So, we'll be talking about PCL management in the multiligament knee injury. These are my disclosures. I do want to recognize my colleagues at University of New Mexico. There's six of us who do multiligament knee injuries, so I really feel that I've learned a lot from them. Hopefully, they've learned a few things from me as well. And then, Mark Miller, I did my fellowship with him. Really want to recognize him. Learned a lot about the multiligament knee from him. And then, he'll be president a little bit later this morning. So, big conference for him. So, Brian Waterman went ahead and talked about epidemiology with these. I'm not going to touch too much on that, but a little bit about terminology. Because you'll see in the literature that folks talk about multiligament knee injuries, knee dislocations. Those terms are not necessarily synonymous. So, a multiligament knee can dislocate, but a knee dislocation is not necessarily a multiligament knee injury. About 50% of these reduce, and spontaneously versus in the field. So, you really have to have a high index of suspicion, and particularly with your vascular examination on these patients. Truly a global problem. This is some of the work that we did with our colleagues from Yale, where we looked at patients who presented with a documented knee dislocation versus those with a multiligament knee injury without a dislocation. And it showed that those who had a documented knee dislocation had more than a four-time higher rate of vascular injury with this. But nonetheless, still in all these instances, you really want to evaluate your patient's vascular exam. We, again, we do a lot of these at UNM, so we've come up with a knee dislocation protocol that all of our residents, fellows, attendings are aware of. The sports folks were called almost immediately about these. Our trauma folks handle some of the kind of immediate evaluation with these folks. But everything's based off of your knee stability, whether the knee's reduced, and then what your vascular exam looks like in the acute setting. So we'll talk about some of these tips and tricks that we can improve our operative efficiency. I think one of the biggest things, like Brian and Mike had noted, is you want to be able to manage these patients. And ideally, you'd like for them to come to you as soon as possible. So you have to own this. This is something that you want to let your colleagues in the community know that, hey, I want to see the knee dislocations. I want to see the multiligament knee injuries. It allows you to discuss when you're going to do timing of surgery, our consult list overnight. I always look at every single consult list to see if any knee dislocations have come in. And then similarly, you know, the private practice folks in town all have our cell phones, and they'll send us text about, hey, I have this patient that came in. Can you see them? Something else that I think is important is that when you have a knee dislocation, that does not equal external fixation. I think that's happened a lot in the past. Even with vascular injuries, that does not necessarily equal external fixation. That really should only be used in the instance if you have a knee that cannot be reduced in a brace. So this is a posterolateral knee dislocation that we had. And after a reduction, there is still some persistent widening of that medial compartment. So instead of trying to reduce this in an external fixator, we went back to surgery, made an incision on the medial aspect of the knee, and you see the bare medial femoral condyle there, and then this medial soft tissue sleeve that was just invaginated in the joint. Once you pull that out, you have a nice reduction of the knee, and this doesn't require any external fixation. Single versus dual surgeon approach, this may not be applicable or easy for everyone, but it's been discussed a lot in the spine literature and predominantly the scoliosis literature. I think this applies to the three and four ligament knees as well. You know, in the spine literature, they've discussed having decreased operative time, decreased complications, and decreased blood loss. In an academic setting, when we're teaching residents and fellows, it's much easier if you have two surgeons, what we call cross-tasking, where you can have one performing graft prep on the back table, and you're up with another one of your fellows going through the knee, drilling tunnels, preparing for all of your graft passage. I think it's less stressful, more efficient. One of our residents termed it fixing fractures with friends, and it's something that we do frequently. The exam under anesthesia, both of these gentlemen touched on that. It's really critical. You cannot rely on your MRI solely. I think the MRI can identify some things, but in the acute setting, it seems that it may over-call some issues. You know, if you have a large medial-sided injury, you'll see a lot of signal on the posterolateral corner as well, whether or not that may be injured. And then similarly, in the chronic setting, so these MRIs are from a chronic setting. PCL