Knee ligaments are responsible for providing the static stability of the knee, control of kinematics, and prevention of abnormal rotation and/or displacement that may damage the articular surfaces or the menisci. Multiligament knee injuries are rare and are estimated to account for 0.02% to 0.2% of orthopaedic injuries. These injuries may spontaneously reduce or may present as an acutely dislocated knee requiring reduction. The diagnosis and management of multiligament injuries pose unique challenges to orthopaedic surgeons, and a wide spectrum of injury exists, ranging from two-ligament injuries such as a cruciate and collateral ligament rupture to a grossly unstable knee that requires spanning external fixation. Although the immediate concerns should be to determine the integrity of the neurovascular structures, other essential concepts include accurate identification of all injured structures, repair versus reconstruction, management of acute versus chronic injuries, single- versus two-stage surgery, and postoperative rehabilitation. During the past three decades, clinical outcome studies along with anatomic and biomechanical investigations have improved the management of these complex injuries.
History
In evaluating a patient who presents with knee pain or instability, the clinician must obtain a careful history of symptom onset, mechanism of injury, history of prior knee injuries, and previous operative and nonoperative treatments. Multiligament injuries associated with sports are considered low energy and are often isolated to the involved extremity, whereas those associated with automobile or motorcycle crashes are considered high-energy and may be combined with other life-threatening injuries.
Acutely injured patients may be unable to ambulate because of swelling, pain, and instability. Determination of time since injury is crucial in patients who present with persistent dislocation because of the possibility of vascular injury and limb ischemia. Patients with chronic injuries may report mechanical symptoms including clicking, catching, or locking or may report instability on uneven ground, with cutting motions, and during activities of daily living. Neurologic deficits may be reported, including the presence of paresthesias in the common peroneal nerve distribution and a foot drop. Synthesis of this information will guide the clinician in the physical examination and selection of imaging studies.
Physical Examination
Examination of a patient with a suspected multiligament injury in the acute setting must include assessment of vascular status. If an arterial injury is suspected, an ankle-brachial index score should be determined; a score of less than 0.9 is an indication that advanced arterial imaging should be obtained. Serial neurovascular examination and selective computed tomography angiography has been recommended; “hard signs” of ischemia warrant emergent vascular consultation.
Neurologic status must also be assessed. The common peroneal nerve supplies motor innervation to the anterior (deep peroneal) and lateral (superficial peroneal) compartments of the leg, as well as the extensor hallucis brevis and extensor digitorum brevis (deep peroneal) on the dorsum of the foot. A 25% to 35% nerve injury rate has been reported in the knee dislocation population. In a series of acute isolated or combined posterolateral corner (PLC) knee injuries in an orthopaedic sports medicine referral practice, 4 of 29 patients had a complete palsy of the common peroneal nerve and an additional 7 of 29 had a partial motor/sensory deficit. Tibial nerve injuries may also occur in knee dislocations; although these injuries occur less frequently than common peroneal nerve injuries, they are more devastating.
Physical examination of knee stability is a repeatable method of predicting intraarticular pathology but may be more difficult in patients with acute injuries. It is important to examine both legs to assess for pathologic instability versus physiologic laxity. Multiligament injuries are not subtle on examination; however, attention to subtle findings will aid the clinician in determining which specific structures are injured. Anteroposterior stability should be assessed with the Lachman, pivot shift, and posterior drawer tests. The posterior sag and quadriceps active tests also aid in the evaluation of the posterior cruciate ligament (PCL).
Lateral and posterolateral knee injuries are typically combined with an injury to one or both of the cruciate ligaments. In acute injuries, the patient may have tenderness to palpation at the fibular head. Examination maneuvers should include varus stress at 0 and 20 degrees, reverse pivot shift, external rotation recurvatum, and the dial test at 30 and 90 degrees. In a patient with a positive varus stress test at 30 degrees and negative findings at 0 degrees, an isolated fibular collateral ligament (FCL) tear is suspected. However, with multiligament injuries, the varus stress test will also be positive at 0 degrees. A positive dial test at both 30 and 90 degrees suggests a combined PCL and PLC injury. A positive posterolateral drawer test reinforces findings consistent with a PLC injury but must be interpreted with caution, as discussed below.
