As orthopedic knee surgeons, we focus on the knee ligaments, menisci, articular cartilage, and extensor mechanism. In multiple ligament knee injuries, it is critically important to be aware of arterial and venous injuries, skin trauma, and peroneal and tibial nerve injuries. Bony injuries to the tibia, femur, patella, pelvis, and spine may also occur in patients with multiple knee ligament injuries. Head injuries also occur in this patient population placing these patients at risk for heterotopic ossification and lower-extremity spasticity complicating the treatment and postoperative course in these patients with multiple knee ligament injuries. Multiple system injuries can affect the outcomes of treatment in multiple ligament knee injuries, and must be considered in the treatment plans in these complex knee injuries.

The incidence of vascular injuries in multiple knee ligament injuries may occur in 32–50 % of cases with bicruciate tears having the same incidence as frank tibiofemoral dislocations [14–16]. Hyperextension mechanisms of injury may result in anterior tibial displacement with subsequent popliteal artery stretch and rupture, while a direct impact to the proximal tibia in the 90° flexed knee leads to posterior tibial displacement with potential arterial contusion and intimal damage [17]. I have also seen posttraumatic deep venous thrombosis in these severe knee injuries.

Evaluation of the acute multiple ligament-injured knee includes careful physical examination of the injured and uninjured lower extremities, and an ankle-brachial index measurement. If there are abnormal or asymmetric pulses or an ankle-brachial index of less than 0.9, more advanced vascular evaluation and vascular surgical consultation is indicated [18]. The absence of pulses distal to the knee requires prompt vascular surgical intervention. It is very important to evaluate the popliteal artery for intimal flap tears that could potentially cause delayed vascular occlusion. Clinical examination suggesting deep venous thrombosis indicates the need for further vascular evaluation.

External fixation is a useful tool in the management of the multiple ligament-injured knee. Preoperative indications for the use of spanning external fixation include open dislocations, vascular repair, and inability to maintain reduction [19]. The advantages of using spanning external fixation include skin assessment, compartment pressure observation, and monitoring the neurovascular status of the affected limb. Preoperative use of external fixation compared to brace immobilization may lead to less terminal flexion postoperatively; however, this may be more dependent on injury severity of the involved extremity than the use of the spanning external fixation device [20]. According to some clinicians, postoperative protection of multiple knee ligament reconstructions in a hinged external fixation device has led to more favorable static stability than postoperative brace immobilization [21]. My opinion regarding the use of spanning external fixation in treatment of the multiple ligament-injured knee preoperatively and postoperatively is that if I can control the knee in a brace, I use a brace. If I cannot control the knee in a brace, I use an external fixation device. Occasionally, I have used a spanning external fixator for treatment of the multiple ligament-injured knee in patients who are not surgical candidates.

Over the past two decades, technical advancements in the use of allograft tissue, arthroscopic surgical instruments, graft fixation methods, improved surgical techniques and postoperative rehabilitation programs, and an improved understanding of knee ligament structure and biomechanics have, in my experience, led to more predictable and successful results with multiple knee ligament reconstructions documented with physical examination, arthrometer measurements, knee ligament rating scales, stress radiography, and return to function [22–31].

Surgical timing in the acute multiple ligament-injured knee is dependent on the vascular status of the extremity, collateral ligament injury severity, and the degree of reduction stability. My experience and that of others demonstrates that a delayed or staged reconstruction of 2–3 weeks has resulted in less motion loss and arthrofibrosis [22–35]. My preferred surgical approach is a single-stage arthroscopic posterior and ACL reconstruction using allograft tissue, and medial- and/or lateral-side primary repair combined with allograft augmentation reconstruction within 2–4 weeks of the initial injury. Some medial-side injuries may be successfully treated with bracing [23, 24, 26].

