Good morning, everyone. Thank you for joining us today. So this is ICL on multiligament knee injuries, expert perspectives. All right, so if you want to scan this QR code that has our disclosures, it's also available on the app or other means as well. So in terms of the outline, a slight change of plan. So Dr. Musall from University of Pittsburgh will actually be going first, presenting on clinical outcomes as he has another conflict in between. So he'll be going first. And then we'll be followed by Dr. Michael Alea from NYU. He'll be talking about assessment and evaluation of multiligamentous knee injuries. This will be followed by Dr. Waterman. He'll be talking about current controversies in multiligamentous knee injuries. I'll be then, my name is Arneith Verham. I'll be sharing a few technical pearls for managing multiligament knee injuries. And then finally, Dr. Al-Ghaqat for the University of Western Ontario will be talking about revision multiligament knee injuries. And then once all this is wrapped up, we'll be sharing some cases. But at any time, you guys are free to ask questions and raise your hands. It's a pretty small group, so we can do that. So without further ado, we'll get Dr. Musall up here. Thank you very much. Thanks for the introduction. Thanks for setting up this ICL. So, you all look good. It sounds like none of you were up on the rooftop last night. Very good. Proud of you. Nobody even knows what I'm talking about. That's good. All right. So, we're talking multi-ligaments, a topic that we love talking about in Pittsburgh because we run the STAR trial over there. More than 500 patients enrolled now. Big study. And I'm going to talk about some outcomes. And I focus on the MCL. I have no disclosures with respect to this talk. Just want to show you a couple of little slides. You know, there are many studies out there. This is from one of my friends from Daniel Gunther. But the MCL is a beautiful, broad, structure with a ton of healing potential if you have the chance to get in there early. And I need to shout out to my mentors here. This is Freddy Fu and Savio Wu, whose names you hopefully know. And they published more than almost 50 papers on MCL. So, pretty much everything we know about the MCL and that it heals and that it can be braced and then higher grade injuries get fixed. You know from these two guys. And of course, Rob LaPraz's data, which these are some crazy numbers. You know, if you have 10 millimeters opening, obviously, everything is torn on that side. The subtleties we're not going to get into in my talk right now, but that's where it's probably more interesting. And really, the Sentinel study about ACL-MCL is done by Steve Abramovich. And it says that if the MCL is torn, there's more strain on the ACL and vice versa, back in an animal model. And so, here's some data from the European football. Today, by the way, England will again not win, but it's just how it is. Or tomorrow, I think. But so, it's pretty obvious if injuries are a little bit higher grade and if they're braced, they had a longer time away from the game. But these were like grade two injuries. Here's a case that's interesting. I learned something in this case. So, you look at this injury. It's not completely off, but it's basically torn all the way up and down the superficial MCL. There's not much displacement. But to me, and somebody who's 280 pounds and runs twice as fast as me, I'm like, this is a surgical case. And the player goes, no, it's not. It's never going to happen. Just tell me what I need to do. I'm like, okay, well, take one of these braces and for six weeks, they're going to be straight. And then after that, we rehab you on and he healed this very beautifully. So, you can brace a lot of things with the MCL. Now, how do you make the diagnosis? Obviously, valgus stress testing and you compare the contralateral side and it's never quite as clear as this case. This is obviously a multi-ligament, but five to 10 and greater than 10 millimeters. I sort of hear it's three grades. And stress x-ray is really helpful, especially in the operating room and the anesthesia. On the sideline, it's a little bit of a different story. These days, we have tents on the sidelines and nobody sees what we're doing. But, you know, you don't want to do a Lachmann 10 times with the camera on top of you. Not necessarily the best thing. On the very right side is an MRI of that same athlete that was taken a year prior for something else. And you can see that MCL on the left after that injury looked very different. Look at the really big sartorius there on this particular patient. But this is a repair that we did and it worked very well. And you don't always have to put tissues to it. So, operative management in my hands, in our hands, is reserved for avulsions, for, you know, persistent grade threes, you know, especially when they're soccer players, it's very difficult. Big combined injuries, standard lesions, etc. So, I'm going to talk about a couple of these topics, you know, acute versus delayed surgery. Obviously, something that the STAR trial is trying to figure out, which one has less complications associated with it and which one has better outcome and more predictable return to work attached to it. Staging surgery, repair versus reconstruction, where I show you a couple of repair cases. I wonder if you guys would reconstruct those instead. Some graft choices and the comeback of synthetics. So, here's some acute cases. You know, you can see that tiny little fleck next to the femur there. That happens to be half of the tibial plateau, the cartilage part of it. So, you don't want to wait on that, obviously. If it's an irreducible dislocation because the MCL is sitting in the joint, you need to go there early. Or these standard lesions where it's interposed. So, this is a 16-year-old. You can see this very acute angle from this, it's in the foul play, it's basically an attack. And you can see on the image that everything is stripped off on the medial side, ACL and PCL are torn as well. And it's a big mess in there. Interesting enough, where the ACL has most always, in these injuries, a mid-substance tear. You can see on the middle image that the PCL oftentimes has a very good tibial stump and sometimes you can repair it. And so, here's some interoperative images. ACL is toast, gets a BTB. The PCL there in the middle, you can repair and it does very well. And then there's meniscus injuries. Sometimes in athletes, the agents want MRIs early. I don't usually get that early, but it's nice to see how everything is back aligned. So, in the middle, the ACL, then the PCL with the repair and the MCL. No grafts, no allografts, no autografts, just a lot, a lot of repair. Anchors, tunnels, etc. Here's some rehab pictures. And then there's an exam about five years later. If you wonder if PCL repair works, it works pretty good. Nice station of the tibia. Now, when do you do reconstruction? So, Rob LaPrade has some data that with reconstruction, you have improved patient-reported outcome. But then with repair, you know, sometimes if you go in there early, you know, whether that's the repair itself or just the timing is tricky to say, you have increased stiffness and sometimes failure. So, there's a push to go towards reconstruction. I hope you all know these two guys. Einar Eriksson, I think is about 95 and still going very strong. And Freddy Fu next to him. But with respect to synthetics, here's what they say. Einar always said, oh man, it's like a shoelace. Why would you put that in there? It's going to disintegrate and not do anything for you. And Freddy pointed out that with all the synthetics, you get these crazy arthritis patterns. So, I never really touched that stuff. But there's some newer stuff out there. Not to make this, of course, an industry talk at all. But so, there is some interesting opportunities probably for the future in biologics. With respect to operative treatment, it's probably all goes back to LaPraz data or the two bundles. But you need to think about, you know, the superficial MCL is the key, obviously. Posterior, not sure I use a graft posterior very much because there's a lot of tissue you can repair. So, even if I use a graft in situations where it's chronic, the posterior part I usually just placate over. But sometimes you may need what you see on the right side, an anterior bundle. And then here's that flat MCL that most recently we're talking about. And so, Christian Fink just did a really nice demo. That's not him on this side. It's just our technique. But at the recent Panther meeting. And if you see that first slide I showed you, then obviously the MCL is a nice, flat, thick structure. So, here we're doing a reconstruction, looking at isometric points on the femur. You can use any type of anchors or also tunnels, if you wish. In my hands, we use a semi-tendinosis allograft. I don't harvest on the medial side to fix the medial side. Doesn't make sense to me. And the allografts work quite reasonably well. And then, obviously, you fix this construct at 30 degrees with some various stress. Now, here's another case. And this is another repair. Another crazy injury with an ACL, MCL, and a patella dislocation. There's a pretty wide opening. As the clinical exam, PCL is nice and stable. Obviously, a big valgus opening and anterior drawer. And you can see here, this sucks. You have cartilage injuries. And just like was said yesterday by David Parker, not sure I do microfracture anymore. This is an older case. Debridement and stabilizing the rim, taking out these loose pieces is maybe all that's needed there. They heal over quite well. Big radial split in the meniscus. ACL again with BTB. And then, if you spend time, so this is about, I don't know, two weeks out or so. Everything is starting to heal already in the wrong position. That tiny little ball between the two forceps is the MCL. Just draw the joint line here for orientation. And then, if you do spend time, you get that whole MCL kind of curled up and made it straight. And then, you can repair. And that's really all that was done in this particular case. But again, without grafting. So, I think on the medial side, the point I want to get across is you don't need to use grafts as much as on the lateral side where we all do that. Some rehab points real quick. So, obviously, we protected with the brace for about six weeks. We do progressive range of motion training quite early. But again, the STAR trial has a very interesting early versus delayed rehab, which we're excited because that trial is closed and the reports will probably come out pretty soon. And then, here's just some follow-up pictures. So, stiffness is an issue with all these. So, just don't turn away from it. Just deal with it. And as you know, five degrees of extension loss and you're in trouble. That's a very small number, but the patient will not be able to function completely with that much extension loss. This is the STAR trial. Many of you are in the room. And I thank you for being part of the trial and supporting it. It's really hard work since 2017, but very gratifying. This is just a