| | Surgical techniques of open surgical reconstruction in the multiple-ligament-injured kneeAbstract Multiple-ligament injuries of the knee present the orthopedic surgeon with a myriad of management and treatment challenges. Often the result of high-energy trauma, such as motor vehicle and industrial accidents, the multiple-ligament-injured knee is increasing in frequency among athletes participating in a variety of sports. These injuries can be treated by arthroscopic techniques, open techniques, or a combination of the two. The open surgical approach has several advantages. First, the approach is relatively straightforward and is effective in minimizing operating-room time. Second, all structures can be evaluated directly and fixed securely. The purpose of this article is to present the open operative techniques that we use to reconstruct and repair the multiple-ligament-injured knee. In the treatment of these injuries, our goal is to create an environment of controlled arthrofibrosis to provide the patient with a reconstructed knee that is functionally stable.
The multiple-ligament-injured knee continues to be a perplexing problem for the orthopedic surgeon. The treatment of this traumatic injury is controversial. This controversy stems from the myriad of vascular, neurologic, and ligament injuries that often accompany this injury. Though most often seen in motor vehicle accidents and industrial accidents, the multiple-ligament-injured knee has been occurring with increasing frequency in athletes participating in sporting events.1 The management difficulties encountered in the treatment of the multiple-ligament-injured knee is compounded by both the relative infrequency of occurrence and the paucity of literature on the subject.
The rate of dislocation as a percentage of all injuries seen in the emergency department has been reported to be 0.001% to 0.013% per year.2, 3, 4, 5, 6 Because most of these dislocations tend to spontaneously reduce in the field, there should be a high index of suspicion for this diagnosis when there is biplanar laxity in any knee, even in the face of a reduced joint on plain radiographs.7 The neurovascular status of the limb and its subsequent management should be performed under the assumption that a dislocation has occurred until proven otherwise.5
The initial steps in the management of the multiple-ligament-injured knee focuses on the ABC’s of trauma.7 Reduction of the dislocated knee is immediately followed by an assessment of its vascular status. The management of the associated vascular, skeletal, and neurologic injuries takes precedence over ligament repair or reconstruction. The timing and extent of surgical intervention for ligament injuries are driven by the vascular stability of the limb and the patient’s comorbidities.5 The senior author pursues ligament reconstruction only after the stabilization of both the limb’s vascular status and the patient’s comorbidities. Ligament reconstruction can be performed via arthroscopic, open, and hybrid approaches. This article will be concerned with the senior author’s preferred surgical technique for open surgical reconstruction in the multiple-ligament-injured knee.
Mechanism of injury  Knee dislocation is the most common trauma injury resulting in multiple-ligament damage.8, 9, 10 This trauma results from high-energy trauma, such as motor vehicle or industrial accidents, as well as low-energy trauma, such as sporting events.1 High-energy trauma, when compared with low-energy trauma, has a tendency to result in a higher incidence of vascular injury and comorbidity, requiring a careful query to illuminate additional ipsilateral injury.7 Classification Knee dislocation has traditionally been classified according to where the tibia ends up relative to the femur.11 Anterior and posterior dislocations make up the majority of knee dislocations, and they have the highest incidence of vascular injury.11 The senior author attempts to determine the energy level involved in the knee dislocation and classify the injury as high- or low-energy to reflect the magnitude of trauma. We use the injury pattern that is discerned from the history, examination, and imaging studies to classify the patient into a category based on the pattern of injury. The most common injury patterns are ACL/PCL/medial side injury and ACL/PCL/PLC injury patterns. These 2 injury patterns are managed quite differently. This injury-pattern categorization determines the individual patient-specific operative intervention. Surgical indications Irreducible knee dislocations require immediate operative intervention.12, 13 This rare injury represents a rotatory injury pattern in which the medial femoral condyle button-holes through the medial capsule, whereas the medial collateral ligament (MCL) invaginates into the joint, preventing reduction. Prompt surgical action is needed to prevent skin necrosis secondary to contact pressure. For