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01-02-2007 | Review Article

A Multidisciplinary Approach to the Evaluation, Reconstruction and Rehabilitation of the Multi-Ligament Injured Athlete

Authors: Michael J. Medvecky, Dr Bohdanna T. Zazulak, Timothy E. Hewett

Published in: Sports Medicine | Issue 2/2007

Abstract

Knee dislocations with multi-ligamentous involvement are potentially limb-threatening injuries that require extensive surgical and rehabilitative intervention. These knee injuries, such as combined anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and/or lateral collateral ligament injuries, are devastating injuries with results that vary from total disability to nearly full recovery of function. Recent surgical advances, including the use of allograft tissues, have increased the efficacy of these procedures while posing new challenges. By combining scientifically based surgical and rehabilitative approaches, improved outcomes in these difficult cases are being reported in the orthopaedic literature.

This review details the epidemiology and biomechanics of these serious knee ligament injuries. In addition, state-of-the-art surgical and rehabilitative techniques will be outlined. Clinical and diagnostic imaging evaluation of these knee injuries is reviewed in order to plan and execute the surgical and rehabilitative practices. We review the basic science, surgical and rehabilitative theories and practices associated with bringing patients with these serious knee injury injuries to full recovery, and detail the development of strategies for developing protocols to address these complicated cases.

US National Electronic Injury Surveillance System (NEISS). US Consumer Product Safety Commission [online]. Available from URL: http://www.cpsc.gov [Accessed 2006 Dec 16]

Hoover NW. Injuries of the pop liteal artery associated with fractures and dislocations. Surg Clin North Am 1961; 41:1099–112PubMed

Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: part II. Arthroscopy 1995; 11 (5): 526–9PubMedCrossRef

Wascher DC, Dvirnak PC, DeCoster T A. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma 1997; 11 (7): 525–9PubMedCrossRef

Walker DC, Hardison R, Schenck RC. A baker’s dozen of knee dislocations. Am J Knee Surg 1994; 7 (3): 117–24

Bratt HD, Newman AP. Complete dislocation of the knee without disruption of both cruciate ligaments. J Trauma 1993; 34(3), 383–9PubMedCrossRef

Toritsuka Y, Horibe S, Hiro-oka A. Knee dislocation following anterior cruciate ligament disruption without any other ligament tears. Arthroscopy 1999; 15 (5): 522–6PubMedCrossRef

Shelbourne KD, Pritchard J, Rettig AC, et al. Knee dislocations with intact PCL. Orthop Rev 1992; 21 (5): 607–11PubMed

Hagino RT, DeCaprio JH, Valentine RJ, et al. Spontaneous pop liteal vascular injury in the morbidly obese. J Vasc Surg 1998; 28 (3): 458–462PubMedCrossRef

10.

Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am 1963; 45: 889–904PubMed

11.

Wascher DC. High-velocity knee dislocation with vascular injury: treatment principles. Clin Sports Med 2000; 19 (3): 457–77PubMedCrossRef

12.

Gable DR, Allen JW, Richardson JD. Blunt popliteal artery injury: is physical examination alone enough for evaluation? J Trauma 1997; 43 (3): 541–4PubMedCrossRef

13.

McCutchan JD, Gillham NR. Injury to the popliteal artery associated with dislocation of the knee: palpable distal pulsesdo not negate the requirement for arteriography. Injury 1989;20 (5): 307–10PubMedCrossRef

14.

Jones RE, Smith EC, Bone GE. Vascular and orthopedic complications of knee dislocation. Surg Gynecol Obstet 1979; 149(4),554–8PubMed

15.

Lynch K, Johansen K. Can Doppler pressure measurement replace “exclusion” arteriography in the diagnosis of occult extremity arterial trauma? Ann Surg 1991; 214 (6): 737–41PubMedCrossRef

16.

Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004; 56 (6): 1261–5PubMedCrossRef

17.

Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am 1977; 59 (2): 236–9PubMed

18.

Stain SC, Yellin AE, Weaver FA, et al. Selective management of nonocclusive arterial injuries. Arch Surg 1989; 124 (10):1136–40PubMedCrossRef

19.

Sawchuk AP, Eldrup-Jorgensen J, Tober C, et al. The natural history of intimal flaps in a canine model. Arch Surg 1990; 125(12): 1614–6PubMedCrossRef

20.

Grood ES, Stowers SF, Noyes FR. Limits of movement in the human knee: effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am 1988; 70 (1): 88–97PubMed

21.

Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee: a biomechanical study. J Bone Joint Surg Am 1987; 69(2),23342

22.