slide with complications. Only 291 complications. In case you're wondering if you want to report 100% good outcome, I'm not going to trust you if you say that. But if you do a randomized control trial, you will collect everything. So, this includes appendicitis and wrist fractures that have absolutely nothing to do with the knee. But most common is pain. Some had required surgical treatment for it. About 13% had stiffness. None of the different treatment options had an outrageous number because otherwise the GSMB would shut us down. Some infections, some nerve injuries, some DVTs, the usual stuff. So, summarizing and finishing up on this talk. So, outcomes are okay of surgical treatment with multi-ligaments. They're not super, but you have good return to sport data here from Brian Forsythe and in the NFL from Ashish Bedi. These combined injuries, if you treat them right, you can bring patients back to the field. These are my points. You know, I think almost every multi-ligament talk kind of ends or shows you at some point drawing everything on the wall, which I think is important. Mark Miller always said that. And I'm just going to say it again. You do not want to do this case with your B team, you know, in the evening. You want to be fresh. You want to have the right people in the room and you communicate openly and say these are the steps that we're doing. Always have a good plan and always know that the plan is not going to work out and plan B needs to be instituted. So, have B and C, et cetera, ready. Now, with respect to the MCL, of course, untreated laxity will overload all your other structures. Again, repair is a good thing to do. And, you know, EUA with stress fluoroscopy is very important in my hands. Surgical timing, still don't quite know. We will come out with that data very soon. And the outcome, you know, you can't expect people to have outcome values greater than 85 like you would have in an isolated ACL. So, stay tuned for the STAR trial. Thanks very much for having me here. All right. Next, we'll have Michael Ayotte from NYU. All right. Thanks, Arvind, and thanks to the AOSSM for having us. About my initial approach to multiligament injured knee. Let's get this clicker to work. Great. Disclosures. So, I'm going to break this talk down into a bunch of points, right? So, take-home points are the easiest things to bring home with you. So, the first thing that we've been talking about recently, especially in some of our discussion groups regarding multiligament knee injuries, is that an MLKI is not 100% a knee dislocation. They are not the same entity. They are not the same pathogenesis, and they do not produce the same outcomes. So, not every multiligament knee injury is a true knee dislocation. And we know this from good studies. Mike Medvecky and his group at Yale published this article a few years back, showing that dislocated injuries versus non-dislocated injuries had a substantial difference in the rate of neurovascular injury, almost a 25% difference. This has to do with the force mechanisms, the vectors, the displacement, and it was unclear what the overall impact on the outcome was going to be. We always talk about the concept of spontaneous reduction, and we have agreements and disagreements over this. I would probably submit that it's rare that the knee spontaneously reduces after a true dislocation. Remember, a true dislocation, there's absolutely no articulation left between the femur and the tibia. The axial load patterns on that will force the muscles to spasm, and the two bones will pretty much bayonet on each other. So, I would probably submit it's rare. It might be more like a subluxation that spontaneously goes back, but these are things that are very difficult to prove. However, we're trying to get some more and more data regarding this. This is a paper that we put out in OJSM looking at KD1 injuries, and we can have a discussion of the skin classification ad nauseum. But the KD1 injuries, which are ACL-MCL, ACL-LCL, PCL-LCL, et cetera, it's extremely rare that those will have a true dislocation. In this paper, we found it was less than 20%. In other papers that we've also put forward, it's less than 5%. So, it's extremely rare that a KD1 injury will be a true dislocation. We've also done some recent literature that's just been published in AJSM looking at average follow-up time of almost seven years on KD3 injuries. And if you look at the IKDCs, the liceomes, and the tegners, or the dislocated versus the non-dislocated knees, the dislocated knees do substantially worse at long-term follow-up. Could be the same ligaments that are injured, same meniscal patterns, et cetera. The knees that dislocate, it's just a much bigger force that's imparted across that knee. Those patients do a lot worse over time. Counseling is really key. If and when we do get a confirmed dislocation of the knee, that is an overnight admission. We've seen cases of compartment syndrome that's developed overnight in patients with knee dislocations. Serial neurovascular exams are of the utmost importance for any residents, fellows in the room. Documentation is so important. We can't even begin to emphasize documentation for every time you see that patient. You document it in the chart that their neurovascular function has not deteriorated. And we always get an X-ray before discharge to make sure that the reduction is maintained in the brace. This is a patient that was discharged inadvertently after a reduction. You could see the first time they present to us in the office, they don't have a brace on, they're posteriorly subluxated, there's some rotational deformity in the AP view. This is obviously not a good look for anybody in the room. So big point number two, if you know a multiligament is coming in and you see them on your schedule for three weeks from now, get that patient to come in earlier. These patients require rapid evaluation. You want to, again, rule out badness, so neurovascular injuries, soft tissue injuries, et cetera. And then there's injuries that need prompt attention, extensor mechanism injuries, bony injuries, whether it's a fracture that needs to be fixed, bucket handle meniscus tears, incarcerated collateral ligaments like Volcker had shown the MCL can easily penetrate into the joint and prevent a reduction. And then avulsions, which can certainly benefit from early treatment. The sooner you see them, the earlier you start the treatment. And every day really does matter because there's interventions that we can do to make sure that the knee starts to become a lot more biologically quiet in the short term. As we know with our ACL literature, the same thing holds true with multiligaments. If we can operate on a biologically quieter knee, that's just better for the patient overall. Okay. So cryotherapy, aspirate the knee, DVT prophylaxis. Our goal is to really minimize the effusion, minimize their pain. I like to get them moving really quickly before surgery. Soft tissue swelling is paramount to elevation. There's really patient counseling and prepare the patient for surgery for usually around two to three weeks. It might take longer than that, but you have to be ready to go. Patient counseling, super, super important, right? Not every multiligament knee injury is the same. Not every patient is the same, right? Trauma is no accident a lot of times. Patients have issues with work. They have patients with family obligations, issues with post-operative care and access, right? A lot of patients that we treat for these have very little access to medical care and the complication rate in those patients are going to be higher. They might not show up for their follow-ups. They might have medical comorbidities. We know from Greg Fennelly's work that these patients will have almost a one-fourth chance of developing knee osteoarthritis that is significant within the first 10 years after their injury. So as we just discussed, not all patients are created equal. Bruce Levy back when he was at Mayo, Aaron Critch have demonstrated that older patients tend to do worse with multiligament knee injuries. Patients that are obese, super obese, the UVA group, Brian Warner and Mark Miller put out their paper showing a 70% complication rate in the obese. Lots of infections, arthrofibrosis, et cetera. You're going to have your Medicaid patients, your non-compliant patients, smokers and diabetics, and then your obvious polytrauma patients. Patients with neurovascular injuries are going to be very, very common. Vascular injuries we obviously need to rule out almost immediately. I like to look at the nerve as a predictor of what the pathology is going to be inside the knee. If you see a patient that comes in acutely with a foot drop, you know there's almost positively going to be an issue with the lateral collateral ligament and the posterolateral corner. And many of these will have actually distal avulsions of the biceps tendon with all the capsular structures on the knee. And we've done some fair amount of research in NYU looking at these kinds of injuries. And a patient, if they come in with a foot drop, there's almost an 80% chance of having a distally based injury to the posterolateral corner that actually is repairable. So we want to look at this, get them in, get them their MRI early and prepare for early fixation if possible. The other thing is that nerve sits so close to the biceps tendon. If you've got a biceps tendon injury that's displaced and retracted about three centimeters, that's a substantial injury to the lateral side. A lot of the time that fascia rips, the nerve goes with it. A stretched peroneal nerve is not a happy peroneal nerve. And those patients tend to have a very, very high rate of foot drop and peroneal nerve palsy. Vascular injuries are not life-threatening most of the time, but they are certainly limb threatening. If these are not recognized, it's almost a 32% rate of vascular injury. If they're not recognized and they're not repaired within eight hours, it's almost a 90% rate of an amputation. So again, these are patients that you have to get to the operating room because if you can repair their artery or graft or bypass their artery, it's got almost a 90% success rate. So these are things that we want to really evaluate. When a revascularization is performed, the X fix should be placed before the vascular repair, in our opinion. Now, what they can do is they can shunt the artery before we put the external fixator on, establish some blood flow, then the X-fix goes on, and then they do a formal repair or a formal bypass. Once the knee is stabilized, they don't have to worry about that anymore. Ligament repairs in the context of the vascular injury can certainly still be performed acutely, but these are things that you have to speak about with your vascular team. The goal here is to minimize leg manipulation and prevent amputation of the limb. Although we love to operate on ligaments, the limb is much more important than the quality of the ligaments at that time. Fourth important point, and I've seen this a number of times, if an arterial procedure is performed on a patient, always get