vascular-stable reduced knees, elective reconstruction is performed as soon as clearance is given from the trauma team, preferably in the first 3 weeks after injury. In cases where repair or grafting of the artery is required, we wait 6 weeks after the vascular reconstruction before attempting ligament reconstruction to insure safe tourniquet use, as recommended by our institution’s vascular surgery department. There have not been any vascular sequelae at our institution when following this time-frame protocol. We have not been able to find any published, peer-reviewed data on tourniquet use for knee-ligament reconstruction after vascular repair. The time elapsed since injury is important. We classify “acute” injuries as those injuries that have occurred less than or equal to 6 weeks ago, whereas “chronic” injuries are those injuries that have occurred greater than 6 weeks ago. In the acute situation, repair of the collateral and capsular structures can be considered, whereas in the chronic situation, reconstruction is usually required. Reconstruction is generally required for the definitive management of ACL/PCL/PLC, regardless of tissue condition. The literature supports the operative reconstruction of the ACL, PCL, and PLC injury. The approach toward the medial side complex is based on degree of injury.3, 14, 15, 16, 17, 18, 19, 20 Because the MCL is an extra-articular structure, it has the potential to heal without reconstruction. Both clinical and basic science studies support a conservative approach in dealing with isolated MCL injuries.21, 22, 23, 24, 25, 26 Additionally, a nonoperative approach is accepted for grades I and II MCL injuries that occur in combination with ACL and PCL injuries. However, a more aggressive approach is used for grade III MCL injuries.26, 27 It has been recommended that low-grade MCL injuries that occur in conjunction with cruciate tears should have their cruciates reconstructed on a delayed basis. This delay will allow for MCL healing and return of normal knee function before definitive cruciate reconstruction. High-grade MCL injuries that demonstrate gross instability, especially valgus laxity in full extension, should acutely undergo repair, if not reconstruction, of the medial-sided complex in conjunction with cruciate reconstruction. In fact, we attempt to reconstruct ACL/PCL/MCL injuries as soon as clinically feasible, so that the knee’s central pivot can be re-established, which allows for early range of motion.20, 28 These acute medial-sided repairs rarely require the addition of extra collagen. This is in contrast to the delayed reconstruction of PLC injuries with an autograph source, which adds collagen to the reconstruction environment. The timing of surgery can be influenced by various conditions, such as vascular stability, reduction stability, soft-tissue envelope viability, multiple system injuries, and other concomitant orthopedic injuries.20 Several studies have provided support for the delayed reconstruction of the multiple-ligament-injured knee.18, 19, 20 The operative indication for surgery in the multiple-ligament-injured knee is severe functional instability. Multiple-ligament-injured knees are at increased risk for progressive instability and the resulting development of post-traumatic arthrosis. The goal of surgical intervention of these knees is to assure a stable neurovascular extremity, to re-establish functional and objective stability, and to attempt to retard the development of degenerative joint disease. Surgical techniques The ACL/PCL/PLC injured knee is reconstructed by using the following open surgical technique. A discussion about the benefits and risks of the procedure should be conducted until the patient demonstrates a good understanding of both the reconstruction procedure and its rehabilitation requirements. Both verbal and written consent are obtained. The patient is placed supine on the operating-room table with the uninjured leg in the extended position. A towel bump secured with Coband wrap is placed under the injured thigh. A lateral valgus bar and the surgeon’s body are used to help secure and position the injured extremity throughout the case. After Esmark exsanguination, the tourniquet is inflated to 300 to 350 mm Hg. The mid-line anterior incision is biased slightly medial to allow for semitendinosus tendon harvest and ACL/PCL tunnel placement. The lateral incision for the posterolateral corner reconstruction is marked, maintaining a 6- to 8-cm skin bridge between the 2 incisions (Fig 1). The quadriceps tendon, patella tendon, and MCL complex can be reached through this midline incision. The bone-patellar tendon-bone autograph is harvested through the anterior incision, which is developed to the patellar paratenon. Care is taken to avoid violating the fibers of the patellar tendon. The paratenon is dissected off of the patellar tendon by pushing the dissecting scissors deep to the paratenon, and