Planning Assistance Freeware for Surgical Management of the Multiple Ligament Knee Injury: From Historical to Modern Surgical Procedures

Abstract

Anatomical knowledge and identification of multiple ligament knee injuries have considerably evolved during the last decade. Consecutively, a trend for anatomical reconstruction of these injuries emerged. These procedures are challenging and require precise planning. Moreover, the planning itself is made difficult by the variety of techniques, whose descriptions are scattered throughout the literature. The objective is to reference and categorize the different ligament reconstruction techniques to provide free planning assistance software using a standardized graphic chart.

The search for ligament reconstruction techniques on nine different databases produced 1,536 articles. After reviewing for relevance, the authors included the full papers of the remaining 306 articles. From the reference lists of the selected articles reviewed, 96 studies describing original techniques were retrieved. Techniques were extracted, drawn following the same graphics chart, and classified into conceptual categories.

After selection, 10, 4, 28, 28, and 26 articles described anterior cruciate ligament, posterior cruciate ligament, posteromedial corner, posterolateral corner, and anterolateral corner procedures for reconstruction, respectively. Early techniques often used tenodesis while nowadays various grafts are fixed to isometric points or anatomic landmarks. An interactive tool was created. It allows the visualization of selected reconstructions on axial, frontal, and sagittal representations of the knee. Tunnel position, preferred transplant type, and fixation mode are represented. The freeware is available at: https://apps.medecine.u-paris.fr/multilig/.

The techniques described for the reconstruction of an isolated ligament or corner cannot always be extrapolated for multiple ligament knee injuries treatment. Bone stock and tunnel convergence are two main concerns to consider during planning. Sometimes, it could be necessary to sacrifice a potentially biomechanically superior approach if simpler reconstructions provide equivalent knee kinematics. Surgical options are multiple and scattered throughout the literature. Our study provides an open-source and clinician-accessible research tool for multiple ligament injuries planification using a standardized graphic chart.

Keywords

multiligament - reconstruction - technique

Ethical Approval and Informed Consent

Not applicable.

Author's Contributions

C.M., L.C., and H.B. selected the relevant studies for the systematic search. They, together with M.G., have extracted the techniques of the articles they are described in. M.G. designed the graphic chart, drew the techniques, and designed the web site. The web site was built by a volunteer. M.G. and C.M. drafted the manual. B.B. and M-A.R. have revised the manual. M-A.R. gave the final approval for the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Publication History