a CT scan with contrast or an MR arteriogram prior to your reconstruction. This is a patient that had a four-ligament injury and had a revascularization. You can see where that graft is. That graft is on the posterior medial side of the joint. Our approach is there for the MCL. Sometimes people make a posterior medial approach even in the context of a PCL reconstruction. So you need to know where that artery is. If you think it's gonna be in the way, vascular surgery has to be there. They have to isolate the vessel. They have to protect the vessel. Our indications to externally fixate these, number one, a vascular injury. Number two, concentric reduction. Now I don't mean just like a one millimeter difference or a one millimeter posterior translation. I mean something that's quite obvious. Morbidly obese patients do not tolerate braces very well. You try and put a 400-pound patient into a hinged drop-lock brace, they are simply not gonna tolerate that. That brace is gonna be by their ankles or by the garbage pail. So that's a patient you might wanna consider externally fixating. Patients that are not gonna comply with immobilization, so psychiatric issues, schizophrenics, et cetera, we've certainly seen our fair share of those. Significant soft tissue injuries or fractures. And finally, anything open that's gonna require a serial washout. It's always easiest to just put an X-Fix on that patient and assess the ligaments when the time is right. When I do externally fixate these patients, I typically remove them at or about two to four weeks after the external fixator is placed. It's a balance and a race here between stiffness and laxity. So we want the knee to stiffen up enough that when we take the fixator off, it's gonna stay reduced. And most of the time I feel that can happen within three to four weeks afterwards. I don't like having this on for more than four weeks because those patients will be very, very stiff and when they come to you, it's just miserable. You have that stiff, unstable knee, which is exactly what we're trying to avoid here. I then give these patients an external fixator holiday and I try and get their motion back. And when their motion comes back, then we can really see which ligaments need to be either reconstructed, repaired, et cetera. Obviously in the chronic setting, it's gonna be a reconstruction, but you have time to see what declares. Once that X-Fix comes off, you don't have to rush right into a multi-ligament knee reconstruction. You can see what declares, make your decisions based on that. It's also important to understand that many patients that come in with a dislocated knee can be successfully braced. I can't even tell you how many times we've seen in our trauma center that a knee dislocation that's perfectly reduced that's now stable in a brace gets an external fixator. It's annoying, it's painful to see. I would submit to everybody, don't be that person to put an X-Fix on a knee that stays perfectly stable in a brace. If you are going to X-Fix this, keep the pins far away from the injury site. We've looked at our data, me and Medveki from Yale, and the further the pins are from the knee, the better understanding that you get when you get an MRI of the knee. If those pins are close to the joint line, then you're gonna get a scattered MRI and you're not gonna be able to see exactly what's going on. So not only does it help you with your MRI, but it also helps you with your postoperative infection risk because we don't like having X-Fix pins around a site of a big incision, especially if you're gonna put allograft in there. My indications to stage are pretty similar to what Volker had mentioned, but I'll expand on them just a little bit. Number one is surge in comfort. If you're not comfortable doing four ligaments at a time, you don't have to, that's okay. Do the ones that you feel like you have to do first. I typically recommend fixing your posterior cruciate ligament if you can early. Patient parameters are important, again, obesity, et cetera. These large medial-sided blowout lesions, I tend to find that if you stage them, you reduce their risk of stiffness. When you do something like this and you go in early and do big repairs and reconstruct multiple ligaments, ACL, PCL, these patients get really, really stiff, particularly for these medial-sided injuries. I don't see it happening so much on the lateral side, but I think on the medial side, these patients tend to get very, very stiff. Fractures are a good indication to stage, as well as extensor mechanism disruptions. You can handle all of your extraticular stuff at the same time, get their motion back, and then you do their ACL and their PCL when you have to. And finally, number five, if there's an absolute indication for early intervention, there's really no right answer for these, and this is why the STAR trial exists, because we still don't know all the right answers. And we come up here and we talk about what to do, what not to do, but there are so many different parameters and so many different algorithms for knee dislocations that you're never gonna have a perfect answer. I do like to try and limit the amount of rehabilitations. So polytrauma that comes in with one or two fractures, a knee dislocation, I'd like to minimize the time that they can be non-weight-bearing, right? I don't wanna give two huge rehabs or three huge rehabs, rather just maybe one huge rehab. Any kind of delay with these surgeries, you're gonna get some scar tissue planes. There is a concept that Bruce Levy talks about, controlled arthrofibrosis, so you have the ability to make that knee a little bit stiff as you're regaining their motion that actually might add stability to your construct and allow the ligaments to heal a little bit better. Stress radiographs, I won't go over this because Volker just discussed them, but obviously if you could do them under anesthesia, that's certainly a lot better. And finally, expect the unexpected. These injuries are difficult to treat, these patients are difficult to treat, and these injuries are hard to treat even surgically because the algorithm and the number of different injuries that you can have is so, so high. So attention to detail is very, very important when you're doing these cases. Every case is a learning opportunity. Think about what you did right after the surgery, how you can make your surgery better, how you can make your surgery more efficient. And the literature can only really help so much at this point because pretty much everything out there is level four evidence, systematic reviews, et cetera, meta-analyses. You know, again, that's why the STAR trial is so, so important, but even with that trial, there's so many different algorithms with injuries. We're gonna certainly have some information, but even with that, we still might not be perfect. So really critically analyze what you do, how you can make your patients better, and I think you'll understand these injuries a lot better and have better outcomes. So thank you for the time. Thank you. Good morning. So I don't have mega points, but I do have controversies. We'll have six of those as well. Talk a little bit about evidence-based approach to these current controversies in 2024. By way of introduction, it's really a humbling condition in order to treat multiligamentous knees. And you don't learn this in a vacuum. So really avail yourself of the opportunity to visit several of these thought leaders. And my journey first started when I was in Fort Bliss in El Paso, Texas. And I took the opportunity to go visit Bruce Levy and spent four weeks with him just analyzing how we can do these things better. And our practices continue to evolve. And I've learned from these thought leaders. And I just want to commend the folks that continue to pour into this data set. A special thanks to the newly revived International Knee Dislocation Study Group. We had our inaugural meeting in Toronto. And it was just a great opportunity to break bread with colleagues and talk a little bit about some of these concepts that we still don't know a fair amount about. The best treatment really does not exist. As Mike alluded to, reconstruction may be better than repair. But we really don't know. And that starts with the posterolateral corner. That's our first controversy we want to try to unpack. Again, repair just may be fraught with a slightly higher risk of failure. And so if you try to do a repair, it probably is going to be highly variable. Up to 40% will fail relative to reconstruction or augmentation. And these are the two players. You have a fibular-based and tibial-based technique. When we talk about these, we also need to emphasize the importance of that capsule or advancement, which I think sometimes gets lost in the shuffle. In terms of the grudge match between those two, you can see that the literature bears out that probably you can anticipate, irrespective of technique, 90% success rate, 10% failure based on stress radiographs, or frank failure. So while it's painful to say, we probably do need further research in order to identify the optimal technique and indications for patients with type 3 posterior lateral coronary injuries. So the winner in this debate is really performing an anatomic reconstruction using whichever technique is more beneficial to you, fibular or tibular-based. So either is appropriate. So for the Levy-Arciero, I'm going to call it a tie. When do I think about doing a tibial-based reconstruction? I think that those are the individuals that have asymmetric recurvatum, a higher demand athlete, a revision reconstruction. And for those that have that rare case of proximal tib-fib instability in our practice. In terms of the next controversy, certainly a hot button debate issue is the posterior cruciate ligament reconstruction. How to do it? When we looked candidly at our patient population in the military, looking at PCL reconstructions both isolated and combined, it was a little bit of a dose of humble pie because you can see our rates of re-operation were quite high. And then you look at rates of failure, even just isolated PCL injuries of 12%. This is a fairly short follow-up. So what we wanted to do is look at how we might innovate this. And is there potentially a reward for adding that additional bundle, doing a double bundle reconstruction, creating that co-dominant load sharing type of reconstructive technique? And so when we look to the literature, certainly there are pros and cons here. We've seen those single bundles that can have some element of persistent laxity, but it is a much more streamlined procedure for most folks versus the double bundle reconstruction, which again, probably has better biomechanical restraint to posteriorly directed force, but may also have risk of over-constraint or attenuation of that second bundle if you look at some of the biomechanical studies. When you take this to the literature, however, there's fairly similar clinical outcomes with a couple caveats. If you look at these studies critically, what you do see with a double bundle construct, there is reduced posterior tibial translation