So, good afternoon, everyone, and welcome to the ESCA session. My name is Michael Hantes, and I'm coming from Greece. The topic is the multiligament injured knee. And I'm really excited to have this faculty member who will join me for this session, David de Jure from France, Berthe Boer from Norway, myself from Greece, and Professor Stefano Zaffanini from Bologna, Italy. So, this is the schedule. First speaker will be David de Jure. He's going to speak about the surgical planning in the multiligament injured knee. Then Berthe Boer will follow about the lateral, posterior lateral corner management in the multiligament injured knee. Then I will address the middle side of the knee. And finally, Professor Zaffanini will speak about early versus delayed management of multiligament injured knees and the factors affecting outcome. So, I hope you enjoy the session. And first speaker is David de Jure, and the topic is surgical planning in multiligament injured knee. Thank you, Michael. I will go and find my slides. But I replaced Juan Carlos Monlao, who is the actual ESCA president. And for some issues, he couldn't be there. So, I took his slides, and I will speak in Spanish to present this presentation. I hope my Spanish will be understandable. So, speaking about this topic, which is a very tough topic. We need to have some definitions, some diagnosis, classification. And when you have that, you can define your priorities and then design the treatment. When we speak about that, it means that you have at least two or more of the four major ligaments of the knee torn. So, it's definitely something very dramatic. And you may make the difference between what we call the multiligament and the knee dislocation, which is a little bit different. And if you look at this video, the red guy will have a hyperextension here, and definitely his ligaments are torn. And then, if you take a motorbike, you could be in trouble. And those videos, I cannot look at them as I'm riding a motorbike. So, I will stop them immediately. So, you have a large spectrum of trauma. And finally, you always end up in a tree with your car. And then, you go to the emergency department. When you are in the emergency department, you first need to save the leg because you will see that you could have a lot of vascular injuries. And it could be really dramatic. So, what is the real injury mechanism? It's always a high energy. And if you have a forced valgus, you will have the LCL, the popliteus. Then, you will have the ACL and PCL torn. And then, it goes on the medial side. And then, you can also turn all your medial structures. If you have a forced valgus, it goes in a different way. You have a deep MCL tear, then a superficial, then the PCL, then the ACL. And then, you go on the lateral side with the LCL and the popliteus. And the other trauma could be the hyperextension, which is pretty frequent. You have seen that on the rugby trauma. And this is terrible for the artery and the nerves. So, the diagnosis is done. And you have to look at the associate injuries, and especially the vascular one, and especially when you have this type of hyperextension trauma. We could find up to 65% of vascular trauma. It could be a total trauma, or it could be intra the artery. And sometimes, you may miss it. So, it means that you need an exam. You need an arteriography, almost 100%. So, you can use the ankle breaker index, which guides you to some more specific examination. And if it's below 0.9, you definitely need a selective arteriography. If it's over 0.9, you could just look and check your patient. So, it's not that emergency. About the vascular injuries, the CT and the angiogram will definitely show you exactly where the trauma is and what to do. And you have to call your vascular surgeon to help you, and to do something in the most effective way. When we speak about artery, we speak also about nerves. The most common one is the peroneal nerve injury, when you have a various trauma. And you could have a total plasty or partial one. And this will be interesting to check, to set, and to write that on the report when you deal with those patients. Because you know that in the future, they may have some problems. So, on the medical point of view, it's fundamental to write down everything that you see. So, the nerves, the partial or the complete injuries will lead to some sutures, will lead some in chronic setting to a tendon transfer on the chronic phase. Then you move to a more deeper diagnosis and imaging. The first is probably the x-rays. X-rays shows you if the knee is still dislocated. It will show you also if you have some fractures. And then you move to some slides imaging. And the slides imaging would be definitely MRI. MRI is probably the best and the most interesting one, because it shows exactly how many ligaments you have, and the exact location of your tear. So, if you have a medial MCL tear, you know that you will go on the femoral side and not on the tibial side. So, it's very useful to direct and to manage and to plan your surgery. So, for me, MRI is definitely the best. And of course, if we speak about x-rays, you can also do some stress x-rays. But if you look on the top left of your slides, when you do stress x-rays, keep cool. Don't do that, because you destroy also the nerves. So, you make a second knee dislocation. So, you have to be careful and very gentle when you do such exam. On the chronic phase, you can use the TELOS laximetry system, which are really good to quantify the laxity, because it's always important to quantify the laxity when you deal with some ligamentous tear. So, when you have done that, you go to the OR. And in the OR, you do the testing again. Here again, I just tell you, do a gentle testing. Go slowly. Don't go too