then superiorly along the paratenon in a superior and inferior direction. The entire distal quadriceps tendon to just distal to the tibial tubercle should be exposed by using this technique. A skin marker is used to identify the center of both the inferior pole of the patella and tibial tubercle. A #10 blade is used to develop a 10-mm-wide one third patellar tendon autograft. An ossicilating saw creates the patellar and tibial tubercle bone plugs that are approximately 25 mm long. The saw cuts for the tibial tubercle plug are made with a 30° angle from the axis, whereas the patellar cuts are created using a 45° angle. Half- and quarter-inch curved osteotomes complete the bone cuts, especially at the edges. Metsenbaum scissors are used to remove the tendon from the underlying fat pad and periosteum. A 10 mm × 70 mm quadriceps tendon graft is harvested for the double-bundle PCL autograft. A similar 25-mm patellar bone plug is created by using the oscillating saw with 45° angled cuts. The center of the quadriceps tendon is harvested full-thickness with at least a 10 mm width (Fig 2). The quadriceps tendon is an excellent double-bundle graft, since it has a natural cleavage in the coronal plane. This allows for the creation of 2 equal soft-tissue limbs (Fig 3). The semitendinosus is harvested for the PLC autograft. The sartorius fascia is incised along the length of its fibers with a #15 blade. Right-angle forceps are used to locate and isolate the gracilis and the semitendinosus tendons (Fig 4). Careful attention is paid to make sure that the crossing fascia slings and vinculae are released around the distal tendon insertion. A tendon harvester is used to harvest the semitendinosus tendon. Sharp dissection frees its distal insertion. The 3 harvested autografts are prepared on the back table (Fig 5). A colored marker is used on the flat bone side where the eventual interference screw will be placed. #2 Ethibond sutures are placed in a whipstitch fashion on the free tendon ends. Bone-plug and free tendon-edge sizes are assessed with cylindrical sizers. The ACL and PCL stumps are debrided with rongeurs. The ACL notchplasty is performed with curved osteotomes and a medium-sized curette (Fig 6). The degree of notchplasty should be performed to allow clear visualization for proper positioning of both the ACL and PCL autografts, preventing graft impingement (Fig 7). The size of the PCL tunnel diameters are based on the bone- and tendon-plug sizes. A PCL guide is used at approximately 50° to 60°. The guide pin is directed through the PCL guide and drilled under fluoroscopic guidance. The starting point for the tibial tunnel on the anteromedial aspect of the tibia is just below the level of the tibial tubercle (Fig 8). This inferior position will allow for tunnel stacking with later ACL tunnel placement. The guide pin should exit the posterior proximal tibia in the distal lateral third of the PCL insertion site. This position can be identified with a lateral radiograph on the posteriorly sloping “PCL Facet,” approximately 1 cm from the posterior cortex (Fig 9). The medial tibial periosteum around the guide pin is cauterized and elevated with a periosteal elevator. An appropriately sized reamer is used to create the tunnel, using extreme caution when exiting the posterior tibial cortex. The PCL femoral tunnels are created in an inside to outside direction. After the notchplasty, the anterolateral tunnel on the medial femoral condyle is created. This site is located at the junction of the roof and notch, 10 mm posterior to the articular margin within the footprint of the PCL. The appropriately sized reamer is used to create the tunnel. A second guide pin is directed 5 mm posterior from the edge of the first tunnel.29 This tunnel is developed, ensuring that the bone bridge between the tunnels is not violated. The ACL tunnels are created by starting the tibial tunnel 1 cm proximal to the tibial tubercle on the anteromedial surface of the proximal tibia, using a 55° ACL guide. This approximate angle facilitates positioning of the tunnel in the center of the ACL footprint stump. Care is taken leave at least a 1-cm bone bridge between the ACL and PCL tunnels. The femoral tunnel is positioned by using the over-the-top position on the medial wall of the lateral femoral condyle (Fig 10). A 5- to 7-mm offset guide is used to create a posterior wall of 1- to 2-mm thickness after taking the bone-plug size into account. Passage and fixation of the PCL graft occurs by using the quadriceps double-bundle autograft. This graft type is preferred to avoid the risks of allograft-disease transmission and long-term loosening, and to provide a more accurate physiologic posterior translation throughout the range of motion.30, 31, 32, 33 A suture passer or a long Kelly clamp is placed through the tibial PCL tunnel to appear in the posterior medial aspect of the notch. The Ethibond sutures from the bone-plug