Medial structures are evaluated with the valgus stress test at 0 and 20 degrees of flexion ; instability at full extension is indicative of a combined cruciate ligament injury. Assessment of medial compartment gapping at 20 degrees under a valgus stress primarily isolates the superficial medial collateral ligament (MCL). Evaluation of associated rotational abnormalities is assessed with anteromedial tibial rotation at 90 degrees of flexion and the dial test at 30 and 90 degrees of flexion. Increased anteromedial rotation suggests a more extensive knee injury that includes the superficial MCL, as well as the posterior oblique ligament (POL) and deep MCL. The examiner must be careful to differentiate anteromedial from posterolateral tibial rotation during the dial test by palpation and visualization of tibial subluxation with the patient in the supine position.
Gait assessment is an important component of the physical examination but may be compromised because of pain in persons with acute injuries. In subacute or chronic injuries, a varus thrust gait or foot drop may be observed in patients with combined lateral injuries. Patients with medial knee injuries may demonstrate a valgus thrust during the stance phase of gait, but this manifestation is less common and usually occurs in patients with genu valgus alignment.
Imaging
Radiographic examination of the knee for patients with a suspected multiligament injury should include standard anteroposterior and lateral views ( Fig. 102-1 ), as well as weight-bearing flexion (Rosenberg) views. These views allow visualization of tibial plateau, femoral condyle, or osteochondral fractures. Segond and/or arcuate fractures may be visualized with lateral/posterolateral injuries, and calcification near the MCL origin (Pellegrini-Stieda ossification) may be visualized in chronic medial-sided injuries. Baseline bilateral standing long-leg radiographs allow the clinician to determine the mechanical axis of the injured and contralateral extremities, which may have a significant impact on treatment decisions for chronic multiligament injuries.
Preoperative stress radiographs provide quantitative objective information on the stability to valgus and varus stress and should also be routinely obtained postoperatively. Biomechanical studies were performed to objectively quantify the amount of joint opening with varus and valgus stress; radiographic techniques were developed and tested by sequential sectioning in cadaveric knees with intact cruciate ligaments. Isolated sectioning of the FCL (simulating a grade III injury) resulted in an increase of 2.7 mm of lateral joint gapping at 20 degrees of flexion when compared with the contralateral knee. Sectioning of the FCL, popliteus tendon, and PFL (simulating a complete grade III PLC injury) was associated with lateral joint gapping of 4 mm at 20 degrees of flexion. Isolated sectioning of the superficial MCL (simulating a grade III injury) resulted in 3.2 mm of increased medial joint gapping at 20 degrees of flexion when compared with the contralateral knee. Increased medial joint gapping of 6.5 mm and 9.8 mm at 0 and 20 degrees of flexion, respectively, was associated with sectioning of the superficial MCL, deep MCL, and POL (simulating a complete medial knee injury).
Several imaging techniques have been developed to allow quantitative assessment of the integrity of the PCL and are especially useful in persons with chronic injuries. Stress radiographs have been described using the kneeling knee technique and Telos device (Telos GmbH, Marburg, Germany) ; these two techniques have been reported to allow quantifying posterior displacement of the tibia and are superior to a physical examination and use of the KT-1000 arthrometer.
Magnetic resonance imaging (MRI) has become part of the standard of care for evaluation of knee instability, especially in persons with acute injuries for whom examination may be limited by pain and swelling ( Fig. 102-2 ). With high sensitivity and accuracy, MRI allows visualization of the cruciate and collateral ligaments, posteromedial corner and PLC, bone marrow edema, meniscal injuries, and cartilage lesions. Anteromedial femoral condyle bone bruises should alert the physician to a possible PLC injury.
It is important to recognize common imaging findings associated with multiligament knee injuries. Plain radiographs may be negative in the acute setting if the patient is lying supine, and it may be difficult to obtain weight-bearing films. In chronic injuries, weight-bearing films may reveal varus or valgus gapping or loss of joint space and early findings of degenerative disease. Stress radiographs are especially useful to quantitatively assess stability of the PCL, medial complex, and posterolateral complex. In persons with acute injuries, MRI will reveal the status of the cruciate ligaments and allow assessment of the collateral structures if appropriate cuts and slice thickness are obtained. Classic bone bruises associated with ACL ruptures may be seen, as well as those associated with PLC injuries.
Decision-Making Principles
Patients with multiligament injuries are a heterogeneous group and may present with a variety of skin, bony, neurovascular, and ligamentous injuries. Although several general treatment algorithms have been developed, individualized treatment for the patient’s specific knee injuries and concomitant injuries is necessary. Meniscus injuries should ideally be repaired, especially in the young patient, but may require a partial meniscectomy. Management of vascular injuries, open injuries, skin coverage, fracture treatment, and meniscus injuries will not be specifically discussed. Important considerations for treatment of multiligament injuries include operative versus nonoperative treatment, surgical timing, single- versus two-stage cruciate ligament reconstruction techniques, and repair versus reconstruction of collateral structures.