fast. Don't try to make some outstanding videos for your next presentations, because you do some damages also. So, be careful. But it will definitely help you in understanding what your patient has. So, you need a classification. And because classification allowed you to put your patient in some different categories and then to address the right treatment. The first problem was Kennedy in 1963. But the most useful one is the anatomic classification done by Schrenk in 1992 with the KD1, one crochet, one ligament. KT2, two crochets, no collateral ligament injuries. For example, the hyperextension. This is exactly the KT2. The KT3 is ACL plus PCL plus medial or lateral collateral ligament. KT4 is almost like a knee dislocation. So, I can say that it's about the same when you speak with KD4 and 5. So, on the lateral side, you have some other classifications. Fennelly and Feldman and Fennelly and Harris did one. And I go through on the medial side. Euston spoke about that and gave some numbers to define the exact amount of laxity if you have a deep or superficial laxity. That's interesting. In terms of rotation, the dial test is interesting at 30 degrees and 90 degrees. And it will help you to know how damaged is your PLC corner. So, it's urgent, definitely. What is urgent is when you have a vascular injury. This is the first thing to look at. If you have a compartmental syndrome, if you have an open dislocation, and if it's impossible to reduce it. So, and if it's combined to tibial plateau fractures. So, these are definitely the emergency. When to do surgery and do we need to do surgery? And you have some controversies about the conservative or the surgical treatment. A few studies and we have a KD consensus and speaking about the timing. It's not so easy to say that the timing is early or delayed. Both seems to have some good or pretty good results. It's probably depending on the amount of ligament torn. And I would say that the conservative treatment is okay if you have medial side damages. But if you have the lateral side damages with LCL, popliteus, ruptures, the conservative treatment is for me not a good option, definitely. One or two stages, some different recommendations about that. Probably if you do emergency surgery, one stage is the best. You do ACL, you do PCL, you reconstruct, you repair. And you do all in one. Some people advise to do ACL plus PCL and then start with the periphery and then do ACL and PCL. I don't think this is a really good option because you deal with a knee which is not in really good shape three weeks later. So, I would say not sure. So, the outcomes, if you look at the literatures, no real differences between acute versus chronic surgery. Worse outcome, higher your energy is. Worse outcome if you have a KD of four or five. And, of course, if you have some vascular damages. So, the take-home message would be to recognize the injury pattern, very important. Diagnosis with accuracy because you understand much better what you will find in your knee. Doing early treatment is probably better. One stage probably better too. And maybe in Prague, when you will come to ASCA meeting, you will know more about that. Thank you. Thank you very much, David. So, now Berthe Boer will address the management of osteoarticular injuries in multi-ligament injured knee. Thank you, Michael, for including me in this symposium. It's a pleasure to be here in Denver for your annual meeting and I was asked to talk about the posterolateral corner. Very interesting patients, I think. Let me see if I can move this. I have some disclosure, most of them scientifically. Okay, first of all, I'll remind you about the structures of the posterolateral corner. In Europe, we tend to call the lateral collateral ligament LCL. I know you say often FCL over here, the fibulocollateral ligament. Well, it's the same structure. Oops, it's moving. Sorry. And it's also the popliteus tendon and the popliteofibular ligament. This small structure is sometimes important in the discussions when it comes to what kind of reconstruction we need after such injury. So we have what we call first and second stabilizers and the LCL and the popliteus tendon is the first stabilizer and the small popliteofibular ligament is one of the second one. And we can see here a nice dissection from my friend Jorge Sala showing how these lateral structures protect the lateral side of the knee. So this small popliteofibular ligament, why is it so important? Well, it will assist the popliteus tendon to provide static stability in external rotation and also secondary varus. And it originates from the musculotendinous junction of the popliteus tendon and inserts distally into the posteromedial part of the fibular head. Some other secondary stabilizer will be the IT band and the long head of the bicep femoris, which is often also included in lateral injuries. It's also the lateral gastroc, the lateral capsule and sometimes important the injury to the capsule and the menisca femoral and menisca tibial ligaments. So we have a lot of these patients in my hospital in Oslo and my friend and colleague Gilbert Moazza looked into the demographic in these injuries. In this cohort of more than 300 patients, he looked into the pattern of injuries and the injury mechanism and the associated injuries. So the mechanisms of injury for the posterolateral corner would be most of the time a various force applied to the entromedial tibia, sometimes ending in hyperextension with or without at the same time external rotation. These injuries are often associated with also cruciate ligaments. So there's only one third or 28 percent of the posterolateral corner injuries that are isolated. So most of them are complex injuries with with massive injury to the knee and also to