Chapter 61 Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral-Side Injury

Introduction

A knee dislocation injury is a rare but potentially devastating injury. The definition of knee dislocation includes the grossly unstable knee, with a minimum of two of the four major knee ligaments injured, regardless of a reduced joint line.¹ Some authors suggest that any combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries be considered a knee dislocation,² although knee dislocations have been described without cruciate injury.³^–⁵ The injury is commonly attributed to high-velocity motor vehicle accidents and low-velocity sports injuries, with the rate of knee dislocation reported to be 0.001% to 0.013% of all knee injuries.⁶^–⁸ This may represent an underestimation of this devastating injury, as some knee dislocations spontaneously reduce before the patient receives a physical examination and the patient may suffer other physical injuries that require medical attention.¹

Commonly, a knee dislocation involves injury to the ACL, PCL, and either the medial collateral ligament (MCL) or the lateral-side structures of the knee. Of knee dislocations, associated medial-side tears represent approximately 90% of all the injuries, whereas lateral-side injuries represent approximately 10% of the knee dislocation injuries.⁹

We see almost 10 times more knee dislocations involving the medial side than we do involving the lateral side. Nonoperative treatment of knee dislocations involving the lateral side usually results in a grossly unstable knee and causes severe functional disability for the patient. Because of these occurrences, acute reconstruction of all injured structures with all knee dislocations has been advocated; this recommendation has included knee dislocations involving the medial side.^10,¹¹ This approach has resulted in many stable but stiff knees after surgery.

The morbidity associated with acute surgery for knee dislocations caused us to alter our treatment approach for knee dislocations to consider the healing potential of each torn structure. Although a knee dislocation involving the lateral side is an injury that requires surgery at least semi-acutely, a knee dislocation involving the medial side is not an injury that requires immediate surgery, and it may not require surgery at all.

In this chapter we review our treatment approach to dislocated knees involving the ACL, PCL, and either the MCL injury or lateral-side structures. This approach was derived from an understanding of the injuries to the individual ligaments and their potential to heal, the natural history of the injury, and the effects of the injury in combination.

Ligament Healing

Anterior Cruciate Ligament

The ACL does not generally heal after injury.¹²^–¹⁵ Lyon et al¹³ found in a histological study that the cellular composition of the ACL resembles that of fibrocartilage and that it has a poor capacity to heal. The injured ACL pulls completely apart as opposed to tearing interstitially, which diminishes the potential for healing. An incompetent ACL represents a complete tear. Yao et al¹⁶ found in a series of 21 partial ACL tears evaluated with magnetic resonance imaging (MRI) and confirmed with arthroscopic evaluation that the ACL tears showed ACL fibers in continuity and the ACL resisted probing. They also found that the MRI was less sensitive for partial tears compared with complete tears. MRI can occasionally demonstrate interstitial femoral-sided tears. These tears may heal spontaneously and can result in functional stability.

Posterior Cruciate Ligament

In contrast to the ACL, PCL injuries have the potential for intrinsic healing (Fig. 61-1). Evaluation with MRI of acute PCL injuries has been found to be 99% to 100% sensitive and specific in documenting acute PCL tears. In contrast, MRI evaluation of chronic PCL laxity is less accurate than that of acute injury because the PCL appears to be healed even when the patient has laxity.¹⁷^–²⁰ Shelbourne et al¹⁹ evaluated 40 patients who had acute PCL injuries with MRI at the time of the acute injury and again at a mean of 3.2 years after injury. Twenty-three patients had isolated PCL tears, and 17 patients had combined PCL and additional ligament injury. The healing of partial and complete tears was graded with MRI. The results showed 37 of 40 PCLs to be healed with continuity. All partial tears and most complete (19 of 22) PCL tears regained continuity. Twelve of 12 combined PCL/MCL injuries healed. In two patients with acute ACL, PCL, and MCL injuries, the MCL and PCL healed without treatment. Location, severity, and associated ligament injuries did not affect healing. The healed PCL demonstrated abnormal morphology in 25 of the 37 cases on follow-up.¹⁹ In a recent follow-up study at a mean of 4.6 years after knee dislocations to the lateral side, the PCL in 16 of 16 patients appeared healed on the MRI and no patient had more than 1+ laxity upon examination.²¹ Tewes et al²⁰ evaluated follow-up MRIs on 13 patients with high-grade PCL injury at an average of 20 months postinjury. Their results showed 10 of 13 patients (77%) had regained MRI continuity of the PCL, although with an abnormal appearance. They could not correlate functional or clinical status with degree of clinical laxity.²⁰ The time to obtain healing after acute PCL injury is yet unknown. However, Shelbourne et al²² described a firm endpoint and a painless posterior drawer at follow-up examination of acute PCL injuries about 2 weeks postinjury.

Fig. 61-1 A, Magnetic resonance image (MRI) of an acute posterior cruciate ligament (PCL) injury. B, A follow-up MRI image at 3 months after injury shows the PCL is in continuity, which may be read by the radiologist as a normal PCL.

