“The trend over the years has been that surgical treatment for multiple-ligament knee injuries yields better results than nonoperative treatment,” asserted Gregory C. Fanelli, MD, during “The Multiple-Ligament Knee Injury: Pearls, Pitfalls, Results,” a presentation sponsored by the Arthroscopy Association of North America (AANA) during the 2007 Specialty Day.

Improvements in the understanding of ligament structure and biomechanics as well as advancements in instrumentation, fixation methods, surgical techniques, and allograft tissue procurement and preservation are among the reasons surgical results are more predictable.

Injuries involving the anterior (ACL) and posterior cruciate ligaments (PCL) can result from low- or high-energy trauma, said Dr. Fanelli. During the physical examination, orthopaedists should evaluate the patient’s neurovascular status and also check for abrasions, contusions, and deformities. “You have to focus on more than just the ligaments,” advised Dr. Fanelli. “Assess the vessels, nerves, and bony anatomy all the way up to the spine.”

Dr. Fanelli emphasized that a knee with three injured ligaments that has been anatomically reduced may have arterial or venous compromise. An ankle-brachial index of less than 0.8 in these patients mandates an arteriogram, magnetic resonance angiogram, or a computed tomography arteriogram, depending on the orthopaedist’s institutional standards. Plain radiographs and magnetic resonance imaging are helpful in facilitating the development of a treatment strategy in the acute setting.

Indications for surgery include irreducible dislocation, vascular injury, inability to maintain reduction, and open dislocation. Surgical timing depends on vascular status, the severity of collateral ligament injuries, and the degree of instability or reduction stability. In cases that require surgery, it is important to address not only the superficial medial collateral ligament, but also the capsular structures.

Dr. Fanelli said that using mechanical tensioning devices improved his results when using a single-bundle PCL repair technique. Treating posterolateral corner injuries with primary repair alone is not recommended; instead, Dr. Fanelli advised that surgeons augment the primary repair with allograft tissue. He also recommended waiting two or three weeks before performing reconstruction to decrease the incidence of arthrofibrosis.