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Preserving native tissue, use of allografts recommended in combined knee ligament reconstruction
 John D. Kelly IV |
When treating multiligamentous knee injuries, a University of Pennsylvania surgeon recommends performing surgery expeditiously, respecting tissue biology and using nonirradiated allografts in reconstruction.
John D. Kelly IV, MD, of the department of sports medicine at the University of Pennsylvania, discussed principles, common patterns and strategies of combined knee ligament reconstruction at Orthopedics Today Hawaii 2011.
“Surgeons should be mindful that these knees are already violated and further tissue trauma in the form of autograft harvest and large incisions should be avoided if possible,” Kelly told Orthopedics Today. “I believe that there is no clear role for ‘double bundle’ anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction in this setting.”
The first step in treating these injuries is to rule out reduced dislocations and vascular injury with an ankle-brachial index, computed tomography angiogram or an arteriogram, Kelly said. He also suggested delaying surgery for 10 to 16 days so that soft tissue swelling dissipates and preserving native tissue by fixing bone avulsions. Kelly prescribes a hinged brace until surgery and recommends external fixation only for extremely unstable injuries.
Treating common injury patterns
Injury to both the ACL and medial collateral ligament (MCL) is the most common of the multiligamentous knee injuries, according to Kelly. In general, he treats the MCL without surgery, and if delaying reconstruction by about 4 to 6 weeks, he trephinates it. However, he strongly recommended surgical fixation in the case of an MCL avulsion with an extruded meniscus.
For the PCL/posterior-lateral corner (PLC) pattern, Kelly referred to a series published in the American Journal of Sports Medicine in 2006. In this series of patients, Ahn treated the PCL by preserving native tissue and saw a more robust healing response. Kelly uses the transseptal portals to drill through the native PCL and reconstructs the lateral side unless the patient has a large bony avulsion. To reconstruct the PLC, Kelly uses a technique presented by Arcerio and colleagues in Arthroscopy in 2005, which involves reconstructing the popliteus and the lateral collateral ligament through a transfibular technique. Kelly believes this technique is more anatomic and superior to the “sling” technique.
In the case of injury to both the ACL and PCL, Kelly addresses both injuries if the PCL is unstable. Otherwise, for a grade 1 PCL injury and some grade 2 PCL injuries, he braces the patient in extension for 2 to 3 weeks — in hope of obtaining some PCL reconstitution. To reconstruct the ACL, Kelly preserves as much native tissue as possible and places a pin via a medial portal into the center of the transcondylar ridge. Whenever the PCL is surgically addressed, Kelly said he splints the patient in extension for 3 weeks postoperatively so that the taut posterior capsule protects the reconstruction.
Additional pearls that Kelly offered to attendees were:
- use low inflow and wrap the tibia to prevent extravasation;
- if the peroneal nerve is stretched, perform gentle neurolysis during surgery;
- use deep vein thrombosis prophylaxis with pumps for all patients;
- keep all patients nonweight-bearing for at least 6 weeks;
- prescribe an unloader brace for lateral-side injuries once weight-bearing commences; and
- avoid quad extensions for 5 months after ACL injuries and hamstring flexion for 5 months after PCL injuries. – by Tina DiMarcantonio
References:
- Ahn JH, et al. Arthroscopic transtibial posterior cruciate ligament reconstruction with preservation of posterior cruciate ligament fibers. Am J Sport Med. 2006;34(2)194-204.
- Kelly JD, IV. Combined knee ligament reconstruction. Presented at Orthopedics Today Hawaii 2011. Jan. 16-19, 2011. Koloa, Hawaii.
- John D. Kelly IV, MD, is the editor of Your Practice/Your Life. He can be reached at the Department of Sports Medicine, University of Pennsylvania, 235 S. 33rd St., Philadelphia, PA 19104-6322; 215-615-4400; e-mail: johndkellyiv@aol.com.
- Disclosure: Kelly has no relevant disclosures related to this presentation.