based on telos and other instrumented measures of laxity. You can also see there's probably a higher rate of normal or near normal reports by our patients on the subjective portion of the IKDC. So for this one, I would say the double bundle reconstruction probably takes it. However, I would say that the broader majority that I do are all inside single bundle PCL reconstructions. I think that's a different animal than the traditional report of a single bundle reconstruction. And all these, I'm doing some element of synthetic augmentation. I would preferentially consider double bundle PCL reconstruction, again, in that higher demand athlete, those with revision surgery. And then again, the other aspect of this is that that flat slope, and that's been borne out in some of the recent papers that have looked at laxity. So rapid fire on PCL, there's several different topics or subtopics within this group. There's been a lot of discussion about stump sparing and the potential merits as it relates to proprioception, healing, and potentially providing some cushion for that killer turn around the tibia. While there is limited support for it, it can also obstruct your view. So I think you can use that if you prefer. I generally will articulate the osteology in the back and I think that helps to make a more anatomic reconstruction. In terms of inlay or trans-tibial technique, again, the literature supports both techniques, so whichever is more executable in your hands. What about synthetic suture or tape augmentation? We know that it provides a biomechanical check rein and it may, you know, the concern is that it may provide stress shielding, but the data doesn't support that. It does decrease, at least in the lab, posterior tibial translation. However, when you take this to our clinical outcomes, again, comparisons show no difference between those with and without suture augmentation. So while it is supported, there's really no clinical difference at this point. What about spring-loaded bracing? You know, I was very interested in this because oftentimes, I would see a little bit more slop in our single bundle reconstructions. And as I converted over to this dynamic spring-loaded brace, what I found is that it really measurably created reproducibly, reproducible outcomes in my single bundle reconstructions. It is an expensive brace. It's important to realize that, but Bob LaPrade has shown us that it's very meaningful for both our single and double bundle reconstructions, and so I'd encourage you to consider this spring-loaded brace. There's a little bit of redundancy in some of our talks. I'll talk briefly about some of our medial-sided management. It's important to realize this is not just a structure that contributes to coronal plane instability, but also rotation. That posterior medial corner is probably a silent contributor to many of our failures. And when you look at those with positive dial tests, it's important to realize that some of these may reflect some degree of injury to the posterior medial corner, at least up to 15 to 30%. So make sure you're doing that prone dial. Make sure you're comparing that with your slocum test. And then when you look at your approach to these patients, you know, you wanna make sure we define our terms appropriately, looking at repair, augmentation with a graft, and then reconstruction. So briefly on this, Volker touched on this briefly. Repair can be very, very helpful in the majority of patients, but there is a higher degree of variability when you look at the clinical outcomes. 75% with less than three millimeters side-to-side difference, 90% IKDC A and B. You can see the rates of failure, which is defined as two plus valgus, 6.1%. So pretty darn good. However, when you look at rates of failure, they are more common, and it's probably as a result of tissue attenuation. So when you look at this fairly limited study from standard, but the best data we have, again, posterior medial corner repair versus reconstruction, it's an order of magnitude higher rate of failure with repair. So these are two cases that we discussed at our International Knee Dislocation Study Group. And I think these are interesting cases. They're definitely provocative. When I remember Al telling me I was crazy for repairing this one, but I thought that she had bilateral bucket-handle menisci, fairly large individual. You can see that disrupted soft tissue envelope. And so I was a little bit concerned about the risk of infection. So what we did is we performed ACL reconstruction, we repaired both menisci, and then she continues to do fairly well but we know that this is a pretty complex environment. How about this next case? 21-year-old, to Mike's point, comes a little bit late after injury, has been in an immobilizer. And so this is an individual that with a bucket-handle meniscus, with an ACL injury, with an MCL injury, and then potentially with a little patella instability formatted on top. What are you gonna do with this one? And so when we looked at repairing this, we re-approximated his meniscus, we did a license of adhesions, we evaluated ACL, found that it was probably a candidate for repair, and then repaired his MCL as well. Again, trying to get motion back, trying to preserve as much of that native anatomy if at all possible. And again, he's continued to be quite stable, if not still a little bit stiff. So reconstruction, we talked a little bit about the different techniques, tendon transfer, non-anatomic reconstructions. Again, if you look at that side-to-side difference, there's measurably more in these non-anatomic techniques. As you get more to the anatomic single and double bundle techniques, again, the side-to-side laxity just starts to diminish. So I would encourage you to restore anatomy, whether that's with repair or reconstruction. While there's equivalent objective outcomes, I think patient-reported outcome measures certainly suggest there may be a competitive advantage to reconstruction, and that's probably by reducing some of the outliers. I've certainly learned a lot from Andy Williams on this, and he's looked at how you might use synthetics on top of a repair, and using this short isometric construct may more reproducibly allow these athletes to return back to side-to-side pivoting and cutting activities. So probably more to come on that. My preferred technique, I use a pretty classic marks technique when doing a single bundle, and there is just isolated MCL laxity. I prefer to use a Achilles allograft, and again, using this isometric point as defined by Gerard Paley, you can use these minimally invasive incisions and tunnel underneath the underlying soft tissue fixed with a spike screw and washer. When needed, a double bundle technique can be either utilized using this, or you can do a separate graft as described by Leprod and colleagues. So in terms of the winner of this debate, I think you could really choose any of these in your armamentarium and execute it very well for your patients. In terms of the next controversy, and Mike alluded to this as well, about the ultra-low velocity knee dislocation, you know, these are difficult patients to take care of, and there's a high rate of complications. You can see peroneal nerve, vascular injury, wound infection, reoperation, and so these are individuals that definitely you have to consider some additional level of constraint, whether that's a custom KFO or external fixation, but definitely approach this with caution and delayed reconstruction, as some of these may ultimately tighten up, and you can just do a more simplified procedure. You know, the other thing that we continue to wait for is conclusive data about surgical timing and postoperative rehabilitation. A lot of this has been populated by dogma. I don't think we know for certain when is the ideal to intervene, either preoperatively or postoperatively, and so our aim, too, of this trial is complete, and we continue to look at surgical timing, so stay tuned. Finally is my preferred technique, an order of operations. You're going to get a lot of different opinions. There's not a lot of data to discuss here, so then it's more just personal preference. I prefer to do our accruciates initially, and I typically do that under tourniquet to allow for visualization. Then I'll go to the outside. We'll allow egress of that fluid. I do prefer largely a fibular-based reconstruction with posterolateral corner, and then, as I alluded to, a two-incision approach with MCL reconstruction if the tissues are not hospitable. Thank you. All right, so next I'll be sharing with you my technical pearls for a successful multiligamentous knee injury. So we'll be talking about, you know, how I position, my technique, my graft preference, as well as the testing sequence. You'll see there's a lot of overlap between the talks in terms of our recommendations. So I like to use radiographic landmarks for, you know, a lot of my collateral ligament reconstruction. So I like to use a radiolucent table, have a large C-arm fluoroscopy. And you know, when I'm doing the lateral work, I'll keep the fluoroscopy on the contralateral side. If I'm doing predominantly medial work, I'll keep it on the ipsilateral side. For the LCL, I like to keep a small bump underneath the ipsilateral hip and typically just hang the leg on the side of the bed, knee flexed at 90 degrees. For the PCL, when I'm using a combined scope and fluoroscopy at certain times, having a large triangle helps as well, as well as accessing with a posterior medial portal. In terms of order of operation, in terms of dissection, to maximize tourniquet time, I like to start with the posterior corner. My first step is to expose and protect the comparineal nerve. So we talked a lot about acute versus delayed and the concern for, you know, foot drop as well. But for me, if it's an acute injury without a foot drop, I'll do the dissections myself. If it's a more chronic situation where there's a lot of scarring or there's also, you know, like a concern for a common perineal nerve injury, I'll have a microvascular surgeon come in, do the dissection, and then I'll go ahead and proceed with my case. So, that's been my approach. In terms of fibular base versus also including the tibular constructs, you know, I typically use a modified Arciero technique with predominantly fibular-based technique. So, you have dual sockets for the LCL and popliteus with retentionable loops. And then, I don't put a screw in the fibular head for concern for fracture. I don't personally feel that's necessary. So, basically, it'll be anchored to the femoral side, the LCL femoral side, loop around the fibular head, and go back into the popliteus side. And personally, I don't think another interference screw in the fibular head is necessary. And the controversies, as Dr. Waterman suggested, between the LaPrad versus the Arciero technique, biomechanically, they're thought to be pretty similar. All right. So, I'll share with you my video here. All right. So, I like to use a semitendinosus allograft. It's about 240 millimeters in length. I'll use tensionable loops on each of the free ends and use a