remember that the peroneal nerve are affected in many of the lateral injuries. So the age of our patients was 37 years. We found that approximately one third had meniscus and or cartilage injuries and approximately 20 percent had peroneal nerve injury that was from the whole group and 5 percent had vascular injuries. So the KD3M is more common. More than half of the patients had the medial-sided injury, but for the lateral side, almost one third of the patients had a KD3L. And when they first have a lateral injury, you have to be aware the risk, the high risk of peroneal nerve injury and vascular injuries. So the odds are so much higher when the lateral structures are involved in the knee dislocation. So the clinical test for lateral side is the easy way to palpate the LCL. Normally, this is a structure that is easy to find, but when you have a lateral injury, it's obviously not so easy to palpate if it's ruptured, but also if it's partially intact, it's often swollen, so it might be hard to feel. So that that can help you in the beginning of your examination. And I have some slides for various testing and dial testing, but as I said, neurovascular function is often injured in the lateral-sided injury, so this is really important. And also, this easy test to lift the patient's first toe to compare the two sides if there's an increased hyperextension and recruvitum in the injured knee compared to the other one. And also, sometimes we need to do the external rotation drawer test, because if you have increased external rotation, this might also be because of an injury of the medial side, but of course, it's also associated with injury in the post-stroke lateral corner. So for the various stress testing, if the knee is unstable in flexion, but it's stable when you have full extension, then it's most probably an isolated LCL injury. However, if the knee is unstable in both flexion, between 20 and 30 degrees, and also unstable in full extension, then it's more probably a combined injury of both LCL and popliteus tendon, and potentially also of the cruciates. The dial test, we saw it also in David's presentation. If it's increased at 30 degrees, it's a post-stroke lateral corner injury at most of the time, but if it's increased at 90 degrees, it's most probably a combination injury with PCL. And back to the nerve injuries again. For the lateral-sided injuries, this is very important. The deep peroneal nerve is responsible for the motor function of dorsiflexion and toe extension. The superficial nerve is responsible for the foot aversion, and you grade them from one to five, according to the Medical Research Council grading system. If you grade it three or more, it's most probably a case for functional recovery, and you should also examine the sensory distribution, of course, and we all know about this little spot between first and second toe that is innervated by the deep peroneal nerve. About imaging, of course, in the acute phase you do MRI and CT scan if you have to, but for more chronical cases, you have to do the long leg radiographs to consider alignment, because we know that if you consider to do reconstruction surgery on the lateral side and the patient is in varus, this will stretch out and the patient will not be very happy with the outcome. And we also perform various stress radiographs that can tell us if it's more probably an isolated injury, or if it opens up more than four millimeters compared to the other side. It's a complete post-lateral corner injury and maybe even a more combined injury. So what to do with the post-lateral corner injuries? Well, for the grade one and two that still have an end point, most of these can be treated non-operatively. For grade two, we recommend brace and partial weight bearing for up to six weeks. For grade three injuries, the patient normally don't have a good result without surgery. But we also have to remember that it's not like we do the diagnosis out from MRI. MRI is very helpful, but it may also overestimate the injury. So if you think that this patient needs surgery because of the MRI finding, you always have to take into consideration your examination. Because we know that many people have a little lax in when you do various stress testing, so it's important to compare with the other side. So for surgical treatment of the post-lateral corner, we prefer to do this surgery within two weeks. Normally, we try to do it between the first and second week. And no matter if the patient have a neurologic injury or not, we always do neuralysis. And there are a few injuries that can be sutured or repaired, and that would be the avulsions from the fibular head and a partial popliteus tendon injury. These can probably be repaired, especially if there's a small bone piece on the LCL. But if there's a complete injury to the LCL and the popliteus tendon, you should do an anatomic reconstruction. If there's more chronical cases, as I said, you have to do the long-legged x-rays to consider if there's a virus. And if there is a virus, the surgery should be first high tibial osteotomy. And in my practice, we often do the osteotomy first, and then let the patient do the rehabilitation. And many of them then don't have to do the ligament surgery. If they still feel the virus instability, we do the ligament surgery with reconstructions later. And also in the chronic cases, we always do neuralysis. So for the surgical techniques, I was raised of these three mentors. So I still do the LaPrade-Engbretsen technique with anatomic reconstruction, and we use an Achilles allograft. This is both biomechanically and clinically validated. But I also have some new younger friends. So sometimes I do this technique, which is also an anatomic reconstruction. But for this technique, you can