Thanks everyone for being here this morning. So I get to talk about the failed multiligament knee injury, which is always a fun topic. So some disclosures. So really, you know, when you have a failed multiligament knee, you get a sort of a spectrum of feelings, obviously with someone else's case, that can be sort of disappointment. When it's your own case, it's more despair and it's absolutely disastrous, obviously. So the question then is how do we actually address these and how do we tackle it? So first of all, I'm going to think about causes of failure. We're going to look at really treatment of arthrofibrosis, because one of the biggest issues with failure, you're probably thinking about stiffness. Clinical assessment, what sort of key tips and tricks for revision multiligament knee and then rehabilitation. So what are the causes of failure? Failed non-operative management. Of course, infection, you've always got to rule out stiffness, recurrent instability and pain. And it's really stiffness and recurrent instability are probably going to be the two top things that are going to come into your clinic. And so that's what we're really going to focus on. Treating the stiff knee. The last time I gave a talk on treating the stiff knee, I got a whole slew of referrals saying I was some sort of expert in arthrofibrosis. So please, no. But anyway, so you can think about the definition, epidemiology, and of course, risk factors. It's really all about what you can do to try and address these issues. In terms of the pathophysiology, we don't need to go into that in a huge amount of detail, but essentially there's a number of different causes. The epidemiology really varies depending on which paper you look at. And it can really, there's a spectrum of about four to 57% of cases. This is more in the ACL literature. When it comes down to the multiligament knee, it's a little bit different. It's certainly not as common as it used to be, because of course, we do things differently. We have more anatomic surgery, maybe faster rehabilitation. And also, we want to try and do surgery when the knee is actually settled down. In terms of classification, we can think of it either as intra-articular versus extra-articular. I want to think about whether or not this is a flexion or extension loss, and then primary versus secondary in terms of whether or not these are some avoidable risk factors. The secondary factors, again, this is something that we should be thinking about as surgeons, because there are some elements of this that we can actually control. And the main things that we can control are really the timing of surgery, technical error, prolonged immobilization, delayed post-op rehab, and infection. So these are the things that we want to really try and reduce. We have very little control over the injury severity. In terms of technical errors, again, when you come to meetings like this and go to courses, these are the things that you really want to hone in your practice to try and reduce the technical errors. And you've already heard from the previous speakers. So obviously, we're trying to avoid poor tunnel position. Graft tensioning is very important in regards to the multiligament knee, because you don't want to over-tension. And then graft choice, a number of different options there. The key to all of this is just knowing the anatomy. In terms of immobilization, the best line of treatment, of course, as always, is prevention. So we really want to get, I think the mantra has been early range of motion, reduced weight bearing, and get things going. Whether or not you use CPM or not is up for debate. And so I think over the last decade, probably, it's been anatomic surgery and early range of motion, but of course, the STAR trial, and you've heard about the STAR trial over and over this morning, this may tease out, there may be actually some options or some scenarios where actually early range of motion is not key, but we'll learn an awful lot. In terms of our patient assessment, we're looking at the history of injury, so severity, extent of injury, have they had past surgery, past history of stiffness, I guess is key. Do they have a family history to have any of these issues? And then post-operatively, how were they treated, whether or not the issues are intra or extra reticular, and whether or not the surgery was early or delayed. Of course, again, you want to exclude infection and CRPS. CRPS is such an issue, and ideally, you want to just let that settle down before thinking about surgery. There's a whole multimodal approach, and yeah, do not aggravate it by doing more surgery too early. Lots of different options in terms of the medications that you can use. Ancillary therapy, physiotherapy is key. We can use dropout casts, lots of different things that we can do to try and reduce that issue. Again, the one thing I would say is early intervention is key, and certainly if I'm thinking of picking up a patient that's got early motion loss post-multiligament surgery, I usually will be thinking about doing something within the first three months. The three-month time frame, if they haven't got their motion back, that's when I'm going to be making my decision to go back in at that earlier stage. So if we have a fixed flexion deformity, which for me is much worse than a lack of flexion, flexion is a little bit easier to come by, but trying to regain extension is a bit more of a problem. We can think about whether this is anterior or posterior. If it's in the anterior interval, it can often be infratella fat pad. You can have issues with the patella tendon, the transverse ligament, or the anterior tibia. An MRI scan will often see this scarred fibrotic fat pad that's sitting in that anterior interval, reducing your patellofemoral volume. You may see a cyclops lesion if you do an arthroscopy that's sitting at the front of the knee. The posterior capsule, that's really when you have capsular fibrosis. And then when you get into the flexion deficits, thinking about the extensor mechanism, do you have patella baja? Is