synthetic suture grown across just to produce some to support the graft at time zero during the early healing phase. And then, typically, the graft size is about six to seven millimeters. So, an extensile lateral approach, about three to four centimeters approximate to the left from the condyle and extended distally between fibular head and girdies. I can see here just dissecting the compendial nerve and protecting that throughout the case. I like to use a posterior retractor, fibular guide, angling slightly from anterolateral posterior medial. Once the tunnel is drilled, you can pass your, you know, suture passers. You can see here, kind of well-centered. You really want to avoid fibular tunnel blowout. In terms of radiographic landmarks, it's been well-described by Bedi et al., but essentially, the intersection between the posterior cortex line to Blumenthal's line, just slightly distal to that, is the LCL insertion on the femoral side. And the palpiteus is about 18 and a half millimeters, just anterior and distal to this. You want to be careful not to, you know, violate that notch. So, you like to get this notch view just to make sure, angling slightly anteriorly and proximally. And then, I like to shuttle, you know, do my tunneling and everything beforehand at this point. So, just anticipate the graft passage later on. So, I'll pass everything underneath the IT band in terms of shuttle sutures. Then, you clean out the cruciates. And then, you can either use a post-ramial portal, or in this case, I'm just showing how you can also use a post-lateral portal, especially when the perineal nerve is already protected. You know, it's pretty straightforward to use. So, you can see here my position for the PCL tibial footprint. So, I like to use x-ray guidance just to kind of make sure that I'm distal enough with this. And, you know, you can see here, you can use both combined fluoroscopy and arthroscopy, you know, in a straightforward manner using the triangle. And you can actually use the tibial guide as a retractor. So, this is me just showing that you can use that as a retractor and use a retrocutting device to drill the tibial PCL tunnel and then pass the shuttle sutures. And then, I typically use a single bundle for the femoral insertion, as Ryan alluded to as well. So, you want to be about three to four millimeters from the articular margin, either 11 o'clock or 1 o'clock depending on if it's a right or left knee, outside-in technique. I'll preserve a little bit of the remnant just for identification for landmark purposes, but usually clean out most of the stump. And then, again, a retrocutting-type device. And then, I like to start by passing my tibial portion of the PCL graft. So, typically, my graft choice is a tibial's anterior or posterior. I have tensionable loops on both sides. So, on the one side, it's kind of folded over and sutured to the tensionable device. The other side, it's just looped around that device. And then, once I get about 20 to 25 millimeters in the tibial tunnel, then I dunk about a similar amount into the femoral tunnel and tension it about 70 to 90 degrees of knee flexion. So, it's a first graft, and then I do your ACL reconstruction in a similar manner. Again, that can be your preferred technique. So, depending on the patient's activa level, that might be either autograft or allograft. So, lower-demand individuals, they'll use allograft for the ACL. Higher-demand, typically autograft. And then, the LCL, at this point, in post-autocoronary reconstruction is pretty straightforward because you've already passed all your shuttling sutures. So, you can start with the LCL, dunking the graft in the LCL femoral tunnel, and going underneath the IT band, and kind of going, you know, front to back through the fibular tunnel, going back up underneath the IT band into the palpiteous femoral tunnel. And with a valgus stress, you need about 30 degrees of flexion. You can complete the tensioning for the LCL and palpiteous. So, we kind of spoke about my preferred graft choices. So, for everything except the ACL, my preference is allograft, and for ACL, it just depends on the patient's age and activity level. My tensioning sequence is very similar to what Dr. Waterman shared with you. So, I like to start with the PCL, tension that, then move on to the ACL, then the lateral side, and then the medial side. LaPrade also wrote an article suggesting there's some biomechanical benefits to this approach as well. My preference is, again, very similar to what Dr. Alejo shared with you all, trying to get these patients, you know, soon. Again, when you get patients, like, in an X-Fix for, you know, more than four weeks, you know, they get really stiff, and then you really have to, you know, get their motion before you can, you know, actually reconstruct their ligaments. So, ideally, if the X-Fix is not required to protect a vascular repair to keep the knee reduced, again, the preference is to avoid that and just keep the knee reduced in the brace. And once the swelling's down, the range of motion is acceptable, you know, typically can do this in a single-stage manner. I like to use on-site suspensory tensional fixation just to take out any laxity. I can cycle the knee, take out any graft creep. This way, for the lateral side, I've really found it helpful to use suture tape augmentation at time zero. I found previous to using this, over time, there would be some increased laxity on the lateral side, you know, throughout the patient's recovery. With this additional augmentation, I found that not to be the case. So, that's been really helpful. And, again, fluoroscopy has been really helpful. There's a nice paper by Bedial in 2018 in JBGS for reference. So, again, thank you very much for your time. All right. Next will be Al Gatgood from the University of Western Ontario, sharing his approach for revision multiligamentous knees. All right. Thanks very much, Arvind. Okay. Good morning, everyone. So, my main disclosures are that I am a member of the STAR trial. I guess now that Volker knows all the complications that are coming into the STAR trial, that's why I get asked to talk about the failed multiligament knee injuries, but. Okay. So, when you see a failed multiligament knee, if it's someone else's case, you usually feel a little bit like this, you know. But when it's my own case, it's an absolute disaster, right? So, you've really got to understand, you know, what's going on. So, I'm going to talk a little bit about my own case. So, you've really got to understand that and then work out exactly how we're going to go about addressing them. So, I'm going to talk a little bit about causes of failure. And really, the main thing that we're going to see is the treatment of arthrofibrosis. Because it's really stiffness is probably the biggest thing that I see rather than actually failed laxity. I'm going to talk about the clinical assessment and then a revision and the rehabilitation. Okay. So, the causes of failure, well, first up is failure of non-operative management. Okay. So, what's unreasonable in many cases with a knee dislocation and multi-ligament knee injury in particular is to try non-operative management. And sometimes they'll continue to have ongoing laxity and ongoing instability. Infection, of course, is a concern post-operatively. But I'm really going to focus on stiffness and recurrent instability. Pain can be a problem. Of course, that can be associated with chronic regional pain syndrome as well as post-traumatic osteoarthritis. But we don't really have an awful lot of great solutions for that. So, I'm going to mostly focus on stiffness and recurrent instability. So, in treating a stiff knee, first thing I'm going to talk about is the definition of pathophysiology with some epidemiology and risk factors. And really things that what we can do as surgeons, as clinicians, is to how we can try and prevent this and then treat. So, lots of processes going on, lots of theories in terms of whether or not this is an inflammatory process, and a number of pathways that are associated with increasing the risk of scar tissue formation, which I'm not going to go into a lot of detail. But there's clearly a lot of issues going on there. Number of studies, you know, most of these are older studies. And of course, a lot of this can be associated with maybe older techniques, older methods of rehabilitation, and maybe some of the more current techniques we can hopefully try and reduce the risk of stiffness. But it certainly is still an ongoing issue, and hopefully with the STAR trial, we'll be able to try and get some predictors of how we can try and reduce these issues. So, in terms of the classification, I like to think about whether or not this is an extra-articular problem. Heterotopic ossification, of course, is a big issue, particularly on the medial side of the knee, particularly in a polytrauma patient with a head injury. So, we've got to be aware of that. I need to think about whether or not this is a flexion or extension loss, or potentially both, and that will lead to the degree of severity. And then whether this is a primary or secondary problem. So, in terms of secondary factors, and these are the things that maybe we can have or we can intervene with. So, injury severity, of course, we've got absolutely no control of, but we do have control of surgery. We want to make sure we minimize our technical errors. We want to think about the immobilization. How long do you immobilize? How quickly do you get things moving? And then delayed post-op rehab, and of course, infection. And so, you know, again, a lot of this information is as the guys have already alluded to, a lot of the information that we know now is sort of level four, level five evidence. But the STAR trial will definitely help tease a lot of these issues out. So, we'll learn an awful lot more. Technical error, just like ACL reconstruction failure, technical error is still an issue within multiligament surgery. So, we basically, we want to avoid per tunnel position. We don't want to over-tension our grafts. The graft choices is an important discussion. We don't want to have too great, you know, if you put two massive grafts in a small notch, you're going to run into problems with just notch impingement. And then thinking about whether or not you use synthetics or not, you can over-constrain. The important thing is, is just know your anatomy, know your technique. And you've already, you've heard just from the guys, lots and lots of different techniques that you can utilize in addressing a knee dislocation. You've got to know them all. You've got to have multiple techniques in your toolbox because not every knee presents in the same manner. So, that's one thing I love about multiligament surgery. You've really got to have a few things up your sleeve to be able to deal with the injuries. So, the best line of treatment for sure is prevention. So, of course, we can get things going at an early stage at the time of presentation. So, the question of really getting that knee moving early, getting the swelling under control, use of non-steroidals and