use one autograft semitendinosus from the same side. And use an adjustable loop in tibia. It reconstructs the same structures anatomically. So back to the incidence of nerve injuries for the posterolateral injuries. So they are really common. So you should always think of that for lateral injuries. And the risk of having both nerve injury and vascular injury in these patients is really high. So if you find a common problem with nerve injury, no matter what, we do neuralysis. And you should then of course try to avoid swelling. Advise the patient to elevate the leg and use some cooling to avoid swelling. We are also a little bit careful with the brace in the beginning if they have nerve injury. And we don't use it when a patient has epidural after the surgery. And of course the patient would benefit from a foot drop brace or adductor span. And if the nerve injury is still there after the surgery and it's resisting until later, we do neurography at three months. And if the patient is not recovering by himself, we cooperate with the nerve surgeons. And sometimes they would like to do a nerve transfer. And if they're not eligible for that, we cooperate with the foot and ankle surgeons that would offer them a transfer of the tibialis posterior so they can get back their dorsiflexion of the foot. As I said, we always do neuralysis. So I advise you to do this when you do surgery on the posterolateral corner injuries. The common peroneal nerve lies deep to the long head of the biceps, one to two centimeters proximal to the fibular head. If it's not easy to find there, you can also palpate it to approximately two centimeters distal to the fibular head. And you should do an extensive decompression. Sometimes it's up to eight centimeters. So this is a young patient of mine. You can see in the picture up to the right that she admitted with a dislocated knee. So in the lower picture, it's a reposition. She had no function in her nerve when she was operated. We did posterolateral reconstruction and both cruciates on her. And she kept sending me videos when she started to feel her toes and her function came back. So she was a gymnast and she was used to doing all kinds of saltos and everything. She wanted to come back to that, of course. I could not promise anything like that with this massive injury. But you can see that the nerve slowly recovered. It's lazy. It takes some time. It looks very good now, but still she's a little bit weaker on this side compared to her normal side. About tunnel converging, when you do anatomic reconstruction of the lateral side, you have to think of it in femur because there might be a collision with the ACL tunnel. Try to aim your lateral tunnels anteriorly, approximately 35 degrees, and you will avoid the ACL tunnel. And you can, of course, look up the tunnel when you're drilling the lateral tunnels. For tibia, there's normally no issue. The tunnel is on the lateral side and if you have stayed pretty central with your cruciate ligament tunnels, that should not be a problem. So this is our treatment algorithm for knee dislocations. And as David said, we have a very low threshold to do a CT angio. If there is a nerve injury or if the ankle brachial index is lower than 0.9, we always do it. I have to admit, I don't do it in every single case, but we have a very low threshold to do it. We prefer to do the surgery within two weeks. And the patient is sent home with a brace while they're waiting for surgery. But of course, some cases we get later, we get them from other places, and we then have to do the workup with long-legged x-rays and alignment stress x-rays. And also, always think about the nerve injuries when it's a lateral sided injury. And most of them do recover, but if not, there are some alternatives for the patients. So some key points. If the lateral sided injuries are unrecognized, they can result of course in lateral instability, but it might also ruin your result for your cruciate ligament reconstruction. So it's very important to diagnose these injuries. Consider early surgery, that's what we do most of the time, and always look for nerve and vascular injuries in the lateral sided injuries. So the outcomes also of lateral sided injuries are improving, but osteoarthritis is still a concern. Thank you. Thank you very much, Berthe. So now we move on with the middle side. Thank you. So once again, it's a pleasure to be here. And my topic is about the management of the middle side in multiligament injured knee. So these are my scientific disclosures. I just would like to remind you briefly the anatomy of the middle part of the knee. It's not just a superficial middle collateral ligament, but it's the deep collateral ligament as well, and the posterior oblique ligament, which plays an important role as well. I remind you the biomechanics of the middle side. So the MCL is the primary knee restraint in valgus forces, and the posterior oblique ligament is the primary stabilizer for internal rotation. This is something that we should not forget, and it's a secondary stabilizer for valgus and external rotation. So if there is a valgus instability in 30 degrees and in zero degrees as well, then this means that the posterior oblique ligament has been ruptured as well. The mechanism of injury, it's usually a combination of forces, external rotation and valgus forces, which are most likely to injure both MCL and the posterior oblique ligament, and this happens during athletic activities like skiing, ice hockey, and soccer, and it could be part of a knee dislocation, or it could be a combined injury of the ACL and MCL, which is a combination very common in knee injuries. So the physical examination, it's usually medial knee pain, of course. When you have a combined injury of ACL, PCL, and