal and anterior, you should be okay relative to the ACL tunnel. Obviously, you gotta be careful that you're not going too anterior so you don't violate the articular surface. And then the tibial tunnel is lateral enough, generally speaking, if you put it in the right spot to avoid the ACL and PCL tunnels and really will even leave you space if you need for like a root repair tunnel between the ACL and PCL and also outer corner tibial tunnel. The order for me is to fix on the femur, then the fibula, and then the tibia. When you're doing final fixation, you wanna pull anterior drawer on the tibia, place the knee in 30 degrees of flexion and apply a gentle valgus stress. And then I fix it with an interference screw on the tibia. All spots are, for me, fixed with biocomposite interference screws at this point. Of some manner, some are anchors, some are screws. On the medial side, again, I wanna repair as much as possible and then augment with the reconstruction. I have used both the modified Bosworth with soft tissue, specifically semitendinosus, allograft or autograft. I have also used an Achilles allograft. I would say most of the time, if the medial side is completely disrupted, I like to use the Achilles allograft. On the femoral side, you can use a screw and spiked washer for the modified Bosworth. That allows you to avoid having to drill all the way across. And so you can avoid the other tunnels. And then for an Achilles bone block, I like to drill just a blind tunnel, place the Achilles block in and fix it with a biocomposite interference screw. And then you're well fixed. Again, then you don't have to drill all the way across. On the tibial side, you can use a screw and spiked washer for both the modified Bosworth or an Achilles. I also have used a suture bridge technique to try to restore both superficial and deep MCL attachments when using an Achilles. And this is done with biocomposite anchors. Again, fixed on the femur followed by the tibia. And just like on the lateral side, fixed in 30 degrees of knee flexion, this time with a gentle varus stress applied during fixation. For the posterior medial corner, the most important structure is the posterior oblique ligament. In many cases, you can repair and or imbricate the soft tissues in the area of the posterior oblique ligament. You can also reconstruct. If you do, then when you're drilling tunnels, you obviously have to be careful in particular of the PCL tunnel on the tibial side. As far as rehabilitation, this is a moving target, but in the immediate postoperative period, the range of motion varies depending upon what ligaments are involved and how solid the fixation is. But in many cases, I start with the knee locked in extension for two weeks and then doing passive range of motion that's performed in a laterally cubitous or prone position. And then in the first six weeks overall, generally speaking, there's some degree of restrictions on weight bearing. Most of the time, in my case, 50% weight bearing in a brace. Range of motion often from zero to 90, but sometimes I'm worried about the collaterals and we'll start that at zero to 30 or zero to 60 and then increase after a couple of weeks. I begin a normalization of the quad recruitment and including quad sets and straight leg braces, straight leg sets, excuse me, with the brace set at zero degrees. And then the key thing is you wanna be preventing AP translation and rotation of the tibia. AP translation, particularly if the PCL is involved. And so in some cases, we'll use a jack brace to help keep the tibia forward. At six weeks, we can start to wean the patients off crutches to full weight bearing and then initiate isometric hamstring exercises. At 12 weeks, we can initiate isokinetic and at 16 weeks, initiate plyometrics. And I just wanna finish by going briefly over a lit review that I did and kind of discuss some of the things that have been highlighted in the recent literature. So the first one is the role of grafts. And I think the bottom line is that in complex knee surgery like this, there is not enough study at this point to delineate between outcomes with auto or allografts. And so it's reasonable to use both. I highlighted that I like to use auto for the ACL and for the rest of the structures, I'm okay using allografts. There, it has been highlighted, there's increased risk of root tears with these injuries. I think that's not surprising, but it has been better delineated in the literature recently. In terms of rehabilitation, the trend has been moving towards more accelerated rehabilitation. And so more to come on that, obviously trying to strike the balance of getting things moving and keeping the leg from getting too stiff, while also trying to protect the stabilization of the knee and the healing of those structures, as well as the neurovascular structures. And then recent literature has also highlighted the common complications, which there is a fairly high likelihood of return to the operating room or readmission. These are big surgeries, so blood loss is common, and oftentimes there's a need for transfusion. Because of the immobilization and the difficulty with getting patients up and moving, there is certainly a risk for DBT and pulmonary embolism. So all of these things need to be counseled with the patients ahead of time, so that they're aware that those are things that could happen. Thank you very much again for the opportunity to present.

ligament reconstruction

knee

stabilizing the limb

multiple ligament injury

diagnostic methods

hinged knee brace