Knee ligament injuries have historically been classified with use of a grading scale that assesses sagittal (anteroposterior) and coronal (varus/valgus) plane stability. Rotational stability does not have a formal classification system, although many injury types have been described. Treatment must be based on the extent of injury to individual structures and the number of structures injured. Knee ligament injuries are often subjectively classified according to the original American Medical Association guidelines, rated as grade I, II, or III. An additional classification system is based on the number and location of torn ligaments.
Nonoperative Versus Operative Treatment
It must be recognized that multiligament knee injuries are rare and that few studies have been conducted that compare treatment strategies with a high level of evidence. Current literature favors surgical management of multiligament knee injuries, whereas in early reports, nonoperative treatment was often recommended for “uncomplicated” cases (i.e., absence of vascular injury or fracture). A recent review indicated improved outcomes in multiple subjective and objective facets for patients treated with an operation compared with those treated conservatively with immobilization.
Surgical Timing
Several studies have evaluated the impact of surgical timing. However, interpretation of outcomes of surgically treated multiligament injuries is difficult because of the wide range of pathology within individual studies. Irreducible knee injuries, open injuries, and popliteal vascular injuries necessitate emergent management. If the multiligament injury is associated with a high-energy trauma, overall medical status and serious concomitant extremity, torso, and head injuries may delay definitive treatment. Overlying skin injuries and associated plateau or femoral condyle fractures may necessitate delayed ligament reconstruction. These complicating factors will not be specifically evaluated; rather, the focus will be single-extremity multiligament injuries without concomitant injuries.
Timing of surgery is typically divided into one of the following three categories: acute (often defined as surgery within 3 weeks), chronic (often defined as surgery after 3 weeks), or staged (the index procedure is performed within 3 weeks of injury and second-stage surgery is delayed). Harner et al. reported improved subjective outcomes in acutely treated patients and no ultimate difference in range of motion; however, 4 of 19 patients with acutely reconstructed knees required manipulation for loss of flexion. Fanelli and Edson reported on 35 patients with multiligament injuries and found no subjective differences (according to Tegner, Lysholm, and Hospital for Special Surgery knee ligament rating scales) or objective differences (according to use of the KT-1000 arthrometer) between the acute and chronic cohorts.
A recent systematic review of surgical treatment for multiligament injuries found increased anterior instability for patients treated acutely but no difference in posterior, varus, or valgus instability when compared with chronically treated injuries. Additionally, flexion loss (>10 degrees), as well as the need to undergo a subsequent repeat operation for stiffness, were more frequent in acutely treated patients; no difference was found for extension. Lastly, patients treated with staged reconstructions had more “excellent” or “good” outcomes than did those treated acutely. As described later in this chapter, these findings may be difficult to interpret because many of these patients were treated with acute PLC repairs (which have been found to frequently fail) rather than reconstructions.
Persons with chronic multiligament injuries may present to the orthopaedic surgeon because of a failed index procedure, failed nonoperative management, or concomitant injuries that precluded acute surgical management of the multiligament injury. These patients may have varus malalignment, and a high-tibial osteotomy may be required to correct the mechanical axis prior to ligament reconstruction, because it has been reported as a cause of PLC repair or reconstruction failure.
Cruciate Ligament Reconstruction
It is widely accepted that cruciate ligament injuries in patients with multiligament injuries require reconstruction. A biomechanical study by Veltri and colleagues demonstrated the importance of reconstructing the cruciate ligaments in multiligament injuries. Options for anterior cruciate ligament (ACL) reconstruction in multiligament injuries include transtibial versus transportal drilling for femoral tunnels and autograft versus allograft; no known studies recommend double-bundle ACL reconstruction in these patients. The debate regarding the best PCL reconstruction technique to use in persons with multiligament injuries is similar to the debate for isolated injuries; graft fixation techniques, single- versus double-bundle technique, and transtibial tunnel versus tibial inlay technique. Few studies have been performed to compare cruciate ligament reconstruction techniques in the multiligament injury patient population; as such, surgeons must apply the principles used for reconstruction of isolated cruciate ligament injuries to this unique patient group.