There are surgical timing modifiers or considerations that may occur in the evaluation and treatment of the acute multiple ligament-injured knee. These modifiers may adversely affect the timing of surgery creating a situation where the surgical procedure may need to be performed earlier or later than desired by the surgeon. These modifiers include vascular status of the extremity, open injuries, reduction stability of the knee, severe medial- or lateral-side injuries, skin conditions, multiple system injuries, other orthopedic injuries, and meniscus and articular surface injuries. It is important to recognize and understand that in complex multiple knee ligament injuries, ideal surgical timing is not always possible.

Chronic multiple knee ligament injuries typically present to my clinic with progressive functional instability. These patients may or may not have some degree of posttraumatic arthrosis depending upon their time from injury. It is important to identify both the structural injuries and the planes of instability in these chronic knee ligament injuries. The structural injuries may include meniscus damage, malalignment, articular surface defects, and gait abnormalities in addition to the chronic knee ligament instability. Surgical options under consideration include osteotomies to correct malalignment and gait abnormalities, ligament reconstruction, meniscus surgery (repair, resection, transplantation), and osteochondral grafting. My preference is to perform staged surgeries in these complex injury patterns beginning with correction of malalignment.

Since beginning my treatment of multiple knee ligament injuries, my preference has been to reconstruct the cruciate ligaments and to perform a combined repair and reconstruction of the medial- and lateral-side injuries. Allograft tissue is preferred for these surgeries, however, we have had successful results with both allograft and autograft tissue [22–26]. Large PCL tibial bony avulsions are treated with reduction and fixation of the bony fragment. Small PCL tibial bony avulsions are evaluated with the arthroscopic three-zone PCL surgical technique to determine the condition of the PCL before proceeding with fixation of the small bony fragment [5]. Several studies have shown high rates of medial- and lateral-side surgical failures with primary repair alone [36–38]. We have had consistently successful results with combined primary repair and reconstruction with allograft or autograft tissue for medial- and lateral-side injuries [22–31, 39, 40]. The important point is that medial- and lateral-side-combined primary repair and reconstruction is more successful than primary repair alone in our experience, and in the recent literature. Allograft and autograft tissue both provide successful results.

Intraoperative graft preparation is a very important part of the surgical procedure, and can enhance or destroy the flow of the operation. I have always prepared my allograft and autograft tissue personally with the help of an assistant. When allograft tissue is used, this tissue is prepared in the sterile operating room prior to bringing the patient into the operating room to minimize general anesthesia time for the patient. Cases where autograft tissue is used, the autografts are harvested, and then I personally prepare them with an assistant. During the graft preparation, the surgeon “gets a feel for the graft” which provides insight into optimal tunnel size, and how the graft will behave during graft passage. This attention to detail facilitates the flow of the surgical procedure by maximizing the probability of uneventful graft passage leading to successful tensioning and final graft fixation. It is not recommended to delegate graft preparation responsibility to the lowest-ranking member of the surgical team.

How do I decide to perform an open or arthroscopic combined posterior and ACL reconstruction in these multiple ligament-injured knees, and whether or not to do a single- or two-stage procedures? My preference is to perform a single-stage arthroscopic posterior and ACL reconstruction using allograft tissue combined with medial- and/or lateral-side-combined primary repair and reconstruction with allograft tissue within 2–4 weeks of the initial injury. Severe medial- and/or lateral-side injuries with significant capsular damage that do not allow arthroscopic fluid to be maintained safely in the knee joint are treated as two-stage surgical procedures. The medial- and/or lateral-side surgery will be performed within the first week following the injury. The knee will be immobilized in full extension, and the arthroscopic combined posterior and ACL reconstruction will be performed approximately 4–5 weeks after the initial medial- or lateral-side surgery. When necessary, all ligament repairs and reconstructions are performed as a single-stage open surgical procedure. As always, surgical timing modifiers such as skin condition, vascular status, reduction stability, fractures, and other systemic injuries may alter the course of treatment.

The patient is positioned on the fully extended operating room table [28, 41–45]. A lateral post is used and the well leg is supported by the fully extended operating room table. The Biomet Sports Medicine PCL/ACL System (Biomet Sports Medicine, Warsaw, Indiana) are the surgical instruments used for this surgical procedure. Intraoperative radiography and C-arm image intensifier are not routinely used for this surgical procedure.