Received: 18 July 2024

Accepted: 01 January 2025

Article published online:
06 March 2025

• References

• 1 Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am 1976; 58 (02) 159-172
• 2 Neri T, Myat D, Beach A, Parker DA. Multiligament knee injury. Injury patterns, outcomes, and gait analysis. Clin Sports Med 2019; 38 (02) 235-246
• 3 Cole BJ, Sayegh ET, Yanke AB, Chalmers PN, Frank RM. Fixation of soft tissue to bone: techniques and fundamentals. J Am Acad Orthop Surg 2016; 24 (02) 83-95
• 4 Eagan MJ, McAllister DR. Biology of allograft incorporation. Clin Sports Med 2009; 28 (02) 203-214 , vii
• 5 Braaten JA, Schreier FJ, Rodriguez AN, Monson J, LaPrade RF. Modern treatment principles for multiligament knee injuries. Arch Bone Jt Surg 2022; 10 (11) 937-950
• 6 Fanelli GC, Stannard JP, Stuart MJ. et al. Management of complex knee ligament injuries. J Bone Joint Surg Am 2010; 92 (12) 2235-2246
• 7 Moatshe G, Chahla J, LaPrade RF, Engebretsen L. Diagnosis and treatment of multiligament knee injury: state of the art. J ISAKOS 2017; 2: 152-161
• 8 LaPrade RF, Engebretsen L. Small incisions can make big mistakes: knee lateral collateral ligament reconstruction is all about the anatomy!. Arthroscopy 2018; 34 (08) 2494-2496
• 9 Ménétrey J, Duthon VB, Laumonier T, Fritschy D. “Biological failure” of the anterior cruciate ligament graft. Knee Surg Sports Traumatol Arthrosc 2008; 16 (03) 224-231
• 10 Moatshe G, Brady AW, Slette EL. et al. Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med 2017; 45 (03) 563-569
• 11 Moatshe G, Slette EL, Engebretsen L, LaPrade RF. Intertunnel relationships in the tibia during reconstruction of multiple knee ligaments: how to avoid tunnel convergence. Am J Sports Med 2016; 44 (11) 2864-2869
• 12 Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg 2001; 14 (01) 33-38
• 13 Menzer H, Treme G, Wascher D. Surgical treatment of medial instability of the knee. Sports Med Arthrosc Rev 2015; 23 (02) 77-84
• 14 McCulloch PC, Lattermann C, Boland AL, Bach Jr BR. An illustrated history of anterior cruciate ligament surgery. J Knee Surg 2007; 20 (02) 95-104
• 15 Bergfeld JA, McAllister DR, Parker RD, Valdevit ADC, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Am J Sports Med 2001; 29 (02) 129-136
• 16 Djian P. Posterolateral knee reconstruction. Orthop Traumatol Surg Res 2015; 101 (1 Suppl): S159-S170
• 17 Robinson J, Carrat L, Granchi C, Colombet P. Influence of anterior cruciate ligament bundles on knee kinematics: clinical assessment using computer-assisted navigation. Am J Sports Med 2007; 35 (12) 2006-2013
• 18 LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med 2015; 43 (12) 3077-3092
• 19 Devitt BM, Bell SW, Ardern CL. et al. The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med 2017; 5 (10) 2325967117731767
• 20 Musahl V, Herbst E, Burnham JM, Fu FH. The anterolateral complex and anterolateral ligament of the knee. J Am Acad Orthop Surg 2018; 26 (08) 261-267
• 21 Sonnery-Cottet B, Daggett M, Fayard J-M. et al. Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee. J Orthop Traumatol 2017; 18 (02) 91-106
• 22 Miyamoto RG, Bosco JA, Sherman OH. Treatment of medial collateral ligament injuries. J Am Acad Orthop Surg 2009; 17 (03) 152-161
• 23 Ng JWG, Myint Y, Ali FM. Management of multiligament knee injuries. EFORT Open Rev 2020; 5 (03) 145-155
• 24 Burrus MT, Werner BC, Griffin JW, Gwathmey FW, Miller MD. Diagnostic and management strategies for multiligament knee injuries: a critical analysis review. JBJS Rev 2016; 4 (02) 1
• 25 Camarda L, D'Arienzo M, Patera GP, Filosto L, LaPrade RF. Avoiding tunnel collisions between fibular collateral ligament and ACL posterolateral bundle reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19 (04) 598-603
• 26 Neven E, D'Hooghe P, Bellemans J. Double-bundle anterior cruciate ligament reconstruction: a cadaveric study on the posterolateral tunnel position and safety of the lateral structures. Arthroscopy 2008; 24 (04) 436-440
• 27 Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med 2010; 38 (04) 804-809
• 28 Stannard JP, Brown SL, Farris RC, McGwin Jr G, Volgas DA. The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med 2005; 33 (06) 881-888
• 29 Markolf KL, Graves BR, Sigward SM, Jackson SR, McAllister DR. How well do anatomical reconstructions of the posterolateral corner restore varus stability to the posterior cruciate ligament-reconstructed knee?. Am J Sports Med 2007; 35 (07) 1117-1122
• 30 Gupte CM, Bull AMJ, Thomas RD, Amis AA. The meniscofemoral ligaments: secondary restraints to the posterior drawer. Analysis of anteroposterior and rotary laxity in the intact and posterior-cruciate-deficient knee. J Bone Joint Surg Br 2003; 85 (05) 765-773
• 31 Trasolini NA, Lindsay A, Gipsman A, Rick Hatch GF. The biomechanics of multiligament knee injuries. Clin Sports Med 2019; 38 (02) 215-234
• 32 Amis AA, Gupte CM, Bull AMJ, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 2006; 14 (03) 257-263
• 33 Samuelsson K, Andersson D, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy 2009; 25 (10) 1139-1174