Collateral Structures
Until recently it was believed that PLC structures could be successfully repaired if treated acutely. This practice has been challenged by outcomes studies that compare repair and reconstruction. It has been biomechanically demonstrated that a deficient PLC leads to increased ACL and PCL graft forces; interestingly, Mook et al. reported that more patients treated acutely for multiligament injuries underwent repairs rather than reconstructions of the PLC and suggest that repairs may have been insufficient to protect the ACL graft during healing. These findings may provide clinical evidence that reinforces the biomechanical principles of secondary stabilization between cruciate and collateral ligaments and may support the trend toward acute reconstruction, rather than repair, of PLC structures. As discussed later in this chapter, a gradual trend has occurred from local tissue transfers and acute repairs toward several different autograft or allograft tissue reconstruction techniques.
A well-defined and successful treatment algorithm for isolated grade III MCL injuries and those combined with ACL ruptures includes a short period of rest and edema control followed by physical therapy. However, treatment of MCL injuries associated with bicruciate injuries is less well defined. Some authors advocate delayed cruciate reconstruction while the medial structures are protected with a brace and allowed to potentially heal. Other authors recommend acute repairs or reconstruction of medial structures, although a higher risk of arthrofibrosis is reported.
Graft Choice
Graft choice in multiligament injury reconstruction is determined by injury pattern, graft availability, and surgeon preference. Often surgeons prefer to use allografts when treating multiligament injuries because of multiple graft size options and the ability to avoid the increased operative time and donor site morbidity associated with harvesting the patellar and hamstring tendon, and possibly quadriceps tendon, grafts. Because of the heterogeneity of multiligament injuries, no conclusive studies are available to recommend a particular graft choice. Several techniques are discussed in the Treatment Options section, along with graft choices.
Special Considerations
Pediatric patients with multiligament injuries require special consideration because of their open physes and the potential risk of growth alteration with traditional ligament reconstruction. Physeal sparing techniques for ACL and PCL reconstruction have been described. Lateral and medial structures may be repaired via augmentation or recess procedures or with use of suture anchors.
A recently defined type of knee dislocation has been termed ultra–low velocity and was described by Azar and colleagues. These injuries are sustained by patients with a high body mass index as a result of falling from a standing height or tripping on objects, for example. Their treatment must be individualized based on medical comorbidities, patient expectations, preinjury activity level, and ability to comply with rigorous rehabilitation.
Conservative therapy with immobilization may be the only treatment suitable for elderly patients with multiligament injuries who have preinjury medical comorbidities. Additionally, the presence of arthritis is a relative contraindication to multiligament reconstruction; in fact, most studies exclude patients with preexisting arthritis.
Treatment Options
Treatment recommendations for specific ligament injuries in this patient population are limited by the lack of comparative studies. No known studies have evaluated the impact of a specific cruciate ligament reconstruction technique on the outcomes of multiligament injuries. Repair versus reconstruction of collateral ligaments has been debated, but specific reconstruction methods have not been directly compared in clinical studies.
Acute Management
Every multiligament knee injury is unique, and a wide range of pathology exists. Most injuries are adequately stabilized in a knee immobilizer. However, some knees associated with a high-energy injury may remain subluxed in a knee immobilizer and require a spanning external fixator to achieve stability in the acute setting.
Anterior Cruciate Ligament
Although ACL reconstruction is recommended, the specific technique receives relatively little discussion in the context of multiligament injuries. Many authors have described single-bundle reconstruction using allograft or autograft with femoral tunnels created via a transtibial technique. Levy et al. prefer to use a tibialis anterior allograft, Strobel et al. recommend use of a hamstring autograft. Engebretsen et al. initially preferred allografts for ACL reconstruction but changed their graft choice to a bone–patellar tendon–bone autograft. Harner et al. prefer allograft bone–patellar tendon–bone but use an anteromedial portal drilling technique for ACL femoral tunnels rather than the transtibial technique as utilized by previous authors.
Posterior Cruciate Ligament
A review of treatment options for addressing PCL insufficiency in this patient population follows. It is generally accepted that PCL tears should be reconstructed in these patients, although the optimal technique has not yet been defined. A review of the causes of failure of a series of PCL reconstructions identified the importance of tunnel positioning and addressing concomitant collateral ligament instability. However, investigators have not yet determined the role for the single- versus double-bundle technique and for transtibial versus tibial inlay graft placement.