My preferred surgical technique is an arthroscopic PCL reconstruction using an Achilles tendon allograft to reconstruct the anterolateral bundle of the PCL. When I perform a double-bundle PCL reconstruction , an Achilles tendon allograft is used to reconstruct the anterolateral bundle of the PCL, and a tibialis anterior allograft for the posteromedial bundle of the PCL reconstruction. The ACL is reconstructed using an Achilles tendon allograft. Lateral-side surgery is a combined primary repair and fibular head-based figure-of-eight reconstruction using a semitendinosus or other soft-tissue allograft. The addition of a tibialis anterior allograft through a drill hole in the proximal tibia is added for knees with severe hyperextension external rotation recurvatum deformity and revision posterolateral reconstruction when needed. Lateral-side surgeries also have a posterolateral capsular shift or capsular reattachment performed as indicated. Medial-side injuries are treated with primary repair combined with allograft augmentation/reconstruction, and posteromedial capsular shift as indicated.

The allograft tissue used is from the same tissue bank with the same methods of tissue procurement and preservation that provide a consistent graft of high quality. It is very important for the surgeon to “know the tissue bank” and to obtain high-quality allograft tissue that will maximize the probability of surgical success. These multiple knee ligament reconstruction procedures are routinely performed in an outpatient setting unless specific circumstances indicate the necessity of an inpatient environment. The same experienced surgical teams are assembled for these complex surgical procedures. Experienced and familiar teams provide for a smoother operation, shorter surgical times, enhanced patient care, and a greater probability of success in these difficult surgical procedures. Preoperative and postoperative prophylactic antibiotics are routinely used in these complex and time-consuming surgical procedures to decrease the probability of infection. The specific details of my surgical procedure, including intraoperative photographs and diagrams, are presented in Chaps. 9 and 15 of this text book. The following sections in this chapter will address specific points that contribute to the success of this complex surgical procedure.

Three factors that contribute to PCL reconstruction surgical failures are failure to address associated ligamentous instabilities, varus osseous malalignment, and incorrect tunnel placement [5, 41–44]. My PCL reconstruction principles are to identify and treat all pathology, protect the neurovascular structures, accurately place tunnels to approximate the PCL anatomic insertion sites, use strong graft material, minimize graft bending, restore the anatomic tibial step-off, utilize a mechanical graft-tensioning device, use primary and backup fixation, and to use a slow and deliberate postoperative rehabilitation program.

My PCL reconstruction surgical technique since 1990 has been an arthroscopic transtibial tunnel PCL reconstruction using a posteromedial safety incision to protect the neurovascular structures, confirm the accuracy of the tibial tunnel placement, and to facilitate the flow of the surgical procedure [5, 41, 43, 44]. An extracapsular extra-articular posteromedial safety incision is made by creating an incision approximately 2–3 cm long at the posteromedial border of the tibia near the diaphyseal–metaphyseal junction of the proximal medial aspect of tibia. Dissection is carried down to the crural fascia, which is incised longitudinally, and as always, the neurovascular structures are protected. An interval is developed between the medial head of the gastrocnemius muscle and the nerves and vessels posterior to the surgeon’s finger, and the capsule of the knee joint anterior to the surgeon’s finger. The posteromedial safety incision enables the surgeon to protect the neurovascular structures, confirm the accuracy of the PCL tibial tunnel, and to facilitate the flow of the surgical procedure. The neurovascular structures of the popliteal fossa are in close proximity to the posterior capsule of the knee joint, and are at risk during transtibial PCL reconstruction. The posteromedial safety incision is very important for the protection of these structures.