this a quadriceps contracture? So again, lots of things that we need to try and rule out. In terms of an arthroscopic license of adhesions, very important to get good anesthesia, but also thinking about your postoperative pain relief. Capsular distention, people have talked about. I very, very rarely use this, so I don't think it's really useful here. In terms of, I tend to use a radiofrequency ablation to try and do the releases, and really just again trying to reduce the buildup of scar tissue postoperatively, and then just go through a methodical approach. Often because of the amount of scar, you may actually find that you can't even get into the supratellar pouch, so you start anteriorly, remove, do an anterior interval release, work up your gutters up into the supratellar pouch, release supratellar pouch, and then eventually you want to get to a point where you can navigate the scope around the knee easily, and then once you do that, do a gentle manipulation under anesthetic. Posterior capsular releases, you can do either open or arthroscopically. This is just some images of an open posterior capsular release from Mandy Williams, and this can be very effective for releasing medial head of gastroc off and reducing, releasing all of that scar tissue. My preferred technique now would be an arthroscopic technique using both poster medial, poster lateral portals, and then releasing some of that really fibrotic tissue, and then followed by a manipulation under anesthesia. Very rarely have to do a more open approach, looking for when you have flexion deficits doing quad releases as the Thompson quadriplasty or the Judae, but something, I think we heard a little bit about the external fixator earlier on, if you have an X-Fix pins that are stuck through the quad at an early stage, absolute nightmare, you may actually have to do more of an open approach to release those. Maybe issues with biologics in the future, this is not something you use on a routine basis. You guys may have more experience using some of these newer biologics for treating arthrofibrosis. So prevention better than cure, determine where the block is, and then treat appropriately. And for me, really, one thing I think is a real, as a take-home message, is to look at the patelloformal joint. If you've got good patelloformal motion, then you can often just get away with doing a manipulation under anesthetic. If that patella is really sucked in and it's really not moving, then doing an arthroscopic arthrolysis followed by a gentle MUA. So that really covers the stiff knee. What about recurrent instability? Well, of course, you need to take a good history, you need to understand what's happening. Physical examination, was there a misdiagnosis of what's going on? Use appropriate imaging, and then surgical planning. Don't forget about neurological examination. These can be a real issue later on down the track. In terms of a clinical examination, I think this is really key. The guys have already gone through this, but it's a full assessment, and if you're thinking about a failed multiligament knee, you could be dealing with a really quite a significant issue in terms of some of the secondary stabilizers, some of the capsular stabilizers, so it may just not be just the primary ligament. So you can have a bit of an issue there. So you've got to really do a full clinical assessment. Don't forget about the dial test. It's really just only an examination of external rotation laxity. It can be a medial disease, it can be a post-lateral disease. MCL clinical examination, zero and 30 degrees. We've heard all this before. The one thing I would say is just ensure a neutral AP position. So if you're assessing valgus stress, make sure that the tibia is sitting in a reduced position on the femur. If it's sitting anteriorly, that can put increased strain on the post-remedial capsule, and actually you can get a false negative. So really make sure that the tibia is reduced. And then don't forget about the Slocum test, looking for anteromedial rotatory laxity, as well as may actually pick up some issues with the post-remedial meniscus. Imaging, of course, plain radiographs is normal. MRI, very helpful for cartilage and meniscal status. Tells you very little about actually graft integrity. I mean, if the graft's completely torn, fair enough, but actually you may see that the graft is still intact. But clinical examination is going to tell you an awful lot more about the laxity pattern. The MRI may not actually tell you the extent of the injury. CT scans, very, very helpful for tunnel position and size. When we're starting it into the multiligament failed injury, then we're thinking about tunnel position, tunnel size, tunnel coalition. What do we need to do about our tunnels? Can we use the same tunnels? Do we have to bone graft and come back in at a secondary stage? So very similar to what you'd be doing with an ACL. Alignment views for me are critical. This is where we really get into the nuts and bolts of what we actually need to do. And certainly trying to address multiligamentous instability when you have abnormal bony alignment, this can be very challenging. So we obviously look at the coronal plane, but also think about the sagittal plane. Stressed radiographs, Volcker's already mentioned. So looking for MCL laxity as well as lateral, and don't forget the PCL. So essentially you can find yourself in a scenario where you've just got such global instability that we really don't know where the laxity is coming from. So having a really good documented objective assessment using stress radiography is very, very helpful to determine what you need to address. So then it comes down to decision making. You've done all of this. We've got to think operative versus non-operative. Maybe some, you know, again, Mike's already talked about some of the issues you may face with your patient population. Is a multiligament revision an option for this particular individual? May not be the best option for them. Then we think single or multistage. Do we need to bone graft? Do