Knee Surgery in Ohio

We have written eBooks on knee ligament surgery and rehabilitation which provide greater detail if you would like more information. Find these eBooks and more at noyeskneebookseries.com

ACL Injury: Everything You Need to Know to Make the Right Treatment Decision

  • What the ACL does and why it is so important
  • Treatment options for partial and complete ACL tears
  • Surgery: graft options, how it is done, what to expect
  • How to prepare for surgery
  • What to do the first week after surgery

ACL Injury Rehabilitation: Everything You Need to Know to Restore Knee Function and Return to Activity

  • Physical therapy programs for ACL tears treated without surgery
  • Physical therapy programs to do after surgery

PCL and Posterolateral Knee Ligament Injuries: Everything You Need to Know to Make the Right Treatment Decision

  • Treatment options for partial and complete ligament tears
  • Surgery options
  • How to prepare for surgery
  • Postoperative rehabilitation programs

Multiple Ligament Reconstruction

A Complex Problem

Patients who have suffered severe damage to 2 or more ligaments in or surrounding the knee joint require reconstructive surgery to rebuild these vital tissues. Without this operation, the knee may be unstable and give-way or collapse with sports or even during simple daily activities. Premature osteoarthritis may develop due to the instability and abnormal movement that occurs between the femur (thigh bone) and tibia (shin bone).

There are 4 major ligaments in the knee joint:

  • Anterior cruciate ligament (ACL)
  • Posterior cruciate ligament (PCL)
  • Lateral collateral ligament (LCL), also termed the fibular collateral ligamentDiagram of a knee Surgery in Ohio
  • Medial collateral ligament (MCL)

In addition, the “posterolateral complex” is an important area of the knee joint in regard to providing stability. This region includes the LCL, the popliteus muscle-tendon-ligament unit, the popliteofibular ligament, and the posterolateral capsule.

Each major ligament of the knee joint has a specific function in terms of preventing abnormal movement between the femur and tibia. For instance, the ACL prevents the tibia from moving too far forward, while the PCL prevents the tibia from moving too far backward. The LCL and MCL prevent side-to-side movement of the tibia. There are other soft tissues that help each ligament; however, these tissues provide only a small amount of assistance. Therefore, when a ligament is completely torn, there is a high chance that abnormal movement swill occur, which causes instability and, in many cases, eventual osteoarthritis.

A Thorough and Accurate Diagnosis

One difficult problem in patients with multiple ligament tears is accurately detecting which ligaments are torn, the extent of the tears, and if other problems exist that may influence the decision of the type of surgical repair to perform. This is where surgeon experience is paramount. If, for instance, a ligament is torn but is not diagnosed or surgically repaired correctly, the entire operation may fail. The ability to accurately diagnose all of the injuries and problems that exist depends upon the surgeon having knowledge of the complex anatomy of the knee joint, the function of the ligaments, and the correct examination techniques to perform in the clinic.

knee ligament

At our Center, the evaluation of these complex knees uses all available technology:

1.  Knee x-rays: anteroposterior, lateral, posteroanterior weight bearing, axial, lateral stress, medial stress, posterior stress, full double-stance standing
2.  MRI: proton-density-weighted, high-resolution, fast-spin-echo

3.  Instrumented knee ligament testing (KT-2000)

4.  Isokinetic muscle testing: quadriceps and hamstrings

5.  Comprehensive clinical evaluation:  knee range of motion, joint effusion, patellar subluxation, Q-angle, patellar compression pain and crepitus, tibiofemoral crepitus and joint line pain, varus recurvatum, gait

6.  Comprehensive ligament evaluation: Lachman, pivot-shift, posterior drawer, reverse pivot-shift, lateral and medial tibiofemoral joint opening, external rotation

ligament

recurvatum, tibiofemoral rotation dial test

7.  Functional testing
In addition, tests are performed during the arthroscopic examination which is performed after the patient has been placed under anesthesia, just before the surgical reconstruction. These tests confirm the diagnosis which was made in the clinic. An example of such a test is the “gap test” in which the amount of space between the femur and tibia is measured. This determines if the LCL or MCL require reconstruction.

Patient Candidates

Candidates for multiple ligament reconstructive surgery are patients who have been diagnosed with complete tears of 2 or more ligaments who are physically active with either work or sports and who require a stable knee for their activities. There are no absolute age limits, although in our experience, patients over the age of 50 rarely undergo this operation.

