about my evidence-based approach and it kind of buzzed the tower on some current controversies in multiligamentous knee injuries. My disclosures are found here. They can also be found online and in the final program. Certainly in this field, it is critically important to make sure you rely on your mentors and colleagues. I want to thank Arvind and our colleagues for assembling this ICL so we can really dive in first thing on a Thursday morning. It's been suggested that a few multiligs come into your clinic, but if you're Rick Hatch, I think this is just any given Tuesday. And I first kind of cut my teeth on this multiligamentous knee injury pattern and taken a bite at the apple when I was in the military and I had a 500-square-mile catchment area, both from Mexico, New Mexico. I think those are the ones that Dustin Richter refused to treat. And they would come to us and it really was a very humbling experience. And so that really got me set on a path of evaluating both these multiligamentous knee injuries as well as the envelope of function. And that includes pretty far and wide in our patients. The sobering facts are that the best treatment really does not exist. So we're left with these type of forms in order to try to figure out what is best for our patients. We've heard from Mike about the morbidity of these as well as the variable degrees of reporting because they can show up in a spontaneously reduced state. But there are several varieties of multiligamentous knees. And I think the athletic field trauma versus the explosive trauma versus the high-energy multi—I'm sorry, the high-energy vehicular trauma, I think those are very different animals. And so I think we need to lend some context to that. So what are best practices? I think we can all agree that in general the surgical treatment is ideal. We're going to go through some principles on surgical timing, concomitant injuries, repair versus reconstruction, look at several techniques, talk at least briefly about the utility of external fixation, although Mike has alluded to this quite well, talk about rehabilitation and some other unique scenarios. This is one of my first patients who had a three-sided dislocation on the lower extremity, had a chance fracture. And really this is one of my first humbling forays into multiligamentous knee. What it showed me was that these can be very, very variable. And despite our best efforts you can see polytrauma patients tend to do worse on average than those individuals with isolated trauma. It's also important to realize that even with amputees you can see this high degree of multiligamentous knee injuries and long bone trauma as well as various different soft tissue injuries. So you need to pay attention to that. We've talked a little bit about some of the hard and soft signs for vascular injury. I think it's really important for you to get a regimented environment around these patients to make sure you're not missing an injury or catching an intimal injury that's in evolution throughout the course of the hospital stay. Again if there is a flow-limiting injury, then I think you need to really consult your vascular team. Make sure you're externally fixated, bridge that with a graft or consider an endovascular approach. Neurologic injury, which I think is a common controversy that we encounter. I had one of these yesterday in the OR. It can be quite common, particularly with those combined post or lateral coronary injuries. There's variable degrees of recovery. I think it's safe to say if somebody has a complete palsy when they come into the office, it's safe to tell them that there's probably going to be about a 40% chance that they can recover against gravity, which I think is an important counseling tool. If you have a partial palsy, if you have presence of some sensory and deficits in motor, I think you can tell those individuals probably around the order of 90% are going to be able to recover full function. Age is definitely correlating with neurologic function. I think how you manage this, I think this is definitely a multidisciplinary approach. If you want to really incorporate your foot and ankle colleagues as well as your rehab colleagues to make sure they have an AFO, if you do have microsurgery or hand consultation on standby, getting them involved during the initial exposure, particularly if there's nerve discontinuity, as they're going to manage this differently. When you see them in the office, I think getting serial EMGs and neuroconductive studies is very helpful. Also dynamic ultrasound at that point in time to confirm continuity throughout the entirety of the course. When you encounter these early, a direct neurolysis is quite effective. And then that way you can have the peace of mind of knowing that these individuals have an unobstructed nerve course and potentially can recover. Again this is the case from yesterday. You can see we've kind of worked through this 3-4 week out multiligamentous knee injury and been able to establish continuity. If you do encounter this late, you can bridge that with a serial nerve graft. You can do direct transfers. Again, this is something that's far outside my skillset, but working in a team approach is very key. And then that tibialis posterior tendon transfer, which we tend to indicate somewhere between 6 and 12 months in most of our patients. It's important to realize despite the morbidity of a perineal nerve injury, it doesn't necessarily correlate with function and