analgesics. Avoiding, you know, we want to potentially avoid prolonged immobilization. You know, we keep talking about STAR, but part of one, the aim to a STAR is to determine how quickly we get the knees moving post-surgery. And again, you know, there is that argument that maybe leaving them immobilized for a period of time will help our ligament reconstructions, excuse me. But it could potentially worsen our risk of stiffness. So, these are things that we have to be aware of. A patient assessment. So, the question, of course, is the history of the injury. So, what is the severity of the injury and the extent of the injury? Mike's already talked about this. You know, a multiligament knee injury is not necessarily a knee dislocation. And certainly, the higher energy trauma, the greater amount of injury pattern will certainly have a major impact in determining the risk of stiffness going further. Have they had past surgery? Is there a past history of stiffness? Is this something that they basically have a tendency for? And of course, then family history. Is this a post-op issue? Is it intra- or extra-articular? And was this an early or a delayed presentation? Most important thing, of course, is to exclude infection. And then, thinking about CRPS. A lot of these patients do present with regional pain syndrome, with some sort of neuropathic issues. And that is a very, very challenging problem to deal with. And certainly, you know, that's some of the most important patients that I have to have these discussions with. Because one thing we don't want to be doing is doing too aggressive surgery at a too early a time point with these patients. Because ideally, you want some of this regional pain syndrome to settle down. Non-operative management, if you have a lot of options in terms of medications, the use of narcotics, we want to try and avoid, if possible. Non-steroidals are very helpful. Corticosteroid, you know, I do use a sort of medrel dose pack. It's something that's very helpful, particularly in the post-operative period. We don't want to initiate that too early. But if we're starting to see a knee that's starting to look like it's becoming a sort of an arthrofibrotic issue, then we have a very low threshold to throw in a medrel dose pack. So, that's essentially a reducing dose of oral prednisone over six days. Physiotherapy, of course, is very important. We want to get that motion going using muscle stim. But it's also making sure that you've got good neuromuscular initiation. So, it has to be active, not just passive treatment. So, dynamic bracing can be helpful, and then serial casting. And the drop-out cast is something I use an awful lot of. So, if you lose, you know, Volcker's already mentioned, if you have a five-degree extension deficit, that's incredibly debilitating. So, even after post-surgery, if I'm going to address this with an arthroscopy, try and reduce some of the scar tissue, putting them in a drop-out cast for 24 hours post-op just to maintain that extension is a very, very helpful thing to do. The classification is developed by Shelburne, and the really thing I want to just highlight here is patellar mobility. So, if I'm seeing patients post-operatively in the clinic, and one of the major assessments that I'm doing is to look at the patellar mobility. If you've got decreased medial lateral or superior and inferior glides, that's starting to become a problem. Okay, so, really nice way of just determining whether or not things are starting to settle out, and also whether or not you can get away with just a manipulation under anesthetic versus a lysis of adhesions. If I've got really very little patellofemoral motion, then it's going for a lysis of adhesions for sure, whereas if you've got good patellofemoral motion, maybe with just a flexion deficit, then we can get away with a manipulation under anesthesia. I find that actually doing a manipulation under anesthetic, however, for an extension deficit tends not to work. That's going to need intra-articular arthroscopic lysis of adhesions. But really, three months is the time period, post-operatively, that I want to see this evolve, okay? So, I'm making my decision. If the patient hasn't got the range of motion by three months, I'm going to make a decision as to intervene, and that's either with the arthroscopy or an MUA. Now, sometimes at the three-month time point, you're going to see a patient, their patella mobility's improving a little bit, and actually their range of motion is starting to improve gradually. So, you're now starting to see a trend of gradual improvement, then that's okay. You might give them a little bit longer. But for sure, three months is that time where I'm thinking, am I going to have to intervene here or not? Fixed flexion deformities, well, it's much worse than a lack of flexion. We've got to think, is this an anterior problem or a posterior problem? So, initially, we're thinking on the anterior interval. So, this is an intra-patella fat pad, patella tendon fibrosis, and then also any issues in and around the anterior tibia. So, the MRI is very helpful to have a look at the fat pad and look as whether or not there's anything that you can target surgically and reduce that and actually do an anterior interval release. There may be a mechanical block. If you can see this, this is fantastic. You get a scoping, you get a cyclops lesion, you get something that you can easily target, remove, get the patient moving. Okay, if you don't actually see that, then that can be a bit of a concern. Posterior capsule, you know, if you've cleared everything anteriorly and you still have this issue of trying to get the knee straight, then we think more about the posterior capsule. That tends to be more of a chronic problem rather than the early time period. And so, we need to think about whether or not we're going to do something with the posterior capsule release. In terms of flexion deficits, think about the extensor mechanism is there a quad contracture? Are there a lot of stiffness and contracture around the medial lateral retinaculae? And so again, that really comes down to your patella formal motion and then whether or not they have patella baja. Okay, so in terms of elasticive adhesions, regional anesthesia is very helpful. I don't use, I use adductor canal blocks, so motor sparing blocks. And then you can look at maybe capsular distention. Don't find that to be very useful. High anterolateral portal. And then often, you know, it's impossible to get the scope into the supratella pouch. Everything's just so sucked in. So put your scope in, start in the anterior interval, start releasing tissue at the anterior part of the knee, then start working up the gutters, releasing the gutters as you go. And eventually, you're going to get your scope up at the supratella pouch and then easily be able to get your, navigate your scope around the knee. And that should make life a little bit easier for you. So anterior interval release and then get your patella mobilization, okay? Gentle MUA, possibly use a dropout cast and continuous passive motion. The arthroscopic posterior capsular release. And, you know, I tend to do that when I really, I'm really struggling to get that last bit of extension. And so we're going to do that. So your Gilquist maneuver. So scope into the posterior medial aspect of the joint, create a posterior medial portal. And then this technique just essentially evolves either using a basket punch or a radiofrequency ablation. And you're going to just do a very controlled removal of that and release of the posterior medial capsule. I tend not to go posterior lateral if I can avoid it. It's a little bit more tiger country back there. So we just want to be aware of that, but certainly start posterior medial. You tend to, once you see the fibers of the gastroc, you can then perform your manipulation under anesthesia and things will improve. In terms of your flexion deficits, you know, these are old techniques that have been described, but, you know, a Thompson quadplasty. Can't remember I've ever done that. But, you know, what I tend to do is just run a Cobb elevator arthroscopically and just release fascis intermedius off of the distal femur. And really you're just trying to get as much clearance of the scar tissue and tethering of the quad. One of the biggest problems, Michael has already alluded to it with the use of external fixators. Often you have your Steinman pins through the quad, get called quad contracture. That can be a problem. So if you're going to use an X-Fix, try and avoid putting it through the center of the quad. Similarly with the Jude quadsplasty, these are big open releases. We try and avoid those if we possibly can. Biologics may play a role in the future. There's Alwan antagonists, so anakinra, lots of other things. I don't use these in regular practice. We don't really have access to them in Canada, but it should be something that maybe will come in the future. So take-home message when it comes to dealing with stiffness is prevention better than cure. Determine where the block is, anterior or posterior, extra-articular versus intra-articular. Treat as early as possible, particularly if they're more severe. Only a gentle MUA. You really don't want to be reefing on the knee too hard. And then arthroscopic lysis of adhesions is certainly safer than a really vigorous MUA. Now what about recurrent instability? Well, the question is, is this a new trauma? Is it a gradual onset? You've got to understand what grafts were done, what hardware was used in the past. Physical examination, make sure you don't miss a diagnosis. Appropriate imaging. And so there's no real difference than what has previously been discussed by the other guys in terms of your workup for a multiligament knee. Very important that you document your neurological examination as well as vascular. And so make sure there's no issues there. Clinical examination, just do a really good clinical examination in the office, looking for missed pathology in the past. I'm not going to labor this. It's already been discussed by the other guys. In terms of imaging, plain radiographs, MRI, very helpful more for chondral and meniscus status. I don't really find it very useful for ligaments. Clinical examination is key. We've got to get away from diagnosis by imaging. Use your clinical examination techniques. You'll get all the information that you need to know about a knee. That's why knee surgery is more fun than shoulders. And then MRI, CT. CT, very helpful for your tunnel. Tunnel placement, tunnel size, tunnel coalition, how you're going to actually manage those tunnels in the future. Alignment views, absolutely critical because osteotomy may come into it, either in the sagittal plane or the coronal plane. And then valgus stress views. And these chronic multiligament settings, particularly, you know, if this is a very sloppy knee, sometimes it's very difficult to determine if this is a medial versus a lateral-sided injury just because of the amount of slop within the joint. So getting an objective assessment using varus and valgus stress radiographs as well as PCL