MCL, you have anteroposterior instability, and for isolated superficial MCL tears, then you have an instability in full 30 degrees of flexion, but when you have an instability in both 30 degrees of flexion extension, like in this case, so most probably you have a rupture of the posterior oblique ligament as well. In acute injuries, there is a gross instability in the anteroposterior plane, and if you have a combined injury, like in this case, you can reproduce the dislocation or subluxation, and in these cases, you have an anteromedial rotator instability, and usually there is a subluxation of the medial plateau to the medial femoral condyle. This is a classification of the medial instability, grade one, with full stability to valgus stress at both zero degrees and 30 degrees. Full stability at zero degrees of flexion means that you have most probably a superficial MCL injury, and when you have an unstable knee in valgus forces, like in this case, in both zero and 30 degrees, then you have injury both structures, the posterior oblique ligament and the superficial medial collateral ligament. So the question is about the treatment. If you choose an acute management, which means repair or reconstruction of these structures within three weeks, if you choose a two-stage reconstruction, which is my preferred approach, which means that you have to primarily do the MCL and POL repair, and then go back and do the cruciate ligaments, or if you do an early conservative management of the MCL and the cruciates, and then go back and do ACL, PCL, and MCL at the same time. Don't forget that the MCL has a high healing potential, and some of these injuries may heal very well, and there is no necessity to do the MCL repair. However, there are some absolute indications for acute surgical management of medial side knee injuries, and this is most probably the most important message of my lecture. So these include the tibial side avulsion injuries, the so-called sternal lesions, and when the MCL is trapped into the joint. And we're going to see some examples of these injuries. So this is a tibial-sided injury. It's a sternal lesion, and you can easily recognize that in MRI with the wave sign, which means the waving of the superficial layer, and if you do it acutely, then in a post-op MRI, like in these cases, you can see the elimination of the wave sign. So this is another example of wave sign and complete rupture of the MCL from the tibial side, and this is the clinical examination. This is a patient with a previous patella fracture, and she has an A-cell, P-cell, and MCL and P-oil injury at the same time, and this is the intraoperative findings, and you can easily repair and augment this injury, and this is the post-op result with repair of both the MCL and the P-oil with suture anchors, and this is the MRI six months later, and you can see very nicely, very good, how both the MCL and the P-oil has healed very well. This is another case of a 42-year-old male, fall from a height, and he has this type of subluxation, which was impossible to reduce it, and this is because the MCL trapped into the knee joint. It was avalanched from the femoral side and trapped into the knee joint, and this is the intraoperative findings, so we release it from inside the joint and suture it with repairs with suture anchors in the femoral side, and then we came back to do the A-cell and P-cell reconstruction. This is another case, the so-called Dibble sign. I've seen that three times in my career, which means that there is a button-holing of the medial femoral condyle into the anteromedial knee capsule. It's impossible to reduce this type of injury. This patient was sutured in another hospital and then transferred to our hospital because something, it was not normal in this knee. And this was actually an open knee dislocation. And of course, you have to go and reduce it by open means. And in this case, once again, if you do VACL and PCL, there is a high risk of knee stiffness. So it's better to go and manage first the medial side and then go back in a stage procedure and do the ACL and PCL. In chronic cases, when there is a grade three instability, like in this case, you can see the opening in full extension and 30 degrees as well. Then you have to do a reconstruction and you have these available techniques, a single bundle reconstruction, a double bundle reconstruction with the Danish technique, and the double bundle anatomical reconstruction popularized by LaPrade. The single bundle reconstruction does not address the posterior oblique ligament. So using the technique, you can address both the superficial M-cell and the posterior oblique ligament. It's a simple procedure, not so complicated. And I would say that I'm using this technique in most of my cases, like in this case, where you have an A-cell, a P-cell, and an M-cell rupture. And as you can see, it's a minimally invasive procedure with excellent results. And of course, the LaPrade anatomical reconstruction technique, which requires two grafts, more tunnels, and of course, you have to be more precise in order to reconstruct the ligaments in this way. And as Bert reported before, there is a risk of tunnel coalescence. So using this paper, you can have some advices how to avoid tunnel coalescence. So in conclusion, the middle side of the knee, it's a very common injury, and especially in knee dislocations. You have to address this type of injuries acutely when you have a tibial-sided injury, when you have an M-cell entrapment, when you have a double sign, and then you can decide if you go for a stage reconstruction or an acute reconstruction, depending on your preference, depending on your experience. Once again, my preference is to do a stage reconstruction, and this guarantees more