patient satisfaction. As you can see in these two studies here, nerve injury was not predictive of either A, a return to work in a general population, or B, their overall patient satisfaction. Additionally, whether you had a KD3M or L, perineal nerve did not predict adverse outcomes. But it was predicted when there was a medial repair or female sex in this patient. We've certainly seen some evolution on the SKINC classification to incorporate extensor mechanism injuries, fracture. And so I think we'll continue to see this. But this is really how we should communicate with each other. You can see these images show the real extent of the corners, the rotational instability, as well as the AP laxity. And I would just make sure that you've got a system in place to systematically evaluate these patients, both in the office as well as in the OR. In terms of timing, Mike alluded to this. I do think early is better. You don't have this thick rind of scar and soft tissue. I think the pathology is easier to address and potentially repair and augment. But there is that heightened risk of developing stiffness-related complications. So I agree, try to calm down that soft tissue envelope. Try to drive out that effusion. At least initiate them in some prehab and potentially you could be able to restore a more anatomic approach. However, a delayed approach is quite valid as well. There can be a situation where you obviate the need for secondary, particularly cruciate reconstruction and a staged approach, particularly based on your entire system and infrastructure around you can be good to limit your time in the OR. In terms of repair and reconstruction, I think we've talked about this at length. But to reinforce, particularly on the lateral side, you can see if you're doing an isolated repair, I think you need to counsel this patient that this may not be the endgame for them. They may require further surgery if done in isolation. You can see 40% generally versus 6% and 9% for repair of the post-model corner versus reconstruction. In terms of techniques, this is something I think we could dedicate an entire ICL to and probably wouldn't get to the end of the discussion. But I hope that our STAR trial will allow us to have some insights on what is the ideal approach. There's two kind of classic camps in our community, the fibular-based RCA or Levy technique as is shown here, which is sling through the fibular head, and then the tibial-based technique, which you can see has two limbs and that's been popularized by our broadened colleagues. What's not featured here is really how we manage the capsule. I think that's something that needs to be more involved in the discussion because I think that that can be a force magnifier for or against several of these techniques. When you look at the things in the biomechanics and you evaluate this in the lab, I think you can maybe see some daylight between these techniques. But as you take this to our clinical data and really look at patients objectively, I think what you find is that generally both are quite effective as is shown in this quote here from Leprod and colleagues who has a PhD in the poster lateral corner, oddly enough. He has a 90% success rate, 10% failure. But as you go to that last line, further research is needed to determine the optimal surgical technique particularly for those chronic Grade 3 PCL injuries. In terms of the poster medial corner, it's important to realize this is not just ferrous valgus but rotation and there's some synergistic effects with the other soft tissue structures. We're classically taught that the dial test helps to root out poster lateral corner injuries. But it's important that maybe 15% to 30% of these may be accounted for by a deficient poster medial corner. So make sure you are assessing this in the office. Again similar study looking at rates of failure with repair versus reconstruction. And certainly you can poke holes in the quality of this data. But when you look at repair, 20% risk of failure versus reconstruction, 4%. So kind of a counterpoint study for the poster medial corner. Again there are variable results. We undertook a systematic review to look at the value of repair. What we found was that 75% were within 3 millimeters of side-to-side difference versus the contralateral side. And 90% had an IKDC of A or B. So overall failure rate, 6.1%. I think that medial envelope may be a little bit more receptive to repair. But we certainly need to be beholding to objective data in order to instruct our management. Just a high-level overview of the several different techniques that you can utilize on the medial side. There's innumerable amount of these. You can, it's like AC joint reconstruction, bunions and a poster medial corner. There's so many different ways that you can do this. But when you look at those non-anatomic tendon transfers, you can get a good result. But if you pull that data, you can see 50% of them may be higher than 3 millimeters side-to-side difference. A triangular base reconstruction may be a little higher rate of success, two-thirds. But you can see as you get more towards this anatomic single and double bundle reconstruction, higher rates of maintenance, particularly with valgus stress. So I really like this Mark's technique. I think that's been very transformative and a poster at a corner where you really are so maximally invasive. I think that this somewhat percutaneous technique has been really helpful to try to preserve