Veltri DM, Deng XH, Torzilli PA, et al. The role of the cruciate and posterolateral ligaments in stability of the knee: a biomechanical study. Am J Sports Med 1995; 23 (4): 436–43PubMedCrossRef

23.

Sisto DJ, Warren RF. Complete knee dislocation: a follow-up study of operative treatment. Clin Orthop Relat Res 1985;(198): 94–101PubMed

24.

Frassica FJ, Sim FR, Staeheli JW, et al. Dislocation of the knee. Clin Orthop Relat Res 1991; (263): 200–5PubMed

25.

Freeman MA, Pinskerova V. The movement of the knee studied by magnetic resonance imaging. Clin Orthop Relat Res 2003 (410), 35–43PubMedCrossRef

26.

Montgomery TJ, Savoie FR, White JL, et al. Orthopedic management of knee dislocations: comparison of surgical reconstructionand immobilization. Am J Knee Surg 1995; 8 (3):97–103PubMed

27.

Taylor AR, Arden GP, Rainey HA. Traumatic dislocation of the knee: a report of forty-three cases with special reference to conservative treatment. J Bone Joint Surg Br 1972; 54 (1):96–102PubMed

28.

Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy 1996; 12 (1): 5–14PubMedCrossRef

29.

Dedmond BT, Almekinders Le. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg 2001; 14 (1): 33–8PubMed

30.

Stannard JP, Brown SL, Farris RC, et al. The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med 2005; 33 (6): 881–8PubMedCrossRef

31.

Stannard JP, Riley RS, Sheils TM, et al. Anatomic reconstruction of the posterior cruciate ligament after multi ligament knee injuries: a combination of the tibial-inlay and two-femoral tunnel techniques. Am J Sports Med 2003; 31 (2): 196–202PubMed

32.

Stannard JP, Sheils 1M, McGwin G, et al. Use of a hinged external knee fixator after surgery for knee dislocation. Arthroscopy 2003; 19 (6): 626–31PubMedCrossRef

33.

Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthro fibrosis in acute anterior cruciate ligament reconstruction:the effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991; 19 (4): 332–6PubMedCrossRef

34.

Indelicato P A. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am 1983; 65 (3): 323–9PubMed

35.

Shelbourne KD, Klootwyk TE. Low-velocity knee dislocation with sports injuries: treatment principles. Clin Sports Med 2000; 19 (3): 443–56PubMedCrossRef

36.

Tewes DP, Fritts HM, Fields RD, et al. Chronically injured posterior cruciate ligament: magnetic resonance imaging. Clin Orthop Relat Res 1997; 335: 224–32PubMed

37.

Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg 1999; 12 (4): 209–13PubMed

38.

Shelbourne KD, Carr DR. Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment. Instructional Course Lecture 2003; 52: 413–8

39.

Hughston JC, Barrett GR. Acute anteromedial rotatory instability: long-term results of surgical repair. J Bone Joint Surg Am 1983; 65 (2): 145–53PubMed

40.

Hughston JC, Andrews JR, Cross MJ, et al. Classification of knee ligament instabilities: part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am 1976; 58 (2):159–72PubMed

41.

Norwood Jr LA, Hughston JC. Cormined anterolateral-anteromedial rotatory instability of the knee. Clin Orthop Relat Res 1980; (147): 62–7PubMed

42.

Clancy WG, Shepard MF, Cain EL. Posterior lateral corner reconstruction. Am J Orthop 2003; 32 (4): 171–6PubMed

43.

Covey DC. Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am 2001; 83-A (1): 106–18PubMedCrossRef

44.

LaPrade RF, Wentorf F. Diagnosis and treatment of posterolateral knee injuries. Clin Orthop Relat Res 2002; 402: 110–21PubMedCrossRef

45.

Hoher J, Harner CD, Vogrin TM, et al. In situ forces in the posterolateral structures of the knee under posterior tibial loading in the intact and posterior cruciate ligament-deficient knee. J Orthop Res 1998; 16 (6): 675–81PubMedCrossRef

46.

Harner CD, Vogrin TM, Hoher J, et al. Biomechanical analysis of a posterior cruciate ligament reconstruction: deficiency ofthe posterolateral structures as a cause of graft failure. Am J Sports Med 2000; 28 (1): 32–9PubMed

47.

LaPrade RF, Resig S, Wentorf F, et al. The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force: a biomechanical analysis. Am J Sports Med 1999; 27 (4): 469–75PubMed

48.