end of the graft are fed into the open Kelly arms and pulled anterograde through the tibial tunnel. Care is taken to keep the bone plug oriented properly. A Beath needle positions the free tendon ends into the anterolateral and posteromedial femoral positions. The posteromedial free tendon end is secured with a soft-tissue screw placed over a guide pin through the femoral notch in retrograde fashion. Tensioning of the posteromedial limb is done in extension (Fig 11). Tibial fixation is provided by a button or post with soft-tissue washer placed anteriorly in the tibia. The anterolateral limb of the PCL autograph is tensioned in 90° of flexion and secured with a soft-tissue screw placed retrograde through the femoral notch over a guide pin, restoring the normal tibial step-off position. Passage and fixation of the bone-patellar tendon-bone autograft for the reconstruction of the ACL graft occurs next. A Beath needle is placed through the ACL tibial tunnel up into the femoral tunnel. The harvested autograft is positioned in a retrograde direction. The femoral side is secured with a cannulated 7 mm × 25 mm interference screw. With the knee in 20° of flexion, the tibial side is secured with a cannulated 9 mm × 30 mm interference screw, whereas an anterograde force is applied to the tibial bone-plug sutures (Fig 12). Next, the posterolateral corner reconstruction is addressed. Low-grade posterolateral corner injuries can be successfully managed with nonoperative treatment.28 Acute repairs of the posterolateral corner are successful in the first 6 weeks, especially if there is a small zone of injury with significant remaining robust tissue. Surgical repair should be performed as soon as the patient is cleared by the trauma team, so that the anatomic structures can be identified before development of inflammatory tissue and subsequent scar-tissue formation.28 Avulsion fractures of the popliteus tendon, fibular collateral ligament, and the arcuate ligament can be repaired with direct sutures to bone, suture anchors, or soft-tissue screws with washers. For both acute and chronic high-grade posterolateral corner injuries, the senior author prefers reconstruction with the semitendinosus hamstring autograft. This reconstruction technique restores both varus and rotational stability. This technique restores the LCL and the popliteus tendon, tightens the posterolateral capsule, and serves to reinforce the posterolateral corner with an autogenous tissue load. Autogenous graft tissue is preferred due to a decreased tendency for complications such as soft-tissue failure and infection. Using a #10 blade, a full-thickness soft-tissue flap is developed through a laterally based hockey incision. Again, care should be taken to maintain a 6- to 8-cm skin bridge from the anterior incision. The femoral starting point is just posterior to the lateral epicondyle. The incision courses distally to bisect the fibular head and Gerdy’s tubercle (Fig 13). The peroneal nerve is identified, dissected free, and protected with a vascular loop throughout the entire procedure. Exposure of the lateral femoral condyle is made through a longitudinal incision of the iliotibial band. The proximal aspect of the fibula and the biceps femoris tendon are exposed. Damage to the LCL, popliteus, and arcuate ligament is assessed. The femoral fixation site for the posterolateral reconstruction is identified between both the footprint of the proximal origin of the LCL and the popliteus insertion (Fig 14). A guide pin is drilled through the fibula in an anterior to posterior direction, superior to the fibular neck. A 7-mm tunnel is created with a reamer (Fig 15). The hamstring autograft is positioned by pulling the graft through the fibular head. Both strands are looped once to produce a “figure 8” alignment underneath the biceps tendon and iliotibial band. The popliteofibular complex is re-created with the posterior limb, whereas the LCL is re-established with the anterior limb. The free ends are wrapped around a 30- to 35-mm cancellous AO screw or screw with soft-tissue washer. Once the screw is tightened into place, the remaining posterior limb is fed through the fibular tunnel, again, and tied onto the anterior limb with whipstitched sutures. 