is a little bit thickened. You look at the coronal. You say, well, maybe there's something going on there, but let's see if I can get this video playing. This is our examination under anesthesia back in the OR, large posterior drawer exam. And then if you look at our valgus, this is in full extension, and then coming up to 30 degrees of flexion. So again, you really have to have a high index of suspicion. Some of these patients can easily be evaluated in clinics. Some of them not. I love what Mike showed about placing your steps on the OR whiteboard. I think that is really critical, lets you, your team, your scrub nurse, if there's a device rep in the room, it lets everyone know what we're planning and what we're doing. And then this is really the order that I look at with my drilling for my cruciates, is I'll do my PCL tibial tunnel first. I think that's the tunnel that we have the least amount of room for error, followed by the ACL femoral tunnel. Then I'll do my PCL femoral tunnels and pass my PCL grafts, and then drill my ACL tibial tunnel and pass my ACL graft. And then after I've done the cruciate work, turn my attention to the collaterals. This is a couple studies that Mike just showed. But again, biomechanics, single versus double bundles. So I completely agree. You do all this work, and then three or six months down the road, you get these patients where their posterior drawer is just a little bit loose, and they say their knee feels great, but you're like, boy, I really wish that was a little bit tighter. This is something that's changed in my practice. I used to do single bundle. I've actually changed to double bundle, and I've been much happier with it. I think it gives a little bit more restraint to the knee. Kinematics do, at least in the biomechanical, cadaveric studies show that they play out. When we look at overall clinical outcomes, both patients do great. You know, this really is dealer's choice, but there is a little bit in the systematic review showing that objectively, double bundle PCL reconstruction has some improved stability. Graph prep. This is, again, critical when you're doing anything. You have your tunnels drilled, and you need to pass your graphs. You can't get out of the room until your graphs are passed. So this is what I use for my double bundle PCL. I do a tibialis anterior for the posterior medial bundle, and then for the ALB, I do an Achilles allograft with bone block. And on the right side, you'll notice that the ends are really tapered or rat-tailed. I do an anagrade passage, which I'll show in a little bit, and that just helps make sure that the graph passes nicely. Greg Fennelli has taught us a lot about knee surgery. He taught us about, we call it the Fennelli finger. It's a Fennelli safety incision. It's done on the posterior medial border of the proximal leg, and it's the interval between the medial head of the gastroc and the posterior capsule. So you stay extra capsular. What's nice about this, I don't use C-arm or fluoroscopy at all anymore. I do it purely with palpation of the landmark. So with making this incision, you can put your knee around the back of the tibia. You can feel the mammillary bodies. You can feel where your tunnel needs to be, and then it protects all the structures when you're using your rasp, when you're doing your tibial guide, and it also allows for egressive fluid. You know, this is a safety thing as well to make sure that we don't get a compartment syndrome. So this is showing on the video that we have our finger actually in our safety incision. You can incorporate part of that into your MCL if you want. This is our rasp coming down. So I have someone typically holding the scope. The person who's using the PCL rasp also has their finger around the back so that you can feel the rasp. And then you bring in your PCL tibial guide. And some of these guides that are out there fit really nice down there, exactly where you need it. And then what we do, we go ahead and drill. We drill our guide pin through, and then the reamer, I like to do the reamer through the near cortex and up to the far cortex. And then I'll leave the reamer in. I'll flip my guide pin around so that the blunt tip is then going towards the posterior structures just in case it advances at all with the reamer. And then I'll put the power back on and finish reaming that far cortex. Once we've done our PCL tibial tunnel, we will drill the ACL femur, and then I'll turn my attention to the PCL femur. So this is showing where the notch point is as well as our medial arch point. Both of these you can usually see very good in patients. I like to use an acorn reamer for my ALB bundle. Most of the time I'll do a size 11. Sometimes if it's a smaller patient, I'll do a size 10. But you can set the reamer on there so that you see exactly how much of the footprint it's covering. And then you drill your guide pin through there. And then you can go ahead and ream with your acorn reamer. Once you've done that tunnel, you look at the medial arch point. Make sure that you have enough of a bone bridge for your