or less that you will avoid stiffness. And in case of chronic M-cell and posterior oblique ligament insufficiency, you have a lot of techniques to address this injury. Of course, we need more studies in order to decide which technique is better, if you have to do an early or late intervention, and we're looking for these upcoming studies to make our final conclusion. Thank you very much. And the next speaker is Stefano, who is going to address early versus late reconstruction. Don't forget to submit your questions through the app. So good morning, everybody. So I will discuss, I'm excited to be here, and these are my disclosures, and I thank ESCA for inviting me to this good meeting and good panel. So as has been said already, multiligament surgery is when you have more than two ligaments involved, and knee dislocation is complete disarticulation of the deep ephemeral joint. And multiligament can occur with or without dislocation. As has been said already, it's about 0.2% of orthopedic injury. Some can have devastating injury, often polytrauma, and they are often associated with nerve or vascular lesion, especially when you have knee dislocation. Associated fractures are almost 50% of the cases, but there is few evidence for literature, and the minor problems are stiffness, failure, and obviously later OA. Operative treatment has been shown to be superior to nonoperative treatment for clinical outcome. However, there is increase of post-traumatic arthritis and surgical complication. So early or delayed treatment is still questionable, and I know that in the U.S. there is a study that has been shown when I was in Pittsburgh two weeks ago, and in fact there is still some debate of what is the best treatment choice. But in some cases, as in this case where we have a vascular lesion, we have no choice. And you have to do, or you have an irreducible knee dislocation as has been shown by Michael, this is an emergency. So you have to do in a really emergency situation. Otherwise, you can wait, and you can decide when you could do this type of surgery. So as they say, when emergency is controlled, what is the perfect time to perform ligament surgery? And we look at the literature, just recent literature, this is what we can find in the literature. Is that surgical timing affect outcome? This is a paper that came out last year, 51 patients and many years of follow-up. But this is acute surgery is considered before six months and chronic after six months of surgery, and there is no correlation between early or delayed surgery. What they found is that women with BMI has a higher increase of complication, and they have poor outcomes. So this is a way of having ladies worse than men. Then this is another paper that came out this year, do age timing influence the outcome of single stage reconstruction at more than 10 years of follow-up? It's 102 multi-ligament surgery, and early surgery in this case is six weeks versus delayed six weeks, more than six weeks. And in this case, similar outcome in acute or delayed reconstruction, and also different change in patient between more than 40 or below 40 years old. However, delayed reconstruction have higher rate of post-operative complication. Then this is another paper just recently came out, and this is a paper of more than 10 years of follow-up, 55 patients, and the patient below 30 years of old has significantly higher tegner than those more than 30 years old, and the risk factor for conversion to arthroplasty, as I say, was age more than 30 years, and higher knee dislocation score at time of injury. So if you have a knee dislocation, you have more increased risk of having complication after surgery. And this is another paper that come out really recently, multi-ligament with or without knee dislocation, more than 6.5 years follow-up, and again, when you have knee dislocation, three injury with documented knee dislocation, these are the patients at the worst outcomes. So knee dislocation is a factor affecting outcomes. So just to bring my experience of Borytholi Institute, this is a paper that we published last year, and in this case, we evaluated the Gunland-Tert patient reported outcome and return to work and return to sport, and survivalship after posterior cruciate ligament based multi-ligament knee injury, and with posterior medial coronate is a significant risk factor. In fact, we used 42 patients with PCL-based multi-ligament surgery, mean follow-up 10 years, and we evaluated PROMs and collected PRE and surgery and follow-up. And this was delayed surgery because the mean time for surgery was 3.3 months. And what we found is we have good to excellent PROMs at the long-term follow-up, but what we found is the posterior medial complex lesion significantly increased the risk of PCL reconstruction failure. And you see the couple of miles how it decreased when you have a posterior medial lesion that is affecting the posterior PCL. And predictor of negative outcome in our series was higher number of surgery and meniscal lesion. So just to show some cases, this is a 14-year, 18-years-old guy that has high-energy trauma. He has ACL and PCR after no neurovascular damage, but he has severe knee instability, and he has this type of dislocation. And what we did, we have an external fixator with the PCR reconstruction because it was irreducible, and it was not fixed and stable after reduction. And so we decided to do this evolution that we did in that period about 10 years ago. We did some paper about this type of treatment. And in fact, in these cases, the stiffness is so high that when you do just the PCL and you just do rehabilitation, maybe you don't need to do a second-stage surgery for ACL. This is another interesting case. This is female, 29 years old. She had a knee