2.0 Vicryl can be used to reinforce the posterior limb. The posterolateral complex is tensioned and tightened with the knee in slight valgus, with an internal rotatory force combined with 30° of flexion. The posterolateral capsule is evaluated and secured to the posterior aspect of the construct using #2 nonabsorbable sutures. Medial-side injuries are addressed in the context of the ACL/PCL/medial-side injury pattern. Grade I and II MCL injuries often respond to nonoperative treatment.26, 27, 30 The senior author prefers to evaluate the medial complex after the above procedural steps are performed, ie, placement of the PCL and then the ACL using the operative technique already stated. If there is still antero-medial instability or significant valgus opening greater than 5 mm, then the decision to imbricate the present available tissue versus Achilles tendon allograft augmentation must be made. When repairing or reconstructing the MCL, in addition to the ACL/PCL, the single anterior medially biased incision is utilized. The soft-tissue envelope is developed to expose the MCL. Allograft tissue has been used on the medial side successfully with a low complication rate at our institution. As a result, the senior author has a low threshold for allograft use in medial-sided reconstructions. Also, the senior author has concerns over the technique of hamstring harvest in this scenario, because it creates additional morbidity to the already compromised medial side of the multiple-ligament-injured knee. Imbrication of available tissue can be performed with a tibial-based repair with anchor sutures, moving the tibial site of the MCL anteriorly on the tibia (Fig 16). If the MCL is in its appropriate location and its fibers are attenuated, then the MCL is incised in the midpoint and imbricated in a pants-over-vest fashion with #2 Ethibond sutures Fig 17, Fig 18. If there is gross tissue damage, then the Achilles tendon allograft is the senior author’s preferred graft. The bone plug is inserted into the MCL origin on the medial femoral condyle at the femoral origin, using 6.5-mm cancellous screw × 2. The tibial end is secured with suture anchors while the knee is in 20° to 30° of flexion. The incisions are closed over drains with deep 0 Vicryl figure-8 interrupted sutures. Subcutaneous skin is closed with 2.0 Vicryl inverted simple sutures. A 3.0 Prolene running suture is used to close the subcuticular layer. The incision is dressed with Steri-Strips, 4 × 4 gauze, soft roll, and Bias wrap. A cryotherapy device is placed over the Bias wrap. The lower extremity is placed into a hinged knee brace that is locked in extension and manually bent into a static valgus position. Care is taken not to place the leg in a varus and or hyperextension position while placing the leg into the brace to avoid excessive stress to the reconstructed ACL/PCL/MCL. Rehabilitation There is little in the literature about rehabilitation of combined ACL/PCL/PLC/MCL injuries that have been treated with open surgical techniques. The goal is to provide an environment that fosters controlled arthrofibrosis, because postoperative fibrosis and stiffness is desirable to a point.34 Avoidance of continuous passive motion, early weight bearing, accelerated rehabilitation, and positions that may lead to subluxation is the main goal for the first 2 weeks of physical therapy at our institution. A long leg brace locked in full extension with touchdown weight bearing is used for 6 to 8 weeks. At 2 weeks, the brace can be unlocked with progression to full range of motion as tolerated. Care must be taken to avoid varus stress and valgus stress in the PLC and MCL reconstructed patients. Crutches can be discontinued with the appearance of good quadriceps control of the leg at 6 weeks. Physical therapy for active and passive range of motion as tolerated is started at 2 weeks. Patients are advised that there is a 20% manipulation under anesthesia rate secondary to arthrofibrosis development. The senior author considers this to be an acceptable rate in light of the alternative likelihood of recurrent instability with a more aggressive physical therapy program. At 3 to 6 months, initial strength training can begin, starting with closed-chained exercises. From 6 to 9 months, advanced strength training can be performed, as long as the patient demonstrates functional progression. Return to heavy labor or sports can occur at 9 to 12 months, only after strength and range of motion are appropriate. Loss of 10° to 15° of terminal flexion is expected in reconstructions of multiple-ligament-injured knees, but this does not usually cause a functional problem for the patient.28 Complications Multiple-ligament-injured-knee injuries are far more devastating than are isolated ligament injuries.35 The 3 main complications inherent to the open reconstruction of these combined injuries are infection, recurrent laxity, and arthrofibrosis. The senior author has experienced more problems with recurrent laxity than arthrofibrosis. We would rather have the central pivot re-established early, and, as a result, we accept a 20% manipulation rate in the postoperative period. Other potential complications include failure to recognize and treat vascular injuries from the trauma itself, along with vascular injury that can result from postoperative subluxation.28, 35 Iatrogenic injuries may range from neurovascular insults to tibial plateau fractures at the time of reconstruction. Failure to understand all instability components may lead to early failure. Postoperative knee pain and painful hardware have also been described.28, 35 References 1.