Patients who have severe muscle atrophy, loss of knee flexion or extension, or severe problems with walking require rehabilitation first in order to correct or lessen these problems. Our pre-operative rehabilitation program greatly improves the prospect for the operation to be successful.

Contraindications for surgery include previous knee joint infection, reflex sympathetic dystrophy, complex regional pain syndrome, morbid obesity, or other disease pathology as deemed by the surgeon. In addition, patients who are unwilling to comply with rehabilitation are not considered candidates for surgery.

Operative Options

There are a variety of ways in which ligaments may be reconstructed. Usually, a graft must be used to replace a completely torn or deficient ligament. The graft is made from either the patient’s own tissues (autograft) or from donor (allograft) tissues. The patient’s own tissues that may used include the patellar tendon, quadriceps tendon, or hamstrings tendons (semitendinosus-gracilis). If the patellar tendon or quadriceps tendon is selected, only one-third of the tendon is harvested. Donor tissues which are frequently used are the patellar tendon and Achilles tendon. In many knees that require 2 or more ligaments to be reconstructed, both autograft and allograft tissues are used.

The most common tissues used at our Center for multiple ligament reconstruction are shown below.

ACL Reconstruction

  • Patellar tendon autograft
  • Hamstrings autograft
  • Patellar tendon allograft

PCL Reconstruction

  • Patellar tendon allograft
  • Achilles tendon allograft
  • Quadriceps tendon autograft

LCL, Posterolateral Reconstruction

  • Patellar tendon allograft
  • Achilles tendon allograft

MCL Reconstruction

    • Patellar tendon allograft
    • Hamstrings autograft

 

In more rare instances, some ruptures to the LCL and MCL may be repaired using either sutures or a procedure known as an advancement, where the torn tissues are moved in a certain direction and the fixed with a screw and washer. In all cases at our Center, tears to the ACL and PCL are reconstructed using graft tissues.

Postoperative Rehabilitation

At our Center, patients meet with a physical therapist before the operation to receive instructions on immediate postoperative care, as well as the long-term program. In many cases, patients require preoperative physical therapy to prepare for this operation. The restoration of normal knee motion and muscle strength are important in order to avoid complications and a prolonged course of rehabilitation after surgery. Patients are advised on crutches and braces that will be required, and shown the exercises they will perform immediately after surgery.

Our carefully structured rehabilitation program begins immediately after surgery with exercises that have been shown in clinical studies to be safe and effective in recovering knee motion and muscle strength. Patients can expect to perform exercises for many months after surgery, usually at least 9-12, for the best possible result to be obtained.

We have different rehabilitation programs that have been published for knee ligament operations. The correct program is determined after the operation has been performed to ensure the exercises are done in the appropriate manner according to the type of grafts and repairs that were done. An example of one protocol for LCL reconstructions may be downloaded here.

Every patient is counseled on the realistic expectations of the potential results of the operation, both before and after surgery. Injuries that involve tears to multiple knee ligaments are serious and it is imperative that patients follow the recommended postoperative physical therapy program in order to achieve the best possible outcome. Patients who have arthritic damage in their knee will be encouraged to return to low-impact activities such as walking, swimming, and bicycling.

Revision Multiple Ligament Surgery

Unfortunately, some ligament reconstructions may fail to restore normal stability to the knee joint. There are many reasons why such failures occur, including:

  • Errors in surgical technique:  improper placement of the graft, use of low-strength grafts, inadequate fixation, excessive or insufficient graft tensioning at surgery
  • Failure of graft integration, tendon-to-bone healing, or remodeling
  • Complete tear or deficiency of another knee ligament which was not surgically corrected
  • Inadequate rehabilitation
  • Postoperative infection
  • Traumatic reinjury

Many patients have come to our Center after operations performed elsewhere failed and we have the experience to diagnose and treat the most complicated cases. Patients undergo an extensive evaluation and the reason(s) for the failure of the prior operations are identified. Then, a comprehensive treatment plan is developed which frequently requires pre-surgical rehabilitation and sometimes, more than 1 operation to achieve the best possible result.

Patients who elect to come to our Center for treatment of previously failed knee ligament operations may be assured that our staff has exceptional experience in handling all of the decisions and issues involved with such complex cases.