Multiligamentous Knee Injuries: Management options by Dr Raju Easwaran

Summary

This presentation provides a comprehensive overview of multi-ligament knee injury management, focusing on classification, clinical evaluation, and surgical approaches. The KD classification system is introduced, with an emphasis on the importance of early intervention for irreducible dislocations, vascular injury, and compound fractures. Key techniques such as open and arthroscopic surgery for cruciate and collateral ligament reconstruction are discussed, alongside rehabilitation strategies. The speaker highlights the use of dynamic splints, graft selection, and gradual return to activity, ensuring optimal patient recovery and long-term knee stability.

Takeaways

• 😀 KD Classification is essential for classifying multi-ligament knee injuries, with KD1 indicating PCL intact knee dislocations and KD2 showing rare bi-cruciate injuries.
• 😀 Vascularity assessment through serial pedal pulse checks is crucial, as non-flow-limiting intimal tears typically don't progress to full occlusion.
• 😀 Clinical inspection is key for diagnosing knee injuries, looking for ecchymosis (PCL/MCL injury) and dimples (irreducible dislocations).
• 😀 X-ray and MRI imaging are required for accurate diagnosis and surgical planning, especially in complex multi-ligament injuries.
• 😀 Immediate surgery is recommended for irreducible dislocations, vascular injuries, open fractures, and other severe cases like KD5 injuries.
• 😀 For bi-cruciate injuries (KD2), early surgery within 2-3 weeks is ideal, with more flexibility for KD3 injuries (3-6 weeks).
• 😀 Dynamic PCL braces can aid in managing tibial translation and maintaining knee stability post-surgery.
• 😀 Peroneus longus grafts are a good option for PCL reconstruction, especially when there is a shortage of suitable tissue for grafting.
• 😀 Surgical order should be to tension the PCL first, followed by ACL, lateral structures, and then medial structures for optimal repair.
• 😀 Rehabilitation should be gradual, with non-weight bearing for 6 weeks and a focus on co-contraction of quadriceps and hamstrings to prevent stress on repairs.
• 😀 Early clinical assessment, appropriate imaging, and timely surgical intervention are key factors in managing complex knee injuries effectively.

Q & A

What is the KD classification, and how is it useful in managing multi-ligament knee injuries?

The KD classification is a simple system used to categorize multi-ligament knee injuries. KD1 refers to a knee dislocation with an intact PCL and torn ACL and PLC. KD2 involves bi-cruciate injuries with intact collaterals, and KD3 refers to more severe injuries with damage to either the medial (KD3M) or lateral (KD3L) side. This classification helps in understanding the severity of the injury and guides treatment, including vascular and neurological assessment.

What are the key clinical assessments when managing multi-ligament knee injuries?

Key clinical assessments include checking for pulses to assess vascularity, examining for signs of ecchymosis or dimples (which can indicate ligament damage or irreducible dislocation), and performing specific ligament tests such as the Landman test for the ACL, posterior drawer for the PCL, and valgus/varus stress tests for collateral ligaments. Neurological assessment is also important, including checking for peroneal nerve function.

Why is angiography used selectively in the management of multi-ligament knee injuries?

Angiography is used selectively because it is not always necessary in cases where vascular injury is unlikely. The clinical assessment through serial pulse checks is often sufficient. Angiography may be used if there are signs of vascular compromise or if the clinical judgment warrants further investigation, but it is not a routine part of initial evaluation.

What are the recommended imaging techniques for multi-ligament knee injuries?

Both X-ray and MRI are essential for evaluating multi-ligament knee injuries. X-rays help assess bone involvement and the alignment of structures, while MRI provides detailed images of the soft tissue, including ligamentous injuries. Understanding the radiological anatomy, especially of the knee’s medial and lateral structures, is crucial for surgical planning.

What is the role of early surgery in managing multi-ligament knee injuries?

Early surgery is recommended in cases of irreducible dislocations, vascular injury, compound or open dislocations, and certain fracture dislocations. Early intervention can help stabilize the knee, prevent further damage, and improve long-term outcomes. The exact timing of surgery may depend on the type and severity of the injury.

What is the rationale for splinting in the management of knee dislocations in multi-ligament injuries?

Splinting is crucial to stabilize the knee and prevent further displacement of structures. A small posterior pad under the calf is often used to maintain normal tibial alignment. A dynamic PCL brace may be used for better control and is preferred over traditional splinting methods in some cases.

What are the surgical options for treating collateral ligament injuries in multi-ligament knee injuries?

For collateral ligament injuries, open surgery is generally recommended to allow direct repair or reconstruction. This approach is preferred over arthroscopy because it offers better exposure and access to the damaged structures, ensuring a more stable and accurate repair.

How are grafts selected for multi-ligament knee injuries, and what is the significance of using the peroneus longus graft?

The selection of grafts depends on the type of ligament involved and the availability of suitable tissue. The peroneus longus graft is particularly useful in multi-ligament knee injuries, especially for PCL reconstruction, due to its robust nature. It is a good alternative when other grafts are unavailable or unsuitable.

What is the recommended rehabilitation strategy following surgery for multi-ligament knee injuries?

Rehabilitation following surgery is slow and gradual. Early stages involve splinting the knee in extension, non-weight-bearing status for up to six weeks, and cautious range-of-motion exercises. A dynamic PCL brace, if used, allows for a supine range of motion. Co-contraction exercises for the quadriceps and hamstrings are crucial to prevent shear stress and support the repair.

Why is it important to understand the anatomy of the knee, especially when performing surgery for multi-ligament injuries?

Understanding the knee's anatomy is crucial for successful surgical outcomes. Knowing the details of ligamentous attachments, such as the fibular collateral ligament and the popliteal ligament, helps guide precise surgical techniques. Using anatomical references during surgery, such as Dr. Rob Laprade's charts, helps ensure accurate reconstruction and safe tunnel placement, reducing the risk of complications.