1
Shelbourne KD, Klootwyk TE.
Low velocity knee dislocation.
Treat Principles Clin Sports Med. 2000;19:443–456. 2.
2
Hoover NW.
Injuries of the popliteal artery associated with fracture and dislocations.
Surg Clin North Am. 1961;47:1099–1112. 3.
3
Jones ER, Smith EC, Bone GE.
Vascular and orthopedic complications of knee dislocation.
Surg Gyn Obs. 1979;149:554–558. 4.
4
Kannus P, Jarvinen M.
Non-operative treatment of acute knee ligament injuries.
Am J Sports Med. 1990;9:244–260. MEDLINE |
CrossRef
5.
5
Treiman GS, Yellin AE, Weaver FA, et al.
Examination of the patient with a knee dislocation. The case for selective arteriography.
Arch Surg. 1992;127:1056–1062. MEDLINE 6.
6
Walker DN, Hardison RR, Schenck RC.
A baker’s dozen of knee dislocations.
Am J Knee Surg. 1994;7:
. 7.
7
Good L, Johnson RJ.
The dislocated knee.
J Am Acad Orthop Surg. 1995;3:284–292. 8.
8
Stuart MJ.
Evaluation and treatment principles of knee dislocations.
Op Tech Sports Med. 2001;9:91–95. 9.
9
Fanelli GC.
PCL injuries in trauma patients.
Arthroscopy. 1993;9:291–294. Abstract |
Full-Text PDF (315 KB)
|
CrossRef
10.
10
Fanelli GC, Edson CJ.
PCL injuries in trauma patients. Part II.
Arthroscopy. 1995;11:526–529. Abstract |
Full-Text PDF (319 KB)
|
CrossRef
11.
11
Kennedy JC.
Complete dislocation of the knee joint.
J Bone Joint Surg Am. 1963;45:889–904. MEDLINE 12.
12
Hill JA, Rana NA.
Complications of posterolateral dislocation of the knee (Case report and literature review).
Clin Orthop. 1981;154:212–215. 13.
13
Quinlan AG, Sharrard WJ.
Posterolateral dislocation of the knee with capsular interposition.
J Bone Joint Surg Br. 1956;40:660. 14.
14
Noyes FR, Barber-Westin SD.
Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation (Use of early postoperative motion to decrease arthrofibrosis).
Am J Sports Med. 1997;25:769–778. MEDLINE |
CrossRef
15.
15
Shapiro MS, Freedman EL.
Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation.
Am J Sports Med. 1995;23:580–587. MEDLINE |
CrossRef
16.
16
Shelbourne KD, Porter CD, Clingman JA, et al.
Low velocity knee dislocation.
Orthop Rev. 1991;20:995–1004. MEDLINE 17.
17
Wagher DC, Becker JR, Dexter JG, et al.
Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation (Results using fresh-frozen nonirradiated allografts).
Am J Sports Med. 1999;27:189–196. MEDLINE 18.
18
Fanelli GC, Giannotti BF, Edson CJ.
Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction.
Arthroscopy. 1996;12:5–14. Abstract |
Full-Text PDF (5435 KB)
|
CrossRef
19.