Some studies have demonstrated that double-bundle PCL reconstructions restore native biomechanics ; however, relatively few studies have specifically described the detailed technique and associated outcomes of double-bundle PCL reconstructions in the multiligament injury population. Spiridonov et al. recently described a double-bundle PCL reconstruction in seven patients with isolated PCL ruptures and 32 with multiligament injuries. Their technique includes two femoral tunnels and a single transtibial tunnel to anatomically reconstruct the anterolateral bundle (ALB) and posteromedial bundle (PMB). Because of the morbidity of graft harvest and the need for large collagen volume, the authors used allografts, specifically Achilles tendon, for the ALB and semitendinosus tendon for the PMB.
Several authors have described single-bundle PCL reconstructions in patients with multiligament injuries. Fanelli and Edson recommend a single-bundle transtibial PCL reconstruction and report using either an autograft or allograft. Engebretsen et al. describe a single-bundle transtibial PCL reconstruction; during the time of data collection, the investigators changed their graft source from allograft to hamstring autograft. Chhabra et al. reported that approximately one third of patients with an acute multiligament injury have an intact PMB and meniscofemoral ligaments. They attempt to preserve these bundles and will perform a reconstruction of the ALB using an Achilles tendon allograft via a transtibial tunnel. In patients with complete ruptures of the entire PCL and patients with chronic injuries, the authors recommend double-bundle PCL reconstruction using an Achilles tendon allograft for the ALB and a semitendinosus autograft for the PMB.
A recent systematic review of the topic of transtibial versus tibial inlay technique for PCL reconstruction revealed a paucity of comparative outcomes studies and recommends surgeon preference as a reasonable factor for technique choice until further evidence is available. Biomechanical studies have compared the two techniques, but it is difficult to apply their results to the multiligament injury population. Some investigators have recommended that the tibial inlay technique not be used for patients with multiligament injuries; however, this evidence is level V. Stannard et al. described a technique for double-bundle PCL reconstruction with a tibial inlay technique in patients with multiligament injuries. Their technique requires a single Achilles tendon allograft, split longitudinally, to reconstruct the ALB and PMB. Cooper and Stewart described a single-bundle tibial inlay PCL reconstruction using either a bone–patellar tendon–bone autograft or allograft to reconstruct the ALB.
Medial/Posteromedial Structures
In a recent review, LaPrade and colleagues underscored the importance of completely evaluating and treating the three main structures of the medial/posteromedial knee: the superficial MCL, deep MCL, and POL. When associated with multiligament injuries, most authors agree that grade III MCL injuries require treatment, often repair or reconstruction. A systematic review reported an absence of sufficient studies to allow formulation of evidence-based recommendations for treatment of MCL injuries in the multiligament injury population. A general trend has been noted in the literature toward repair and/or reconstruction of medial knee injuries, which may be due to increased understanding of the anatomy and availability of biomechanically validated reconstruction techniques.
In early reports, Fanelli et al. compared valgus stability in patients with bicruciate ruptures and medial-sided injuries. Bicruciate reconstructions were performed in all patients; two acutely presenting patients were treated with primary surgical repair of the MCL tears, and seven were treated with bracing to allow the MCL injury to heal with nonoperative treatment followed by subsequent bicruciate ligament reconstruction. More recently, Fanelli and Edson describe an anterosuperior shift of the posteromedial capsule for repair of MCL injuries; when lesions are not amenable for repair, an autograft semitendinosus or allograft is used to reconstruct the superficial MCL and is accompanied by a capsular shift.
Lind et al. described a rerouting of the ipsilateral semitendinosus tendon to reconstruct the superficial MCL and posteromedial structures in patients with multiligament injuries. The semitendinosus tendon was identified and harvested proximally but left intact at the pes insertion. A blind femoral tunnel, located at the isometric point of the MCL insertion, was created with a diameter equal to the size of the double-looped tendon. Additionally, a transtibial tunnel exiting 10 mm below the tibial plateau and posterolateral to the semimembranosus was drilled through the medial tibial plateau from anterior to posterior and reamed to the diameter of the semitendinosus tendon. The double-looped tendon was secured using interference screw fixation in the femur, pulled through the tibial tunnel, and secured with an additional interference screw.
LaPrade and colleagues described an anatomically based and biomechanically validated reconstruction of the medial knee structures. Their technique reconstructs the POL and both the proximal and distal divisions of the superficial MCL. Two femoral and two tibial tunnels are created, and grafts are fixed in the tunnels with use of interference screws.
In a series of patients with knee dislocations, Harner et al. describe repair or reconstruction of MCL injuries. Avulsions and midsubstance injuries were repaired with suture anchors and nonabsorbable sutures, respectively. Chronic injuries were treated with a reconstruction of the MCL using a semitendinosus autograft or Achilles tendon allograft.
