Nerve injuries in multiligamentary knees are really a tough thing because you got two injuries. You got the nerve and the multiligamentary knee. And collision athletes, they are guys that doesn't tolerate nerve injuries. So I think that we got to think a lot and this is much level five because there's not a lot of experience in the whole literature. So how we try to do or have an algorithm for treating these injuries. First we try to keep it simple. So first thing you can, you may think is how severe injury is. And then you can have this injury and think what you do with your multiligamentary knee. So how we deal with that, let's start for the first. How severe injury is, is it complete or partial? And these are two main things. What means complete? That you got no motor, nothing, you got no tibial anteriors, you don't have extensive allosis longus and you have no sensation at all. And this is complete. Any kind of mixture of other type of injury is partial. And why that? What the utility of this? It's very simple. You search literature, partial injuries resolves mainly all. But complete injuries, you got from 12%, one of 10 people that have some degree of functional recovery but mainly nothing at all. In the best result, 38% in our series of 11% collision sport athletes, we had only one partial recovery and it was not functional. So there's a lot of thinking in MRE, ultrasonography and AMG to how to look and see what's going on with this difficult injuries. But however, if it's complete, it won't work. And if it's partial, it will work. So that makes a huge difference. Why? For example, you got this PCL and posterolateral acute knee with nerve injury. But the nerve injury was partial. So what you do? It's quite simple. You perform your surgery. This was some out-of-the-box because we got to plunge the graft in the peroneal head because we don't have it. We do all our surgery and in the meantime, the CPA will recover. So you don't have any issues with the nerve recovery. So if it's partial, just move along with your reconstruction. But what had happened with our patients that have complete injuries? These are very different. This was 20 years ago. By that time, now he's not a big surgeon, we do a nerve grafting, intercalar grafting because the side joint was awful. And he had some kind of injury, the injury went well, it was the best of the nerve graftings. He didn't regain extended hallucinus longus, but still it's working. However, if you see this knee at 20 years, it has gone atrocious, even if you got a good PCL repair and all meniscus was nearly intact, but it has some progression of atrocious. This is the worst case, he never recovered. He doesn't want to use splints as all the coalition doesn't want to do it. And you see the deterioration of the knee 15 years later. So what do we know? If it's complete, you will have CPF dysfunction. And this is very useful because they had taken a look at the gait. At the gait of the peroneal nerve palsy, it's bad. He never regained a good one, even with an A4. But if you do a posterior tibial transfer, it was not normal, but nearly normal. So it's something to do and something to think about that. So we know that you have a nerve injury, it won't give your ankle back well. So we know that the gait will not be well. So when you do a PTG or whatever, it varies in the literature. Some guys at one year do something, some expect a little bit more. We got this report from the Mayo Clinic that said that between three and six months you got to do something, but there are other reports that say you should do something quite aggressively because it won't do well your nerve injuries with time. So thinking about that, we don't like people to walk like this when they are doing your rehab for multiligamentary knees. So we do exactly the opposite, and this is strictly level five. So for example, we started doing this seven years ago. You see a complete injury, so you do a PTG transfer very early, and you do all the rehab of the PTG, and then you do the reconstruction. This is six years later. You see the hypertrophy of the transfer, and the ligament is doing well. So we try to do PT early and do our knee reconstruction. There's a considerable discrepancy in literature between how it's going, the nerve injuries, in time with multiligamentary knees. But there's not a general idea of what doing. Some of them say that they work even, nerve injuries, and without nerve injuries. But however, results tend to be lower in knee room and tend to a lower rate of return to work. And other guys said that perhaps IKDCL literature does not accurately reflect the dysfunction, and even if the results are not very different, the gate of the foot drop doesn't think to work well in time. So this is complete level five. It's a takeaway message. So complete injuries rarely improve. Don't leave peroneal nerve untreated. PTG transfer is still the best option, and do not wait. And this is what we do. If we got a nerve injury in multiligamentary knee, we split it in complete and partial. If it's partial, just move to multiligamentary knee reconstruction, and if it's complete, we move to an early PTG transfer and do then the multiligamentary knee reconstruction. So thank you, and thank you for everyone.

nerve injuries

multiligamentary knees

collision athletes

complete injuries

partial injuries