poster medial bundle. This is usually a size 7 that I'm doing. Both of these are reamed to a depth of about 20 to 23 millimeters. So I have my passing stitches in there on the left. You can actually see where the passing suture is for the ACL and the femur. Then we'll put up our nitinol guide wire and put a couple passing sutures up with that. And then we bring in our Gore-Tex smoother. I like to use that chamfer. I think it allows things to pass nice and easy. When I bring it back down out of the knee, I have my two passing sutures for both of the bundles. Then the bundle that we start with is our poster medial bundle. So I'll pull one of these sutures and dock it outside of the knee so that when I'm passing the first bundle, the other suture doesn't come out. Then we start with the poster medial. And that's because if you do the ALB, it sometimes can block seeing your PMB and the fixation. So we'll bring that in. And this is antegrade passage. We dock it in the femur. And then I like to pass the tibia side before I put any hardware in the femur in case you have any issue with passage that you don't already have it fixed on that side. We'll fix it with a peak screw. Then we'll move on to the anterolateral bundle. So again, we'll pull out both the femoral passing and tibial passing sutures together. That prevents getting any kind of soft tissue bridge. Then you'll see our bone block for the Achilles allograft for ALB docking into the tunnel. And then similar like we did with our poster medial bundle, we'll dock that in the tunnel. We'll pass the tibial side to make sure that that comes down and passes smooth. Then we'll go ahead and put in our fixation. And I fixed this with a titanium interference screw. This shows both our PCL fixed, ACL is in. It's been passed on the femoral side. So now we're going to move to the tibial side with this. We'll start with the PCL fixation. That's the one that we tension first. We do sequential tensioning with this. Our anterolateral bundle, I have it over a triangle here. And we'll fix it at 90 degrees with putting an anterior drawer. I use a screw and spike washer for the anterolateral bundle. And then in near full extension I'll fix our poster medial bundle. At that point, oftentimes I'll leave the ACL on the tibia not fixed yet. And I'll go to my poster lateral corner. Go ahead and expose the poster lateral corner. Drill my tunnels. Because if you're going to get any tunnel collision, typically it's going to be with your LCL tunnel on the poster lateral corner. So once you get the poster lateral corner tunnels drilled, then I'll go back, fix my ACL on the tibia, and then do whatever work we need on the collaterals. So Dr. LaPrade, he's given us lots of information on this. But sequence of graft tensioning, what they looked at was a bicruciate injury with a corner. And it showed that you need to tension the posterior cruciate ligament first to avoid any posterior translation of the tibia and extension. Because we do most of our weight bearing in near full extension. And then lastly, you would do your corner. Because otherwise, you could inadvertently increase the tibial internal rotation. Avoiding tunnel collision, again, we have our PCL, ACL, MCL, and then poster lateral corner. So lots of tunnels that you have to contend with. We just talked about the order of fixation that I prefer. And then for the medial side, this is a study that is published in this month's issue of AJSM, where we looked at a novel technique that one of my senior partners, Garen Trimmy, came up with. And it's where we still do an anatomic reconstruction, a single bundle of the MCL. But for our poster medial corner, we're doing a capsular imbrication. And we compared this to LaPrade's technique with the two free grafts. And this really provides excellent stability, particularly with valgus and full extension. It showed that it worked as good or potentially even a little bit better. But I think the main thing with this is that in the setting of a multiligament knee injury, you aren't drilling additional tunnels for the poster medial corner. This is a little diagram of what that looks like with the imbrication, superficial MCL. And then that's our cadaveric reconstruction. So to conclude, you really need to be flexible with these. When you go into a multilig, you have to have plans A, B, C, and D. Do what you do best. This isn't the time to necessarily try something new. Practice it in the lab. Do what you do best. I always get a final radiographic check before I get out of the OR, although I don't use any fluoroscopy during it. And I think patient expectations, you always need to temper these. Patients can certainly do very well and get back to high-level activities. But if you look at the studies, that's probably a third of patients. Maybe half get back to their activities of daily living. And 15% to 20% can continue to have some sort of issues or complications, because these can definitely be devastating injuries. Thank you.

PCL management

multiligament knee injuries

vascular exams

knee dislocations

surgical approaches