kneeling stress views will really help you determine what's going on. In terms of your decision making, operative versus non-operative in the failed scenario. Does the patient even need an operation? Can they manage with a brace? What other issues are you dealing with? Are we going to manage this in a single or multi-stage? Of course, that's going to come down to what's happening with your tunnels. Tunnel coalition, tunnel size, graft options. You've got lots of autograft options, okay? So don't be afraid to go to the contralateral side. Peroneus longus autograft, okay? I don't know. Very, very common use in Asia and certainly it's something worth looking at. It's actually a fantastic graft. So you've got lots of autograft options. But of course, if you have access to allograft, then again, that can be very helpful, particularly with the bone blocks because you can help you deal with tunnels. Osteotomy, I can't stress enough, is super helpful in the chronic scenario. This is a guy with a chronic post-lateral corner injury. And of course, what you're really trying to do is just get balance across the knee. And with that ground reaction force away from the center of mass, you get that adduction moment. And so if you don't have the soft tissues on the outside of the knee, you're not able to counteract that ground reaction force and that adduction moment. And that's going to put more stress on your intra-articular grafts. So think about getting that patient a straight knee. Very similar in the sagittal plane, if you've got hyperextension regrovatum, that's asymmetric. You're going to put a lot of stress in the posterior capsule. And so if you're post-lateral corner or post-termedial corner, a reconstruction can fail in that regard. So think about what you're going to do in terms of actually manage that with a slope correction. We know that tibial slope is important for ACL. It's also critically important for PCL. So if you do have a flat slope, that's a higher risk of failure of a PCL reconstruction and may be counteracted by a double bundle reconstruction. So again, these are things that you have to take into consideration. This is a guy who I treated. Actually, it was probably my first year of practice. I did an ACL-PCL post-lateral corner reconstruction. Unfortunately, he was in varus, and he failed. Went on to be treated just with a high tibial osteotomy. Didn't need any further ligament reconstruction. Did very well. Similarly, another guy, chronic PCL with a post-lateral corner. And in this scenario, we just did a poorly performed medial opening wedge. So we were just increasing the slope somewhat, and that deals with the posterior station of the tibia. Didn't need any further soft tissue reconstruction. And again, did very well. This is a medial-sided knee injury. Guy had a valgus knee, ACL-PCL-MCL, treated with a distal femoral varus osteotomy, and then staged with a ligament reconstruction. So again, very, very powerful to be able to control some of these more challenging cases. In terms of your technique, know your anatomy. Use your bony attachments for both the lateral and medial side. And then thinking about rehabilitation and return to sport. I think this is very important. If you already had a failed multi-ligament knee, to be thinking about trying to go back to sport. Sometimes you just need to sit down with your patients and give them a big reality check. Ultimately, you're trying to give them a knee that's functional, allows them to do their activities of daily living, and then get on with their lives and return to sport as a bonus. So really, in the first phase, is just protecting your grafts, protecting them against cyclic load. And then you want to prevent stiffness. You want to get good neuromuscular rehab. And the use of dynamic brace is incredibly helpful, particularly not only in the primary, but also in the revision setting. So that's my talk, essentially. I've got a couple of cases now. So if the guys want to come up onto the... Brian Volker, can you join us up here? We're going to go through some cases. I don't know if you have time, Volker. I know you've got to catch a flight. So I'm going to go through these couple of cases. And then I think, Arvind, you've got some cases as well. So we've got another 20 minutes. We can get through some cases, OK? So this is a young girl. It's a 23-year-old paramedic student, a little bit overweight somewhat, and unfortunately had an acute left knee injury playing flag football. And so she had a KD3L, so lateral-based knee dislocation. Unfortunately, had a common perineal nerve palsy, but her vascular status was intact. So fairly significant injury and a relatively innocuous knee injury, or innocuous mechanism. So here's her MRI. So ACL and PCL are out. And you see that bone... Arvind, see that bone bruise in that medial femoral condyle? What does that tell you? Obviously, you have a hyperextension type injury there. So that would be a concern of mine. Yeah, so if you see that bone bruise... I'd be worried to find a little bit further over lateral, maybe an anterior tibia impaction too. Right. So you're going to end up with it. So an anterior tibial fracture, you can have the bone bruise on the medial femoral condyle. It's telling you the extent that this was a hyperextension, this was a hyperextension, probably an element of alveolus. So post-lateral corner injury, that explains her neurological status. For a second, the patella tendon, are you worried when you look at this, I don't know if you call it strain or that high signal harvesting BTB? I personally would not be worried about that. Would you be worried about that? You know, I'm always worried. You know, like I said, plan B, plan C. I've been in one case, I should have showed it. I didn't look at the MRI closely enough. I made my medial approach for the MCL and the BTB harvest together. I go through the skin and then I realized that the MCL is torn from posterior to anterior and halfway through the patella tendon. And one coronal cut showed it. You don't look at the coronal cut for the patella tendon, do you? Now I always do. And I had to abort. And I didn't have the patient consented for another graft. So I had to walk out, talk to the family. It's not good to consent them for many grafts, okay? Freddy always did that. He consented everyone for an allograft possible. Yeah. Takeaway points. Coronal plane, okay? So medial side. I think one thing with MRI scans, particularly in the acute setting, it often tells you what's injured. It doesn't tell you how badly it's injured. So sometimes you're going to see a lot of high signal in the structures in the MRI, but there won't necessarily be significant laxity. So again, go back to your clinical examination, your examination and anesthesia to determine what you're dealing with, okay? So Volker, what do you think of this one though? I mean, the lateral side is completely out from IT band all the way to everything's gone. So you reconstruct probably all of it. All of it meaning you do a popliteus bypass of some sort. You do a fibula-based LCL reconstruction. And then I try to repair the biceps, repair what you can on the IT band. Is that what you wanted to hear? Yeah. So it's a much more significant injury, right? And we're really thinking, we've got to be thinking about repairing as much as we possibly can. Will you do, Brian, you'll do repair plus reconstruction when you see an MRI like this? Yeah, for sure. For sure. I don't think there's good substantive tissue there. Okay. So I did a ACL reconstruction with a quad autograft. You didn't like the patellar tendon. Well, I just like the quad in some scenarios. You were worried. Okay. So then PCL with a tendon Achilles allograft. And I'd say one thing, if you're doing ACL PCL and you're using a BTB autograft, I tend to find that if you're using both tunnels on the medial side on the proximal tibia, if you're worried about tunnel mismatch, it's a little bit more challenging to drop the level of your ACL tunnel to try and get a longer tibial tunnel length to avoid that mismatch. That's the beauty about using a quad. You don't have to worry about that. You can make it much more shallow. Who's making your grafts? Who's making them? My fellow user. Yeah? Yeah. Because you have four grafts here, you know, they better make the grafts small enough they go in the tunnels. You have four chances to fumble. No, if it's a 10, this better be a 9.8. It's not a 10.2, right? But the fellow, you know, is that. Yeah, yeah. Okay. I got consistency. He's a master. My fellowship, they even put sterile mineral oil on the bone ends of the grafts so they go in easier. So we do the reconstruction one month post-op. We get some radiographs and it looks like this. Brian, you're concerned about this? Absolutely. So lateral gapping on the radiograph. So that was pretty disappointing to see. Now, she's, I said, she's pretty, fairly overweight. She was in a tracker brace post-operatively. She's in valgus. And I just wonder with the brace use, whether or not I actually kept her knee a little bit too straight and straightened up and put some stress on the lateral side. I'm still not sure actually what happened here because I thought the reconstruction went very well. You know, the braces never fit on the larger people and they're upset with us medical professionals that we don't design braces that fit, right? And you just can't. And so on two occasions, and I hate, I want to go out by saying I hate X fixes. Okay. You all need to know that. But on two occasions, instead of the brace, I put the X fix on for six weeks to prevent this because this I think happens in the recovery room. I don't think this happens, you know, over six weeks and 12 weeks. They immediately, you know, it's just the girth of the leg. Yeah. So something happens. So Arvind, what are you going to do? What should I do here? Yeah. So, I mean, I think it's only one month post-op. I'll still disclose to the patient that I'm a little concerned about the lateral side, but I'd probably start initially just rehabbing their knee and a hinge brace and seeing, you know, what they declare. I mean, some of these patients, even with this x-ray may become less symptomatic over time. Radiographs can also potentially improve with some acute scarring. So I'd probably start with conservative initially. Cool. Yeah. That's what I did, hoping for a miracle that it would all tighten up. So maybe put my head in the sand. Yeah. But, you know, I don't, I will after I do that, which is I'm going to go to the x-ray booth myself and put those lead gloves on and I'm going to stress her gently, you know, because I don't think a lot of stress is needed to see much. But if this x-ray stays the way, or maybe opens another millimeter or two, then I go non-op. So I went basically non-operatively, see what happens at the three month time point. She had ongoing laxity, very clear clinical laxity. So I returned, we returned to the OR. She was a little bit stiff in terms of reflection. So the license of adhesions and then a post-lateral coronary revision with a 10 to Achilles allograft. And I found at that time