Lateral/Posterolateral Structures
In contrast to the extraarticular medial structures, it is well recognized that grade III PLC injuries do not heal with bracing and can lead to significant morbidity without operative treatment. Recently reconstruction rather than repair of PLC injuries has been emphasized because of results of comparative outcomes studies. Early investigators reported good results with acute anatomic repair of PLC injuries; however, these patients were immobilized in a cast for 6 weeks postoperatively, and subjective outcomes scoring tools were not available.
Fanelli and Edson described a biceps tenodesis procedure combined with a posterolateral capsular shift. More recently, Stannard et al. and Levy et al. performed a mix of single- and dual-stage operations and found lower failure rates with reconstructions when compared with repairs of the PLC. Stannard et al. performed a modified two-tailed technique with a tibialis anterior or posterior allograft for PLC reconstructions. This technique uses a single femoral tunnel at the isometric point along with a single fibular and tibial tunnel. Levy et al. used a fibula-based technique with an Achilles tendon allograft, along with an anterodistal shift of the posterolateral capsule, to reconstruct the PLC.
LaPrade and colleagues recently reported on acute and chronic treatment of isolated and combined PLC injuries. All PLC and concomitant cruciate ligament tears were treated with a single-stage surgery. Acute avulsions of PLC structures were repaired with suture anchors or recess procedures; however, most acute PLC injuries were not amenable for repair and were treated with a complete anatomic PLC reconstruction of the FCL, popliteus tendon, and/or PFL. A minority of the patients in the chronic PLC injury study were found to have varus malalignment and required an opening wedge proximal tibial osteotomy to correct their mechanical axis before undergoing a soft tissue reconstruction. The remainder of the patients were treated with an anatomic reconstruction of the PLC with single-stage reconstruction of coexistent cruciate ligament tears.
Our preferred technique for treatment of multiligament injuries is an anatomic single-stage reconstruction of the cruciate ligament(s) with concurrent treatment of medial/posteromedial and lateral/posterolateral supporting structures with anatomically based and biomechanically validated techniques. Grade III injuries to the medial and lateral structures require surgical treatment for patients with multiligament injuries with a repair and/or reconstruction when indicated. A repair of some structures may be possible in acute injuries with avulsions directly off bone; however, a reconstruction is required for acute injuries with midsubstance tears or inadequate tissue quality and for chronic injuries. It is the preference of the senior author to operate on patients with acute injuries within 3 weeks of injury to allow identification of injured structures and repair of meniscal pathology and extraarticular structures.
Preoperative Planning
Preoperative planning for treatment of multiligament injuries is critical because of the inherent complexity. The injury history, physical examination, and imaging studies will allow the surgeon to plan the details of the operation. The surgeon must be certain that all required equipment is available, including surgical instruments and any required allograft materials. Standard cruciate ligament reconstruction instruments including cannulated drill guides, eyelet-tipped passing pins, suture anchors, and cannulated interference screws (metallic or bioabsorbable) will be necessary. Appropriate graft harvesting instruments will be needed if the surgeon plans to use autografts; a graft preparation station will also be needed. A standard arthroscopic setup with 30- and 70-degree scopes will be necessary for evaluation and treatment of intraarticular injuries.
Patient Positioning
The patient is placed supine on the operating table, and after administration of an anesthetic, an examination is performed to confirm suspected ligamentous pathology. A leg holder is placed to allow sufficient access to the medial and lateral aspect of the injured extremity. A well-padded proximal thigh tourniquet is set in place but is not routinely used. The operative leg is prepped and draped free in the usual sterile fashion.
Extraarticular Injury Identification and Treatment
We recommend that open dissection for lateral and/or medial injuries be performed prior to arthroscopic examination, which will allow identification of injuries and assessment of tissue quality prior to arthroscopic fluid extravasation.
Lateral and Posterolateral Knee
A hockey-stick shaped incision centered over the posterior to mid portion of the iliotibial band is used to expose the lateral/posterolateral knee. The incision is positioned more posteriorly in patients with a planned autogenous patellar tendon graft harvest for concurrent ACL reconstruction to maintain a minimum of 6 cm between the two incisions. This incision is continued down through the skin and superficial tissues to the superficial layer of the iliotibial band. Posteriorly, the long and short heads of the biceps femoris are identified; palpation approximately 2 to 3 cm distal to the long head will usually allow identification of the common peroneal nerve. A neurolysis is then performed to release the nerve from scar tissue entrapment and safely isolate it from the surgical site ( Fig. 102-3 ).