The arm of the PCL/ACL guide (Biomet Sports Medicine, Warsaw, Indiana) is inserted through the inferior medial patellar portal. The tip of the guide is positioned at the inferior lateral aspect of the PCL anatomic insertion site. This is below the tibial ridge posterior and in the lateral aspect of the PCL anatomic insertion site. The bullet portion of the guide contacts the anteromedial surface of the proximal tibia at a point midway between the posteromedial border of the tibia, and the tibial crest anterior at or just below the level of the tibial tubercle. This will provide a relatively vertically oriented PCL tibial tunnel, and an angle of graft orientation such that the graft will turn two very smooth 45° angles on the posterior aspect of the tibia. The tip of the guide, in the posterior aspect of the tibia, is confirmed with the surgeon’s finger through the extracapsular extra-articular posteromedial safety incision. Intraoperative anteroposterior and lateral X-ray may also be used, however, I do not routinely use intraoperative X-ray. When the PCL/ACL guide is positioned in the desired area, a blunt spade-tipped guide wire is drilled from anterior to posterior. The surgeon’s finger confirms the position of the guide wire through the posterior medial safety incision. The critical posteromedial safety incision protects the neurovascular structures, confirms the accuracy of the PCL tibial tunnel placement, and enhances the flow of the surgical procedure.

The appropriately sized standard cannulated reamer is used to create the tibial tunnel. The surgeon’s finger through the extracapsular extraarticular posteromedial incision is monitoring the position of the guide wire. When the drill is engaged in bone, the guide wire is reversed, blunt end pointing posterior, for additional patient safety. The drill is advanced until it comes to the posterior cortex of the tibia. The chuck is disengaged from the drill, and completion of the tibial tunnel is performed by hand. The position and orientation of the PCL reconstruction transtibial tunnel creates a trough in the back of the tibia that mimics the tibial inlay technique, and provides a very smooth transition for the PCL grafts from the back of the tibia into the joint.

The PCL single- or double-bundle femoral tunnels are made from inside out using the double-bundle aimers, or using an endoscopic reamer as an aiming device (Biomet Sports Medicine, Warsaw, Indiana). With the knee in approximately 100–110° of flexion, the appropriately sized double-bundle aimer or endoscopic reamer is inserted through a low anterior lateral patellar arthroscopic portal to create the PCL anterior lateral bundle femoral tunnel. The double-bundle aimer or endoscopic reamer is positioned directly on the footprint of the femoral anterior lateral bundle PCL insertion site. The appropriately sized guide wire is drilled through the aimer or endoscopic reamer, through the bone, and out from a small skin incision. Care is taken to prevent any compromise of the articular surface. The double-bundle aimer is removed, and the endoscopic reamer is used to drill the anterior lateral PCL femoral tunnel from inside to outside. When the surgeon chooses to perform a double-bundle double-femoral tunnel PCL reconstruction , the same process is repeated for the posterior medial bundle of the PCL. Care must be taken to ensure that there will be an adequate bone bridge (approximately 5 mm) between the two femoral tunnels prior to drilling. This is accomplished using the calibrated probe, and direct arthroscopic visualization of the PCL femoral anatomic insertion sites.

I have evolved from outside-to-inside PCL femoral tunnel creation to inside-to-outside PCL femoral tunnel creation for two reasons. There is a greater distance and margin of safety between the PCL femoral tunnels and the medial femoral condyle articular surface using the inside-to-outside method. Additionally, a more accurate placement of the PCL femoral tunnel(s) is possible because I can place the double-bundle aimer or endoscopic reamer on the anatomic foot print of the anterior lateral and posterior medial PCL insertion sites under direct visualization.

With the knee in approximately 90° of flexion, the ACL tibial tunnel is created using a drill guide. My preferred method of ACL reconstruction is the transtibial femoral tunnel endoscopic surgical technique. The arm of the drill guide enters the knee joint through the inferior medial patellar portal. The bullet of the drill guide contacts the anterior medial proximal tibia externally at a point midway between the posterior medial border of the tibia, and the anterior tibial crest just above the level of the tibial tubercle. A 1-cm bone bridge or greater exists between the PCL and ACL tibial tunnels. This will reduce the possibility of tibial fracture. The guide wire is drilled through the guide and positioned so that after creating the ACL tibial tunnel, the graft will approximate the tibial anatomic insertion site of the ACL. A standard cannulated reamer is used to create the tibial tunnel.