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Knee Surgery & Rehabilitation

Patients who have suffered severe damage to two 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 ligament
  • 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.

Traumatic knee dislocations that cause damage to 2 or more ligaments are rare, accounting for 0.02 - 0.2% of all musculoskeletal injuries. It is estimated that 50% of knee dislocations may go untreated initially because the knee goes back into place on its own and the initial severe symptoms of pain and swelling resolve after a few weeks. However, over time the loss of the function of knee ligaments causes continued problems of pain, swelling, and instability. The diagnosis and treatment of these injuries require the expertise of highly trained and experienced medical personnel such as those at the Noyes Knee Institute. We have treated patients with these injuries for over three decades.

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.

Evaluation of these Complex Issues

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 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.

Why Choose NKI for your Multiple Ligament Reconstruction

The Noyes Knee Institute using a team-based approach to treat patients with cutting-edge technology and advanced clinical techniques.

"Every patient is counseled on the realistic expectations of the potential results of the operation, both before and after surgery."

“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."

Frequently Asked Questions

Multiple Ligament Reconstruction What you need to know:

How do I know if I've torn multiple ligaments?

Knee dislocations cause the tearing of 2 or more ligaments in the knee. Dislocations can occur from high-impact sports injuries, motor vehicle accidents, high-impact falls, and other severe trauma. Knee dislocations can also result from low-velocity mechanisms in morbidly obese patients (such as rising from a chair). A knee dislocation indicates that the major bones (the femur or thigh bone and tibia or shin bone) are out of place from their normal position as a result of multiple ligament tears.

The major symptoms are:

  • Immediate severe pain and swelling
  • An inability to move the knee joint
  • There may be a loss of feeling or sensation below the knee
  • There may be a loss of a pulse in the foot
  • The leg may appear crooked or angulated

When should I see a physician?

If you have any of the symptoms noted above from a serious injury, seek immediate medical attention at a hospital emergency room. Inappropriate or delayed treatment may result in loss of the leg due to potential damage to arteries that supply blood to the limb. Approximately 5% of patients will require emergency surgery for a vascular injury and this is usually performed within 8 hours of the injury.

The knee needs to be put back into place (relocate) as soon as possible. Sometimes this occur on its own and other times a physician is required. Tests that need to be performed immediately include x-rays, a Doppler ultrasound, MRI or CT imaging, examination of foot pulses, and examination of nerve function.

The ER physician referred me to an orthopaedic surgeon - what are the next steps?

Most patients with knee dislocations are treated in the emergency room and then released, with a referral to see an orthopaedic surgeon for treatment of the torn ligaments. We recommend you seek the advice of an experienced sportsmedicine-trained board certified surgeon. The training of an orthopaedic surgeon involves many years of undergraduate, medical school, and residency education. The specialization of sports medicine involves additional training, usually at an educational center where a fellowship year is completed. This involves advanced training in surgery and rehabilitation. A sports medicine center combines the disciplines of physicians, physical therapists, athletic trainers, and more to totally heal all aspects of an injury.

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 procedure to perform. This is where surgeon experience is paramount. If, for instance, a ligament is torn but is not diagnosed or surgically restored 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.

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

  • Knee x-rays: anteroposterior, lateral, posteroanterior weight bearing, axial, lateral stress, medial stress, posterior stress, full double-stance standing
  • MRI
  • Instrumented knee ligament testing (KT-2000)
  • Isokinetic muscle testing: quadriceps and hamstrings
  • 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
  • Comprehensive ligament evaluation: Lachman, pivot-shift, posterior drawer, reverse pivot-shift, lateral and medial tibiofemoral joint opening, external rotation recurvatum, tibiofemoral rotation dial test.

Who are candidates for surgery?

Candidates for surgery are patients who:

  • have been diagnosed with complete tears of 2 or more ligaments
  • are physically active with either work or sports
  • require a stable knee for their activities.
  • are usually younger than 50 years of age

Who are NOT candidates for surgery?

Knee surgery is not usually performed in patients who:

  • had a previous knee joint infection
  • have reflex sympathetic dystrophy
  • have complex regional pain syndrome
  • are morbidly obese
  • have other disease pathology as determined by the surgeon
  • are unwilling or not able to comply with the lengthy postoperative rehabilitation program

When is physical therapy required before the operation?

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

At our Center, all patients meet with a physical therapist at least one time before the operation to receive instructions on immediate postoperative care, as well as the long-term program. Patients are advised on crutches and braces that will be required, and shown the exercises they will perform immediately after surgery.

How is the surgery done?

There are many ways in which ligaments may be reconstructed. A graft is 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 be 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 (allografts) 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

  • Quadriceps tendon autograft
  • Achilles tendon allograft

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.

What happens 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.

What happens if I already had surgery that failed?

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.

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