Allografts effective for multiligament injury repair

Repair, augmentation and reconstruction are viable for multiligament knee injuries.

Issue: February 2007

Multiligament knee injuries have complex injury patterns. Allografts offer a safe and effective treatment option for these injuries, according to Thomas L. Wickiewicz, MD.

Wickiewicz prefers allografts because there is an almost unlimited availability in most settings and allografts are malleable and allow the surgeon to mold the grafts to the size and shape needed.

Evaluating a multiligament knee injury begins with the physical exam.

"In essence, your physical examination is going to be a drill in anatomy and biomechanics," said Wickiewicz, of the Hospital for Special Surgery in New York. "You understand what your primary ligament restraints are, what directions they are trying to control and you're basically trying to prove in your own mind whether an instability patterns exist." Wickiewicz said at the Orthopedics Today New York 2006, A Comprehensive CME Course.

Clinical tests critical

Clinical tests can yield a lot of information about these injuries, he said. A surgeon should examine varus and valgus stress at 0° and 30° to determine if there is a major collateral ligament injury. External rotation would indicate either profound posterolateral or medial disruption. More advanced tests, like the posterior drawer or reverse shift, should be done only in the operating room under anesthesia, Wickiewicz said.

Imaging studies should include plain radiographs, CT and MRI. "The utility of MRI is not to necessarily tell you what you already know, but to give you information about what you don't know or what you don't suspect," he said. When done appropriately, an MRI can: show potential articular cartilage damage; reveal significant meniscal pathology not detected during the physical exam; indicate occult chondral injuries; and it may reveal remote injuries such as proximal tibial-fibular disruptions, Wickiewicz said.

The general patterns of multiligament injuries are as follows:

single cruciate plus a collateral ligament;
both cruciates and a collateral ligament; and
both cruciates and both collateral ligaments.

There are three treatment options for multiligament knee injuries: repair, augmentation or reconstruction.

"If you're lucky enough to have an avulsion — some low-speed multiligament injuries will, in fact, peel the cruciates so that you have good substance of tissue — you can repair it," Wickiewicz said. "Often, the medial side is repairable and so is the lateral side if there are avulsions."

For injuries on the medial side, repair is an option if good tissue is available.

"In general, with medial side injuries, even with acute dislocation and both cruciates out, you should err on the side of delaying [surgery] because of the complication of myositis, which is much more prevalent medially than posterolaterally." For these patients, Wickiewicz will brace the knee, restore the range of motion and will perform a reconstruction later on.

For medial collateral ligament (MCL)-side injuries, Wickiewicz generally prefers to repair them. "I'm going to use hamstring tendons for augmentation, but occasionally for chronic situations, I will use an allograft. The repairs are straightforward; you'll suture what you can."

For cruciate augmentation, one option is to use ipsilateral-side hamstrings. "You can use the hamstrings from the contralateral side, if you're a believer," Wickiewicz said. Hamstrings are also effective for cruciate and posterolateral repair, especially for popliteal ligament constructs. Autogenous biceps facia are useful for lateral collateral ligament reconstruction.

Allograft vs. autograft

"But I think in today's world it is much more a concept of reconstruction rather than repair and augmentation of the cruciates," Wickiewicz said.

For reconstruction, he said surgeons can use bone-tendon-bone, hamstring or quadriceps tendon autograft, but he prefers allograft tissue.

"As you are already dealing with a significantly traumatized knee, I don't think you need to do further damage to it by harvesting autogenous tissue. I have never been on the side of going to the normal knee, especially in these injury patterns, where it may take 3 to 6 months of recuperation; I'd rather not violate the normal side."

If MCL surgery requires augmentation, Wickiewicz suggests keeping the isometric point the same. "The knee is a cam; it is not a hinge."

Be prepared: These procedures can be difficult. "These will not be simple surgeries. These are not 50-minute endoscopic ACL reconstructions," Wickiewicz said. "Don't schedule them at 6 p.m., if you can. Get your necessary equipment to assist, as they are typically long cases."

Graft preferences

For the ACL, Wickiewicz prefers allograft bone-tendon-bone or Achilles grafts. For the posterior cruciate collateral ligament, he also uses allograft bone-tendon-bone or posterior tibial tendons. For the MCL, he prefers autograft hamstring or allograft Achilles. Finally, for the lateral side, he uses autograft hamstring and allograft Achilles.

"One technical point for the lateral side: Bone-tendon-bone tissue, whether it is from same knee or from a donor knee, will usually be too short to make the turn for the popliteal construct," he said. "I think you need to get longer grafts in order to do that."

Wickiewicz tried to dispel the notion that medial side injuries will always heal without repair.

Medial side needs help

"That is true 90% of the time," he said, but in chronic situations, where there is no biologic response, the medial side must be addressed surgically. Not reconstructing this type of injury will lead to higher cruciate failures.

Postoperatively, Wickiewicz recommends cryotherapy, continuous passive motion, hydrotherapy, deep vein thrombosis prophylaxis and bracing. Wickiewicz keeps his patients nonweightbearing for 6 weeks. In addition, patients do a closed chain rehabilitation program. For PCL surgery, he allows open chain quadriceps rehabilitation.

"These are significant injuries," Wickiewicz said. "I want to do whatever it takes in that individual to get them firing their quadriceps and try to get that knee functioning." He prohibits open chain hamstring rehabilitation in PCL reconstruction. Complications include wound healing, motion loss, myositis on the medial side and graft failure.

For more information:
Wickiewicz TL. Management of multiligament injuries. Presented at Orthopedics Today New York 2006, A Comprehensive CME Course. Nov. 11-12, 2006. New York.
Thomas L. Wickiewicz, MD, Hospital for Special Surgery, New York, NY 10021; 212-606-1450; wickiewicz@hss.edu.