we need to be thinking about alignment? Or can we do everything all at the same stage? Our graft options. Well, graft options are important because, of course, we may not have a lot of autograft available, lots of allograft options, but don't forget about the other leg. You've still got a lot of autografts left on the other leg, and if you ever really want to go crazy as well, think about using the peroneus longus graft. It's actually a very, very nice graft if you don't have access to allograft. Osteotomy, you'll find this is a recurrent theme in terms of high address, a lot of these complex deformities. Why is it so important? Well, when you stand, so this guy's got a post-lateral corner injury, basically your center of mass is medial to the center of rotation of the knee, so the ground reaction force creates an adduction moment, and that is counteracted by the lateral soft tissue. So if you try and address this guy with just a post-lateral corner reconstruction, particularly in the chronic setting, you're going to run into problems, so we've got to think about addressing the alignment. Why is it important? Essentially, if you don't have those lateral structures, it puts extremely increased force onto the central pivot of either the PCL or the ACL. Don't forget about the sagittal balance. This is a patient with hyperextension recurvatum, so exactly the same principle. You've got a ground reaction force creating an extension moment, and that can cause problems with post-medial, post-lateral capsule, PCL, and so we've got to be thinking about whether or not this is a lax posterior capsule, some of these other structures, is there a reduced posterior tibial slope, and this can be extremely debilitating. Patients hate having a hyperextension thrust, and it's something that you can't treat in a very straightforward manner. So ACL, we know the issues with slope regarding ACL in terms of increasing strain on your graft, but also with PCL, so slope is directly proportional to the amount of strain that you get on these particular ligaments, so you've got to be thinking about it. So what about this guy? He's a 61-year-old former shot putter. This is a case that I did actually pretty early in my career, I think it was the first year in practice, and it was acute injury, so I did do ACL, PCL, post-lateral coronary reconstruction. Unfortunately, he slipped when he was getting out of the hot tub, and so he ended up having the lateral side failed, and so we ended up doing a medial opening wedge, high tibial osteotomy, and didn't need to do any further ligamentous reconstruction. This is a guy with a chronic PCL, post-lateral coronary, so not really essentially a failed multi-ligament reconstruction, but it just again shows the issue here. He's got some medial disease, he's in varus, he's got significant posterior sag, and again, you can just do a medial opening wedge, increasing his tibial slope, improves the station of his knee, didn't require any further soft tissue reconstructions. What about the medial side injury with valgus? This is a guy who had a dirt bike accident, significant valgus deformity, which is symmetrical, and again, so we did a staged reconstruction where we did basically the PCL-MCL first, and then came back at a second stage for a distal femoral osteotomy with the ACL reconstruction. The techniques that are involved here, the key really is just knowing your anatomy, knowing your bony attachments, using your imaging to understand where previous tunnels are, and these are all very well documented in the literature, so make sure you understand what's going on. Rehabilitation and return to sport. I think this is really important in terms of the conversation that you have with your patient. The psychology behind these injuries, I don't think really we can speak highly enough. It's so important that they understand from the outset, particularly when you're dealing in the primary scenario, the extent of the injury, the length of time that they're going to be rehabilitating. This is not a quick fix, it's not uncommon to need secondary surgery at three months for a range of motion issues, so we've got to be thinking about that, and this is just my general post-operative rehab strategies. So I'm going to leave you this last case, and this really sort of sums it all up. This is an 18-year-old female, she had an ACL-PCL post-lateral corner injury, she had generalized ligamentous laxity, a significant issue, no bony abnormality, MRI scan confirming the clinical picture. We did stress views, so she only really, her PCL was about a grade two, but I did a full ACL-PCL post-lateral corner reconstruction, and unfortunately she went on to stretch out, so about 14 months, she had a slip and fall on ice, she had a hyperextension injury, she re-injured her knee, and then she got an asymmetric hyperextension, varus laxity, anterior laxity as well as posterior laxity, so I did a revision multiligament knee injury, knee reconstruction, used the same tunnels, I was pretty happy with the tunnels. This was now an all-allograft reconstruction, and then over time, after doing this, she started about two years later, she started complaining of a hyperextension thrust, her grafts had stretched out, so now reaching a level of despair. You can see that she's got neutral coronal plane, she's got a fairly flat tibial slope, so here's a clinical examination on table, she's got a bit of hyperextension recurvatum, and her main problem was hyperextension thrust, and so we did a anterior opening wedge, proximal tibial osteotomy with a TTO, thermal head, allograft, so we can pop that in, fix the TTO, pop a plate on, and six months post-op, she's already in a better situation in terms of her hyperextension, and she ultimately had her plate out, and she's doing very well. If you want to learn more about these sorts of techniques, come to our osteotomy course in October. And with that, I'll say thank you very much for your attention.

failed multiligament knee injuries

stiffness

recurrent instability

treatment options

osteotomy