dislocation with popliteal artery ischemia, femoral popliteal bypass, compartmental syndrome. He has a fasciotomy and temporary knee fixation with external fixator. And this lady was an American lady that was in Vermont, and since she was living in Bologna, I received this in this situation. And so we delayed the surgery, so we has complete ACL, PCL, MCL grade 3, and lateral bucket endothelium. So after a few weeks after removing of the fixator, we did the PCL plus MCL reconstruction and lateral meniscectomy. And this was done almost 10 years ago. And this was the X-ray of 18 months follow-up. She has a stable posterior drawer test, no valgus instability, and no surgical complication, considering the gravity of the early phase. And I saw this patient 10 years later, and we did the second part of the surgery. So I did a meniscus transplant of the lateral meniscectomy that I did 10 years before, and then I did the ACL reconstruction, always with allograft. And I saw this patient just last week, and she's doing fine at six-month follow-up. This is the third case, male, 20 years old, violent sport trauma, multiligament injury, ACL, PCL, superficial MCL, and pole. So what we did after six weeks, we did this autologous hamstring for PCL reconstruction, Achilles tendon allograft for ACL over the top, and the MCL reconstruction with the Y-shape. So this is the images of the PCL and MCL reconstruction. Then we did the ACL plus lateral plasty in accordance to our technique, but with allograft. And this is the evaluation at the end of the surgery, and it's quite stable. So looking at the end, I think that multiligament injury is a complicated, severe injury associated with high morbidity. Recognizing limb and life-threatening injuries is paramount, and it's definitely you need to have a neurovascular lesion fracture and irreducible knee dislocation require obviously early treatment. Different injury patterns, you should individualize the treatment as much as you can. So there is still no consensus on the best timing for treatment, early versus delayed. However, I would say that delayed treatment show an increase of complication rates. And the factors affecting outcome are older patient more than 40 years old, female with 3 BMI more than 30, high energy trauma, documented knee dislocation, higher number of surgery, and obviously meniscal lesion. So my message is regardless of the injury, try to treat as soon as you can to have the best results. Thank you. Thank you very much, Stefano. So we already have some questions through the app. The first one is for Berthe. When you are dissecting the femoral side on a posterolateral corner injury, do you dissect the entire lateral femoral condyle, even the capsule, or you consider it is not necessary? If I dissect a capsule? Was that the question? Well, the capsule is often injured. So if it's injured, I try to suture it back where it belongs. If it's not injured, I make the typical incisions through the IT band to find the femoral insertion of the LCL and the popliteus tendon. The split in the IT band is typically like 5 centimeters. And there's one opening at the joint space, and then there's the biceps bursa on the fibular head, where we also often find some remnants from the LCL to tell me where to place the fibular tunnel. Okay, I hope this answers your question. There is another one. In skeletally immature patients, do you do anything different in terms of technique or staging, Stefano? In cases of skeletally immature patients, in young patients with open physis probably, do you do something different in terms of technique? Open physis. Unfortunately, I haven't seen so very big dislocation in this type of patients so far. So I'm lucky. But in the really open physis, I would be more conservative as much as I can before going to do some surgery. Yes, I will postpone the surgery. I will put in the brace, and then I will wait a little bit and see what can heal by themselves. Yeah, me as well. What I'm doing is to repair the lateral collateral ligaments if it's necessary, and then wait, depending on the age, a few months or even years, depending on the instability to go for the final reconstruction. Are there any other questions from the audience? Yes? I have a question regarding the medial side of the knee. Two questions. First of all, MCL reconstruction or repair? Second, when you approach to the MCL, usually you repair or reconstruct both oblique ligament and MCL or not? At some times, you consider just one of them. We have some techniques for the MCL reconstruction, just one bundle, not two bundles. The V-bundle that you talk is one of the techniques. So is there any test or exam that you can identify this patient needs for both reconstruction or just one tendon reconstruction? What do you think? Would you please talk about this more? So if we're talking about acute cases, then I'm not doing usually an augmentation of the repair. So I'm putting back the MCL, either if it's a vault from the tibial side, like the examples I showed you, or from the femoral side, and I stage my reconstruction, which means that I come back to reconstruct the ACL and PCL at the lateral side. So in acute setting, no augmentation or reconstruction. But in chronic cases, yes, definitely. Most of the times, I'm using, as I told you, the Danish technique, which addresses the superficial MCL and the posterior oblique ligament. And I think the clinical test is when you have an unstable knee in valgus forces in both extension and 30 degrees of flexion. I have to admit that I very often augment repair in the acute setting as well. Maybe 10, 15 years ago, we tried to suture, tried to repair, but now more and more often I use the patient's semi-tendinosis to do an augmentation of the MCL also in the