that then we fractured through the fibular styloid. So basically now I've got a fracture of the fibular styloid. I tried to move the tunnel distally and it fractured again. So now, and so then two weeks post the revision looks like this, what did I do now? Do you think this was a compliance issue? The initial reason for her failure, is it a body habitus mechanical alignment? No, I think this is a technical error. I think I got my femoral tunnel in the wrong place. And so essentially the length change characteristics weren't optimal. And so after the first, so when I revised her in the second case, I tried to remove the femoral tunnel and essentially I still couldn't. It was really, really difficult to manage that. Also her lateral capsule had failed as well. So just a bit of a cluster to be perfectly honest with you. And now I'm sitting in this scenario, what do I do? So I usually get a 3D CT scan now so I can study a little bit more where, how low do I have to go for my next construct? It sucks. I don't think there's a great solution here, but the CT scan would I think help you understand it better. So got the CT scan, worked out where the tunnels were, could see where the fracture was. So I knew that, so I couldn't leave it. She's symptomatic. And all the whole time, this young girl is just, her and her mom were just unbelievably grateful for the treatment that I've been giving them. It's kind of amazing. It's hugely humbling treating these people. But anyway, so went back to the OR, did a bone grafting. So this is the scenario, found these two big tunnels that I'd, so this was the tend to Achilles allograft that I'd basically moved around. So effectively now doing a staged reconstruction. Thankfully our ACL and our PCL are still intact at this stage. And just took some femoral head dowels and bone grafted, packed the fibular head. So what have I, what have I actually learned from that? Well, now when I do post-lateral coronary reconstruction, I pass my grafts into the tibia and the popliteus and leave my fibular collateral femoral attachment until I've actually fixed my cruciates. And then I bring it up to the femur and check the length change characteristics based on a pin that I put into the femur. So I make sure that I've got good isometry on the fibular collateral insertion rather than just going with the anatomy based on either fluoroscopy or palpation. So I look for, I basically look for that at that stage. And my preferred technique is using a single loop, a single graft modified leproid, which works, tends to work extremely well. So that's what I do as a result of that case. What about this case? Next one. So this is a 26-year-old female. She's an office worker. She had a low energy knee dislocation in July, 2021. ACL, PCL, post-lateral coronary. She's got a Batten score of 9 out of 9. She had a reconstruction in January 22. Did an ACL, double bundle PCL, and a post-lateral coronary. Everything went extremely well. Post-operative radiographs. Anything you notice there, Arva? If I tell you, I'll just give you a little bit of clinical history to this one. So she was starting to get a little bit of pain coming into full extension. And so passive hyperextension, she got pain at the front of her knee. Just looking at the AP, I mean, I think overall good alignment. You don't see that lateral gapping that you did in the prior x-ray. So I'd say the AP looks pretty good. Looking at the lateral, maybe a little concerned with the height of the patella. Again, it's hard to know without the you know, pre-op x-rays, whether or not there's any concern with the extension mechanism there, but potentially just her, you know, underlying patella alta. But it looks like you have full extension there. So I don't know. I've done this before. I think what I'm looking at is, is it a quad tendon? Yes, correct. With quad tendon autographed, right? So sometimes you only get a six and a half. And then in the tibial tunnel, they're quite high up. And then you put your screw in, you dive with the screw deeper and deeper and deeper to finally catch it. And I think your screw's in the joint. I've done this before and I didn't realize it. And then sort of slowly amputated. Nice stump there. I found that the screw was a little bit, little bit long. You can just see that on the lateral view. I think that was the thing that was causing the hyperextension. So even when you do a lot of these cases, unfortunately, you're going to have some issues from time to time. And so pain in terminal extension. Went back to the OR, did a very simple arthroscopy, just shaved away the bi-absorbable screw, the front of the knee. Two weeks post-op, she returns to emergency department with symptoms of a septic knee. It's good, eh? You're just showing us shit, huh? He asked me to talk about complications and failed revision for failed multi-legs. It's fantastic. Do you have tissues? I mean, this is just a sad, sad day. Yeah. Someone's got a violin playing, eh? All right. So she basically was, unfortunately, someone started her on oral antibiotics. Thanks for that. No aspirate, no nothing. So oral antibiotics. And then she came to my office because I heard about this, that she was presented to an emergency department. She's also the daughter of the chief of surgeries, a secretary, right? So his admin assistant, daughter of. Fantastic. So he's on the phone to me saying, what's going on? Get good. What's happening? Jeez. Killing me. Anyway, so three days later, she presents, clearly got signs and symptoms of a septic knee. Okay. So what would you do? Oh, you're going in, you're washing this out and you are not removing any grafts. Okay. Repeat. You're not removing grafts and they will look like shit. You will probe them. Don't probe them. They are going to look awful. They're going to probe terrible. Leave them, leave them, leave them and wash her out again. So how many times are you going to wash her out? I don't know. However many times it takes before that last bullet there is not there anymore. They're hot. So routinely you're going to do multiple washouts or would you do one washout and then? I do probably routinely two. And I will explain to her at this stage that there may be many more coming in this together. I really say that. I will not let you hang. All right. So first washout, May 9th, May 11th, repeat arthroscopic washout. That's absolutely routine for me. So retention of grafts, two washouts. I'm incredibly aggressive with both ACL as well as particularly multi-leg. I want to retain these grafts. She's a prolonged course of IV antibiotics. We got no growth on culture or on PCR, unfortunately, and the infectious disease guys all thought this was secondary to the fact that she had already been started on oral antibiotics. She presented again June 8th. This is getting better, right? So emergency department pain, swelling, fever, aspirator knee. She's got cloudy yellow fluid. What do you do now, Brian? Yeah. I mean, with the autograph, you've got a little bit of skin in the game, but at this point in time, I'm probably taking out the intra-articular graft tissue and hardware or try to preserve anything extra articulately. If you have advanced imaging, you can see for any bone marrow edema, make sure you're not missing an abscess, but this is a bad day. I've had this exact same case. In fact, it was one of my board collection cases, so that was a good one to defend. So now we're excision of graft material, removal of all hardware, repeat washout, closure of wounds June 10th, ongoing IV antibiotics. Finally, September 22, she's off her antibiotics, doing well. Knee feels unstable. Okay, what do we do now, Arvind? Yeah, I would wait before putting any more graft in there. I mean, sometimes, yeah. Swiss cheese. Okay. Yeah, I would wait. I mean, probably stage. CT scans always look worse than particularly multi-leg. CT scan of a post-op multi-leg looks absolutely horrible. Yeah. So once you're off antibiotics, I would make sure they have several normal, you know, CRP, ESR, consent for, you know, staged, right, bone graft, and then go back and reconstruct it when you're absolutely certain that, you know, the infection's gone. Cool. So I think, Volker, you said this again about there's multiple surgeries. You know, I hate multiple surgeries, if I can avoid it. This girl's already been through so many operations, so many periods of rehab. So I elected to do this as a one-stage revision. And so we got her all fixed up, and she's actually doing really well. She's seven operations later. Back in the gym, she's powerlifting. She qualified for Ontario Provincial. So it's not all that bad, but that was an ordeal for her and for me. Al, two questions. What do you think the role is for synthetic augmentation, say, for instance, on your first case? And then also in this type of scenario, maybe where you have some lysis and that PCL, what are your thoughts about these single-stage bone substitutes putties that are fast-setting? Have you used it? Any experience with that? So I don't think I've ever seen any sort of bone substitute that actually reliably turns into bone. So I love this concept of putting in either blocking screws or putty that you can then re-drill a new tunnel. It looks great at the time of surgery, but what happens over time when that thing starts to remodel, I worry about losing fixation of my graft, so I don't use it. The synthetic augmentation, I'm not convinced that it's a major win. I don't know what it does to the graft. I think, depending where you put your synthetic in relation to your graft, and if it's sitting on the bone, there's a very good chance of a cheese wiring through the bone. If you lose a couple of millimeters, then it's not doing anything anymore. So I've never been really that convinced about synthetic. In the older patients where they've got poor bones, sometimes I have used it, but I'm not entirely sure it really works. Any thoughts about soaking grafts in Vanco, anything like that? All my grafts go in Vanco for sure. Didn't help that case though. But I think the difficulty there is where did you get the infection? I don't think it was from the original surgery. I don't think it was from the original reconstruction, unfortunately. I mean, how common is it to get a septic knee post knee arthroscopy? You've got so much fluid running through the joint. So it was just a bit of a freak incident. I think the take home from your story is, in the end, the patient loved you because you didn't let her hang. And I think that's what you need to do. These infections will happen to you. You passed your boards because of it, because all of your mentors had this case. Deal with it. Own your complications. Move on. I've been doing it for a time ago now. So thank you very much everybody for joining us. Some of us can stay behind if you have any questions. Thank you very much.

multiligament knee injuries

clinical outcomes

medial collateral ligament

neurovascular assessment

patient factors

posterior cruciate ligament

surgical interventions

graft preferences

revision strategies

rehabilitation protocols

case studies

surgical techniques