Multi-ligament Knee Reconstruction

While rare, multi-ligament knee injuries (MLKI) are often career ending injuries for athletes, are frequently debilitating and can be complicated by associated injuries of the meniscus and the patella. Historically, these types of injuries ended professional sports participation. Today, many athletes who suffer MLKI can return to play following multi-ligament knee reconstruction by a surgeon with expertise in complex knee surgeries. Dr. Tom Hackett is a complex knee surgeon, and sports medicine orthopedic surgeon located in Vail, Colorado.

Management of these injuries is complex and depends upon a number of factors. Anatomical surgical knee reconstruction and ‘return to sport’ rehabilitation are essential to optimal outcomes and return the athlete to their pre-injury activity level.

Knee anatomy

The knee is a complex joint made of three bones – the thigh bone, the shin bone and the kneecap. Ligaments connect bone to bone. There are four primary knee ligaments: The Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) control side to side movement and knee stability. The medial collateral (MCL)and the lateral collateral ligament (MCL) control back and forth knee motion and knee stability. Additionally, there is the meniscus, a piece of cartilage that acts as a shock absorber between the bones, and the patella, a small bone in front of the knee joint.

About Multi-ligament knee injuries

Multiple ligament injuries are complex and by definition involve at least two of the four major knee ligaments. Multi-ligament injuries are considered a medical emergency because of the risk of a compromised blood supply to the leg, and nerve and muscle damage that in severe cases can lead to amputation. Injuries to the ACL are common and sometimes also involve damage the MCL. Studies report that early operative treatment yields improved function and clinical outcomes when compared to nonoperative care or delayed surgery.

What causes a multi-ligament knee injury?

They commonly occur during high energy sports like downhill skiing and football. Often, they are a serious consequence of a traumatic knee dislocation from an auto accident.  Male skiers have a higher proportion of multiple knee ligament injuries than females. The combined ACL and MCL injury are the most common injury type in both sexes.

Diagnosing multi-ligament knee injuries

Accurate diagnosis is essential and requires a comprehensive physical examination while the patient is in pain, often in the emergency room. Frequently the examination must occur under anesthesia. Regular and stress x-rays, and imaging studies including MRI and CT scans will be used to quantify the extent of the injury and rule out soft tissue damage. Each case is unique.

Once the extent of the injuries is established, surgical reconstruction of the injured knee ligaments will be necessary. A torn ligament cannot be sewn back together. In order to restore knee stability, the torn ligament is removed and replaced with a graft. Multiple ligament injuries will require multiple grafts.

Surgical reconstruction

Surgical planning is vital and will include the results of imaging, physical examination, graft selection and the use of diagnostic knee arthroscopy to identify lesions of the articular cartilage, and tears of the meniscus. Early surgical reconstruction is common and frequently occurs within two weeks of the injury.

Dr. Hackett may perform the surgery using a combination of arthroscopic and open techniques based upon the sequence of surgical repairs.  In some circumstances all the repairs can be achieved successfully in one surgery. In other cases, more than one surgical procedure may be required to restore knee structure and function. Every case is unique.

During surgery Dr. Hackett will reconstruct the damaged ligaments with a graft or multiple grafts of tissue from the patient (autograft) or donor (allograft) or a combination. The new grafts are secured to the bone with sutures, pins, screws, plates and wires. Other repairs of the meniscus, patella and cartilage will be performed as needed. When there is blood vessel and or nerve involvement, a neurovascular surgeon will be called in to treat these conditions.

Postoperative rehabilitation

The goal is to promote knee range of motion while protecting the reconstructed ligaments. Studies of severe multi-ligament knee injuries have demonstrated that early mobilization is associated with better outcomes when compared with immobilization.

Early intensive rehabilitation is critical to optimal recovery, restoration of function, stability and return to play. The first four to six weeks after surgery the patient will wear a knee brace, a cryotherapy sleeve and use crutches to restrict weight bearing. Initially only passive range of motion will be permitted, and the patient may use a continuous passive motion machine. At six weeks, the patient is weaned from crutches and progresses to full weight bearing.

Progressive rehabilitation is tailored to the patient, the injury pattern, the extent of repair and pain management. Range of motion will be regained by twelve weeks after surgery and then rehab will focus on restoration of strength. Full rehabilitation can take eight to twelve months.

MLKI is a complex surgery that requires the experience of experts. Dr. Tom Hackett is an acknowledged expert knee surgeon in Vail Colorado.