acute phase. For the POL, that depends a little bit. It's often also a huge capsular injury on the knee dislocations in the medial side, so also there. Suture the capsule. And the last year, there's been increased focus on the meniscus femoral and the meniscus tibial ligaments, because they can also be the reason for rotational instability. So we more often now suture also those ligaments and augment the MCL. So even in acute cases? Yeah, that depends where the injury is. I do the scope first, and if the meniscus lifts up, it's obviously on the tibial side, so then you have to tighten up and repair on the tibial side. If you see that the joint is opening up above the meniscus, it's on the femoral side. Yeah, use anchors. Do you have any experience of using the synthetic ligament for the PCL in knee dislocations? I personally don't do synthetic ligaments, and this would be my next question. I mean, in cases you face a multi-ligament injured knee, which has three ligaments to be reconstructed, what kind of grafts do you use? I mean, how many allografts, how many autografts? Starting from Stefano. If I have the chance, I can use one autograft and one or two allografts. It depends on the type of lesion that I have to face. But normally I try to have at least one of the ligaments done by autograft. If we speak about acute surgery, I'm not super fond of doing any graft for ACL or PCL. That's why I really feel that repairing the PCL first is the most important thing to reduce the epitranslation. And we did a long time ago a study using the lost ligament, automated ligament at that time, with excessively good results because it makes an internal fixation. And then you repair or you reconstruct the periphery. And it works really, really well. I love it. Yeah, I don't use synthetic grafts. Normally I will use an allograft for PCL because we do double bundles. So most of the time an Achilles tendon where we use the bone block 11 meter for the AL bundle and the rest of the tendon as a PM bundle, 7 millimeters normally. And I try to use autograft for ACL. I try to use autograft for MCL, the semi-tendinosis. And for the lateral side, if we do reconstruction, most of the time it will be with allografts. For me, for the PCL, it's always Achilles tendon allograft. And for the rest, autograft as Bertie said, usually harvesting the hamstrings from the contralateral side and from the ipsilateral side, which is most of the time enough. Any other question? So if not, I would like to ask all the panelists, which is your indication today for external fixator in multiligament injured knee? I saw, Stefano, in your presentation that you're using it quite common. Yes, we have a case, especially when there is a knee dislocation that is reducing the gain when you try to reduce. Then in this case, we just do one PCL reconstruction, and we put the external fixator that allow mobilization of the knee. So in order to have maintaining of the knee inflection extension, but you just do a PCL. And after this, you remove the external fixator after one or two months. And the patient is doing fine, and he has to return to normal physiological, normal range of motion. And then if he needs, we do ACL after this. So usually you keep the external fixator for how long? One month minimum, because in this case, you have the possibility to do range of motion. So they do kinetect from the second day. David? Only in case of vascular injuries and compartmental syndrome. Yes, same for me. Only with vascular injuries, and then we normally keep it for three to four weeks. I think today the indication for external fixator is just the vascular injury, and I don't see any other indications, at least in my practice. So any other questions? Yes? So, this is my biggest fear, and that's why I prefer almost always stage reconstruction. First, the collateral ligament, if it's an absolute indication, and then going back for the cruciate. Or, if there is no absolute indication, I wait until the knee gets full extension and at least 120 degrees of flexion, and in this case, I have almost no stiffness. We published a series some years ago using this approach with almost no stiffness in this knee. Yes, we normally do it early, the surgery early, and I cannot say that we hardly ever have stiffness, because we do. So, there's at least 15 to 20 percent that has to go back to second surgery to improve the movements. And the extension is not often the problem, but it's the flexion. No, for me, the important thing is the extension, because the patient needs to walk well, and you have to have extension if you want to decrease the risk of having an extension deficit, and this is detrimental for the results and even for arthritic changes. And you can maybe, in these type of cases that are really so, and you have a lot of surgery to be done, you can really, if you have 120, 25 degree is acceptable for me for flexion. I can add something that when you do a conservative treatment with a strong immobilization, I really feel that I prefer to have a stiff knee, because I'm always able to do an arthrolysis and bring them back to 120, 130 degrees of flexion where they can do whatever they want. And it's better to have a little bit of stiff knee than a loose knee. So, if you have to make a choice, make it stiff. Okay, so I think we're perfectly on time. I would like to thank all the speakers and to you as well for being with us and enjoy the rest of the day. Thank you very much. Thank you.

multiligament knee injuries

surgical planning

anatomical considerations

vascular damage

nerve damage

posterolateral corner

medial-sided knee injuries

early surgery

delayed management

postoperative stiffness

Michael Hantes, MD

Romain Seil, MD, PhD

Berte Boe, MD, PhD

Stefano Zaffagnini, MD