that soft tissue envelope. And again, based on his limited series as well as others, it's done quite well. This is how it's done. You can see it's use of C-arm identifying your isometric point posterior and proximal to the medial epicondyle, bridging in those two incisions, medial base distally which is utilized for your ACL, and then performing fixation. You can see there you can also incorporate a little bit of the deep MCL just distal to the joint line about 1 centimeter down in either metal or bioabsorbable suture anchors in order to re-approximate in place. In terms of the medial side, a double bundle reconstruction can be helpful. Again, LaPrade has shown the use of two grafts. I think this is sometimes difficult to obtain fixation. I do prefer this standard base technique which is more of a sling. You go around the semimembranosus and then you can perform independent fixation of those limbs and that more posterior limb is positioned in full extension in order to make sure that you're cradling the knee and helping to maintain valgus stability with full knee extension. In terms of the grudge match, repair versus reconstruction, I think you need to take into account the patient in front of you. I think both of these result in equivalent objective outcomes. But patient-reported outcome measures at this point in time still favor reconstruction. In terms of PCL reconstruction, we could again spend an entire day on this. But what's important to realize is when you look at the bundles, the AL and PM bundles, you can see this sharing relationship, particularly in the high degrees of flexion as is shown in the graph on the left side of the screen. This is a sequential sectioning study. What you can see as you approach higher degrees of flexion, you can see those bundles playing equal role. As you reconstruct them, you more closely re-approximate native anatomy. When you take this to the clinical setting, again, fairly equivalent outcomes. You can see a single bundle technique may be streamlined in terms of surgical technique. It may limit tunnel convergence. Double bundle more closely reproduces this co-dominant load-sharing environment and maybe has better biomechanical restraint to posterior directed force. Relevant critiques of these techniques, obviously single bundle could be associated with persistent laxity, double bundle with potentially more over-constraint. So my preferred technique, as is Mike's, is to try to approach this early, particularly for those avulsions, those distally-based repairs, threatened soft tissue extensor mechanism disruptions. And I usually like to try to do that within the first two weeks. In general, it's a single bundle for both the ACL and the PCL. I do use a combination of the fibular-based and tibial-based technique. And again, I've emphasized the two-incision approach for the posterior medial corner. This is what that looks like. And really, I think you have to follow your data. We looked carefully at my technique and tried to see how we were doing. And you can see our rates from the military, we had a high degree of re-operation and revision. And this is that fairly short-term outcome. And so as we look introspectively on how we can change our approach, I think this spring-loaded brace has been very critical for trying to support particularly our PCL reconstruction. You can see as you go into higher degrees of flexion, that may offload your graft and encourage incorporation. So where I consider using the double bundle PCL reconstruction and a tibial-based posterior lateral corner, this is more for asymmetric recurve bottom, high-demand athletes, revision reconstructions. Briefly about ultra-low velocity knee dislocations, we've emphasized the morbidity of this both in terms of the neurovascular structure as well as the potential rates of secondary failure. So I agree, using liberal external fixation, a custom or clamshell KAFO, and delayed reconstruction. Bracewear is a nightmare for these patients just because they're a soft tissue envelope. So trying to find a way that you can stabilize them to prevent worsening subluxation and potentially bony erosion. We've already talked a little bit about external fixation. I think there still needs to be room for an evolving discussion with a compass hinge as potentially an adjunct. And this work from Standard has certainly shown that. Lastly, just a brief word about rehabilitation paradigms. I think this is something that I'm passionate about. I'm very excited because the STAR trial will really help us to root out kind of this classic finale-based technique versus LaPrade and how quickly can we rehab this to avoid stepping in it. Again, this is an excellent team from the STAR trial led by our fearless leader, Volker, and colleagues. So I really am excited about what that will show. I think it's also important and sobering to know that really we haven't figured this out. Despite our best efforts to look objectively at our patients, you can see it's very sobering to see the way they are returning to their pre-injury function. This is a life-altering injury. It's also important to realize that we have very high rates of post-traumatic osteoarthritis. So I think we need to try to find ways that we can further tamp this down in order to ensure long-term success for our patients. With that, I'll say thanks and welcome the next speaker.

multiligamentous knee injuries

evidence-based approach

surgical timing

rehabilitation

patient satisfaction