Markolf KL, Wascher DC, Finerman GA. Direct in vitro measurement of forces in the cruciate ligaments: part II. The effectof section of the posterolateral structures. J Bone Joint Surg Am 1993; 75 (3): 387–94PubMed

49.

Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am 2001; 83-A (8): 1131–43PubMed

50.

Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction: part 1. Causes of surgical failure in 52 consecutive operations. Am J Sports Med 2005; 33 (5): 646–54PubMedCrossRef

51.

Dye SF. The knee as a biologic transmission with an envelope of function: a theory. Clin Orthop Relat Res 1996; (325): 10–8PubMedCrossRef

52.

Arnoczky SP. Physiologic principles of ligament injuries and healing. In: Scott WN, editor. Ligament and extensor mechanism injuries of the knee: diagnosis and treatment. St Louis(MO): CV Mosby, 1991: 67–81

53.

Arms SW, Pope MR, Johnson RJ, et al. The biomechanics of anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med 1984; 12 (1): 8–18PubMedCrossRef

54.

Grocrl ES, Suntay WJ, Noyes FR, et al. Biomechanics of the knee-extension exercise: effect of cutting the anterior cruciateligament. J Bone Joint Surg Am 1984; 66 (5): 725–34

55.

Renstrom P, Arms SW, Stanwyck TS, et al. Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med 1986; 14 (1): 83–7PubMedCrossRef

56.

Herzog W, Read LJ. Lines of action and moment arms of the major force-carrying structures crossing the human knee joint. J Anat 1993; 182 (Pt 2): 213–30PubMed

57.

Beynnon BD, Fleming BC, Johnson RJ, et al. Anterior cruciate ligament strain behavior during rehabilitation exercises invivo. Am J Sports Med 1995; 23 (1): 24–34PubMedCrossRef

58.

Lutz GE, Palmitier RA, An KN, et al. Comparison of tibio femoral joint forces during open-kinetic-chain and closed kinetic-chain exercises. J Bone Joint Surg Am 1993; 75 (5):732–9PubMed

59.

Wilk KE, Romaniello WT, Soscia SM, et al. The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther 1994; 20 (2): 60–73PubMed

60.

Kvist J, Gillquist J. Sagittal plane knee translation and electromyographic activity during closed and open kinetic chainexercises in anterior cruciate ligament-deficient patients and control subjects. Am J Sports Med 2001; 29 (1): 72–82PubMed

61.

Escamilla RF, Fleisig GS, Zheng N, et al. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc 1998; 30 (4): 556–69PubMedCrossRef

62.

Wilk KE, Escamilla RF, Fleisig GS, et al. A comparison of tibio femoral joint forces and electromyo graphic activity during open and closed kinetic chain exercises. Am J Sports Med 1996; 24 (4): 518–27PubMedCrossRef

63.

Steinkamp LA, DillinghamMF, Markel MD, et al. Biomechanical considerations in patello femoral joint rehabilitation. Am J Sports Med 1993; 21 (3): 438–44PubMedCrossRef

64.

Hungerford DS, Barry M. Biomechanics of the patello femoral joint. Clin Orthop Relat Res 1979; (144): 9–15PubMed

65.

Beynnon BD, Fleming BC, Labovitch R, et al. Chronic anterior cruciate ligament deficiency is associated with increased anterior translation of the tibia during the transition from nonweight bearing to weight bearing. J Orthop Res 2002; 20 (2):332–7PubMedCrossRef

66.

Markolf KL, Bargar WL, Shoemaker SC, et al. The role of joint load in knee stability. J Bone Joint Surg Am 1981; 63 (4):570–85PubMed

67.

Yack HJ, Riley LM, Whieldon TR. Anterior tibial translation during progressive loading of the ACL-deficient knee during weight-bearing and nonweight-bearing isometric exercise. J Orthop Sports Phys Ther 1994; 20 (5): 247–53PubMed

68.

Heijne A, Fleming BC, Renstrom P A, et al. Strain on the anterior cruciate ligament during closed kinetic chain exercises. Med Sci Sports Exerc 2004; 36 (6): 935–41PubMedCrossRef

69.

Beynnon BD, Johnson RJ, Heming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res 2002; 402: 9–20PubMedCrossRef

70.

Morrissey MC, Hudson ZL, Drechsler WI, et al. Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2000; 8 (6): 343–8PubMedCrossRef

71.

Mikkelson C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercise for quadriceps strengthening after acl reconstruction with respect to return to sport: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc 2000; 8: 337–42CrossRef

72.

