Management of the Posterior Cruciate Ligament-Based Multiligament-Injured Knee

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Injuries of the posterior cruciate ligament in the setting of the multiligament-injured knee can pose a challenge to the orthopedic surgeon. The decision to proceed with operative or nonoperative management and which surgical technique to use remain controversial. Moreover, sparse clinical data are available to support any one treatment approach for these complicated injuries. In this chapter, we describe our current management strategies for posterior cruciate ligament-based multiligament knee injuries in the context of the existing published data and our own current clinical investigations. We discuss methods of diagnosis, the importance of stress radiography, imaging, indications and timing of surgery, graft selection, and surgical techniques. In addition, we detail our approach to postoperative rehabilitation with regard to thromboprophylaxis, weight-bearing status, and return to work or sport.

Section snippets

Diagnosis

PCL tears are diagnosed according to history, mechanism of injury, physical examination, and diagnostic imaging, including standard radiographs and magnetic resonance imaging. In the multiligament-injured knee, PCL disruption is determined by the posterior drawer test at 90°, the posterior sag test at approximately 70°, and the quadriceps activation test. The anterior cruciate ligament (ACL) integrity is examined with the Lachman and pivot-shift tests. The medial collateral ligament

Surgical Timing

As opposed to isolated PCL injuries, which are treated nonoperatively in a majority of cases,1 we recommend open reduction and internal fixation of isolated PCL avulsion injuries and PCL reconstruction in the setting of the multiligament-injured knee.3, 4, 5 In the polytrauma patient with associated injuries and comorbidities, surgery is performed on patients who can withstand a prolonged surgical procedure as well as an extensive rehabilitation program.6 We caution against multiligament knee

Surgical Timing Based on Specific Patterns of Ligament Injury

For most multiligament-injured knees, we recommend early single-staged surgical intervention for all damaged ligament structures. For medial-sided injuries, we performed an extensive systematic review of the literature and found only 8 studies to help guide treatment strategies: 5 studies on outcomes of MCL repair in the multiligament-injured knee and 3 studies on reconstruction. Using the best available evidence, both repair and reconstruction offer satisfactory results.12 Currently, we

Technical Considerations

Patients receive preoperative antibiotics, and both knees are examined under anesthesia using stress fluoroscopy. Diagnostic arthroscopy identifies all associated intra-articular pathology (meniscus, articular cartilage, loose bodies), and the appropriate treatment is carried out. On the basis of arthroscopic assessment, comparison stress views, physical examination, and magnetic resonance imaging findings, final decisions are made as to which ligamentous structures will be repaired and/or

Postoperative Rehabilitation

All multiligament knee reconstruction patients are treated with a standard postoperative rehabilitation protocol. Patients are usually admitted for overnight observation and deep vein thrombosis prophylaxis is initiated. We currently use low-molecular-weight heparin, starting approximately 12 hours after surgery and continuing for a minimum of 3 weeks or until adequate mobilization is obtained.

We follow the rehabilitation protocol described by Fanelli and Edson.27 In this protocol, patients

Conclusion

In summary, treatment of the multiligament-injured knee is highly complex and requires a detailed surgical plan, a dedicated surgical team, and specific rehabilitation protocols. Controversies persist with regard to the advantage or disadvantage of single- vs double-bundle PCL reconstructions, autograft vs allograft tissue, inlay vs transtibial technique, and postoperative rehabilitation.

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  • Cited by (2)

    The authors did not receive grants or outside funding in support of their research or preparation of this manuscript.

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