19
Fanelli GC, Giannotti BF, Edson CJ.
Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction.
Arthroscopy. 1996;12:521–530. Abstract |
Full-Text PDF (5118 KB)
|
CrossRef
20.
20
Fanelli GC, Giannotti BF, Edson CJ.
Current concepts review (The posterior cruciate ligament arthroscopic evaluation and treatment).
Arthroscopy. 1994;10:673–688. Abstract |
Full-Text PDF (14710 KB)
|
CrossRef
21.
21
Dersheid GL, Garrick JG.
Medial collateral ligament injuries in football (Nonoperative management of grade I and grade II sprains).
Am J Sports Med. 1981;9:365–368. MEDLINE |
CrossRef
22.
22
Ellsaasser JC, Reynolds FC, Omohundro JR.
The non-operative treatment of collateral ligament injuries of the knee in professional football players (An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically).
J Bone Joint Surg Am. 1974;56:1185–1190. MEDLINE 23.
23
Indelicato PA.
Isolated medial collateral ligament injuries in the knee.
J Am Acad Orthop Surg. 1995;3:9–14. 24.
24
Indelicato PA, Hermansdorfer J, Huegel M.
Non-operative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players.
Clin Orthop. 1990;256:174–177. 25.
25
Inoue M, McGurk-Burleson E, Hollis JM, et al.
Treatment of the medial collateral ligament injury. I (The importance of the anterior cruciate ligament on varus-valgus knee laxity).
Am J Sports Med. 1987;15:15–21. MEDLINE |
CrossRef
26.
26
Jones RE, Henley MB, Francis P.
Non-operative management of grade III collateral ligament injury in high school football players.
Clin Orthop. 1986;213:137–140. 27.
27
Hillard-Semball D, Daniel DM, Stone ML, et al.
Combined injuries to the anterior cruciate and medial collateral ligaments of the knee.
J Bone Joint Surg Am. 1996;78:169–175. MEDLINE 28.
28
Fanelli GC.
Treatment of combined anterior cruciate ligament posterior cruciate ligament-lateral side injuries of the knee.
Clin Sports Med. 2000;19:493–501. Abstract | Full Text |
Full-Text PDF (547 KB)
|
CrossRef
29.
29
Paulos LE, Bair BA.
Transosseous reconstruction of the posterior cruciate ligament (Single- and double-tunnel techniques).
Op Tech Sports Med. 2001;9:60–68. 30.
30
Harner CD, Irrgang JJ, Paul J, et al.
Loss of motion after anterior cruciate reconstruction.
Am J Sports Med. 1992;20:499–506. MEDLINE |
CrossRef
31.
31
Race A, Amis AA.
PCL reconstruction in vitro biomechanical comparison of ‘isometric’ versus single and double-bundled ‘anatomic’ grafts.
J Bone Joint Surg Br. 1998;80:173–179.
CrossRef
32.
32
Petrie R, Harner C.
Double-bundle posterior cruciate ligament reconstruction technique (University of Pittsburgh approach).
Op Tech Sports Med. 1999;7:118–126. 33.
33
Petrie R, Harner C.
Evaluation and management of the posterior cruciate injured knee.
Op Tech Sports Med. 1999;7:93–103. 34.
34
Cooper DE.
Treatment of combined posterior cruciate ligament and posterolateral injuries of the knee.
Op Tech Sports Med. 1999;7:135–142. 35.
35
Klimkiewicz JJU, Petrie RS, Harner CD.
Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures.
Clin Sports Med. 2000;19:479–491. Abstract | Full Text |
Full-Text PDF (787 KB)
|
CrossRef
a Sports Medicine and Shoulder Service, Duke University Medical Center, Durham, NC, USA  Address reprint requests to Claude T. Moorman, III, MD, Duke Sports Medicine/DUMC, Rm 317 Finch-Yeager Bldg, Durham, NC 27710, USA
PII: S1060-1872(03)00037-6 doi:10.1016/S1060-1872(03)00037-6 © 2003 Elsevier Inc. All rights reserved. | |
|
FULL TEXT