Hewett IE, Stroupe AL, Nance TA, et al. Plyometric training in female athletes: decreased impact forces and increased hamstring torques. Am J Sports Med 1996; 24 (6): 765–73PubMedCrossRef

73.

Shelbourne KD, Patel DV. Management of combined injuries of the anterior cruciate and medial collateral ligaments. Instr Course Lect 1996; 45: 275–80PubMed

74.

Noyes FR, Dunworth LA, Andriacchi IF, et al. Knee hyperextension gait abnormalities in unstable knees: recognition and preoperative gait retraining. American Journal of SportsMedicine 1996; 24: 35–45CrossRef

75.

Berchuck M, Andriacchi IF, Bach BR, et al. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am 1990; 72 (6): 871–7PubMed

76.

Prodromos CC, Andriacchi TP, Galante JO. A relationship between gait and clinical changes following high tibial osteotomy. J Bone Joint Surg Am 1985; 67 (8): 1188–94PubMed

77.

Perry J, Antonelli D, Ford W. Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am 1975; 57 (7):961–7PubMed

78.

Saunders JB, Inman VT, Ebethart HD. The major determinants in nonnal and pathological gait. J Bone Joint Surg Am 1953; 35-A (3), 543–58PubMed

79.

Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciateligament-deficient knees: a two- to seven-year follow-up study. Am J Sports Med 1993; 21 (1): 2–12PubMedCrossRef

80.

Noyes FR, Schipplein OD, Andriacchi TP, et al. The anterior cruciate ligament-deficient knee with varus alignment: an analysis of gait adaptations and dynamic loadings. Am J Sports Med 1992; 20 (6): 707–16PubMedCrossRef

81.

Perry J. Gait analysis: normal and pathological function. Thorofare (NJ): SLACK Inc., 1992

82.

Snyder-Mackler L, Ladin Z, Schepsis AA, et al. Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 1991; 73 (7):1025–36PubMed

83.

Shelbourne KD, Wilckens JD. Current concepts in anterior cruciate ligament rehabilitation. Orthop Rev 1990; 19 (11):957–64PubMed

84.

Eckhardt R, Scharf HP, Publ W. The ifIllortance of neuromuscular coordination for athletic stress of the knee joint after anterior cruciate ligament injuries: a gait and locomotion analysis with EMG on treadmill. Sportverletz Sportschaden 1994;8 (1), 16–24PubMedCrossRef

85.

Messier SP, Cirillo KJ. Effects of a verbal and visual feedback system on running technique, perceived exertion and running economy in female novice runners. J Sports Sci 1989; 7 (2):113–26PubMedCrossRef

86.

Grood ES, Noyes FR. Diagnosis of knee ligament injuries: biomechanics precepts. New York: Churchill Livingstone, 1997

87.

Self BP, Greenwald RM, Pflaster DS. A biomechanical analysis of a medial unloading brace for osteoarthritis in the knee. Arthritis Care Res 2000; 13 (4): 191–7PubMedCrossRef

88.

Pollo FE, Otis JC, Backus SI, et al. Reduction of medial compartment loads with valgus bracing of the osteo arthritic knee. Am J Sports Med 2002; 30 (3): 414–21PubMed

89.

Birmingham IE, Kramer JF, Kirkley A, et al. Association among neuromuscular and anatomic measures for patients with knee osteo arthritis. Arch Phys Med Rehabil 2001; 82 (8):1115–8PubMedCrossRef

90.

Komistek RD, Dennis DA, Northcut EJ, et al. An in vivo analysis of the effectiveness of the osteo arthritic knee brace during heel-strike of gait. J Arthroplasty 1999; 14 (6): 738–42PubMedCrossRef

91.

Hewett TE, Noyes FR, Barber-Westin SD, et al. Decrease in knee joint pain and increase in function in patients with medial compartment arthrosis: a prospective analysis of valgus bracing. Orthopedics 1998; 21 (2): 131–8PubMed

Title: A Multidisciplinary Approach to the Evaluation, Reconstruction and Rehabilitation of the Multi-Ligament Injured Athlete
Authors: Michael J. Medvecky
Dr Bohdanna T. Zazulak
Timothy E. Hewett
Publication date: 01-02-2007
Publisher: Springer International Publishing
Published in: Sports Medicine / Issue 2/2007
Print ISSN: 0112-1642
Electronic ISSN: 1179-2035
DOI: https://doi.org/10.2165/00007256-200737020-00005

Keynote webinar | Spotlight on medication adherence

Springer Medicine

A Multidisciplinary Approach to the Evaluation, Reconstruction and Rehabilitation of the Multi-Ligament Injured Athlete

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

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