Medial Collateral Ligament

The MCL is an extraarticular ligament with an intrinsic ability to heal. In contrast to the ACL, the MCL is made up of fibroblast-type cells with the potential to heal.¹³ Animal studies indicate the MCL can heal with scar tissue with strength and stiffness similar to that of native MCL.^23,²⁴ This intrinsic capacity to heal has also been observed clinically with isolated MCL injury.^25,²⁶ The ability of injured ligaments to heal may also be affected by extrinsic factors such as surgical apposition, immobilization, and early protected range of motion.^27,²⁸ Prolonged immobilization may adversely affect the mechanical properties by loss of collagen fiber orientation and decreased strength of the bone ligament junction.^29,³⁰ Long et al³¹ found in a rabbit model that the ultimate load of rabbit MCL treated with intermittent passive motion was four times greater than immobilized ligament, with improvements in matrix organization and collagen concentration. The location of MCL injury has also been found to affect healing potential. Proximal tears, which have a more pronounced blood supply, tend to heal rapidly and may lead to knee stiffness. Distal tears seem to heal more slowly, and patients usually do not develop range of motion problems.^32,³³

Lateral-Side Structures

Lateral-side injuries involve several structures, and several combinations of injuries to these structures can occur with a knee dislocation. The lateral-side structures from anterior to posterior are the iliotibial band, lateral capsule, popliteus tendon, lateral collateral ligament, and biceps. These structures tend to tear distally and retract proximally and then heal “en masse” but do not heal in such a way to provide lateral stability. Lateral-side injuries are the only type of ligament knee injury that require acute repair.

Clinical Examination

Listening carefully to the patient explain how the injury occurred and the position of the limb at the time of the injury combined with a thorough physical examination should allow the physician to arrive at a diagnosis. Evaluation of the uninjured extremity will establish a baseline and gain the patient’s confidence. Initial evaluation may be difficult because the patient will probably have pain, swelling, muscle spasm, and limited knee motion and will be apprehensive. The physician should have a high index of suspicion based on the history of the patient’s injury, especially with a multi-ligamentous knee injury, because 50% of knee dislocations will reduce before evaluation ^1,³² and capsular tears may prevent the appearance of significant effusion. The complications that arise from not recognizing associated injuries can be devastating. Close follow-up and reexamination are helpful. In addition, imaging studies and vascular surgery consultation may be needed.

Clinical assessment of the ACL can be done using the Lachman test. A positive Lachman test, performed properly, is diagnostic of ACL disruption because the ACL prevents contribution from secondary stabilizers to anterior stability.^34,³⁵

The PCL is the primary restraint to posterior instability in the knee.²⁶To determine PCL deficiency, the involved knee should be compared with the noninvolved extremity to determine the proper relationship of the tibia to the femoral condyles. When the PCLs are intact, the anteromedial proximal tibia usually rests 1 cm anterior to the distal femoral condyles with 90 degrees of knee flexion. In patients with PCL deficiency, the anteromedial tibia will “sag” posteriorly in relationship to the femoral condyles.^36,³⁷

The most sensitive test for evaluating the PCL is the posterior drawer test at 90 degrees of flexion.^38,³⁹ Rubinstein et al³⁹ found the posterior drawer test in conjunction with palpating anterior tibial step-off to be 96% accurate, 90% sensitive, and 99% specific, with an interobserver grade agreement of 81% in diagnosing PCL insufficiency. The posterior drawer test with internal tibial rotation can also provide assessment of medial structures. Posterior tibial translation with posterior drawer testing should decrease with internal rotation of the tibia as the medial capsular structures tighten. In combined PCL/medial-side injury, this reduction in the posterior laxity is lost.

In the combined ACL/PCL deficient knee, the tibia will be subluxated posteriorly, making it more difficult to quantify the contribution of each ligament to anterior translation. It is important to compare and examine the noninvolved extremity and determine the proper relationship of the tibia to the femoral condyles. The pivot-shift test and flexion-rotation drawer test augment evaluation of ACL insufficiency but may not be useful in an injury involving the ACL, PCL, and MCL because these tests rely on the knee pivoting around intact medial structures.

It is difficult to perform ligamentous testing on a patient with an acute knee dislocation. In particular, PCL laxity is difficult to determine because the patient may not be able to bend his or her knee to 90 degrees of flexion. Although MRI is helpful in determining the status of the PCL, treatment should not be determined based on MRI findings. It is important to remember that complete grade III PCL injuries can heal with continuity and little or no laxity when left in situ.^19,²⁰ Predictable healing of the torn PCL is more important than any laxity in the healed PCL. The fact that the PCL will heal with continuity is important to our treatment philosophy for knee dislocation injuries.

An MCL injury is diagnosed and graded by physical examination. Palpation along the ligament will localize the site of the injury, which is critical to know in order to determine the treatment and rehabilitation process. The MCL is the primary medial restraint to valgus stress at 30 degrees of knee flexion. Valgus stress testing is preformed at 30 degrees of flexion to isolate the MCL and then again at 0 degrees of flexion to assess the contribution of capsular structures as well as the cruciate ligaments. In greater degrees of knee extension the ACL, PCL, posterior capsule, and posterior oblique ligaments assume a greater responsibility in preventing medial joint opening.⁴⁰ Grading of MCL injury is based on tenderness, laxity, and the presence of a firm endpoint. A grade I injury has tenderness, no laxity with valgus stress testing at 30 degrees of knee flexion, and a firm endpoint. A grade II injury is similar but reveals some medial laxity and the presence of a firm endpoint. A grade III injury represents a complete disruption of the MCL with no palpable endpoint on valgus stress testing.

A lateral-side knee injury usually appears differently than an isolated ACL injury. The knee has a mild effusion, but the lateral side of the leg appears swollen with ecchymosis from the lateral capsule avulsion that allows the hemarthrosis to dissipate into the lateral leg (Fig. 61-2, A, B

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