AANA Lab Course 913 - Advanced Knee Course-Early management of MLI Knee Treatment Principles Faculty Lecture

Early management of MLI Knee Treatment Principles Faculty Lecture_ Darren L. Johnson, MD

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This presentation by Dr. Darren L. Johnson addresses the early management and surgical treatment principles of multi-ligament injured (MLI) knees, emphasizing the complexity and urgency of these injuries.<br /><br />Definition and Classification:<br />MLI knees involve injuries to multiple knee ligaments including central pivots (ACL/PCL), collaterals (MCL/FCL), and the posterolateral corners (POL/PFL). The Schenck classification categorizes injuries by ligament involvement, from Type I (one ligament injured) up to Type V (all four major ligaments affected).<br /><br />Initial Evaluation:<br />Immediate knee reduction is critical, followed by rapid varus/valgus stress tests and a thorough neurovascular exam, given vascular injury incidence may be as high as 32%. Delayed diagnosis risks amputation. Ankle-brachial index (ABI) and serial neurovascular assessments over 24-48 hours are vital. CT angiography is indicated for suspected vascular injury.<br /><br />Imaging and Assessment:<br />Stress X-rays quantify collateral ligament damage (e.g., >3 mm valgus stress indicates complete MCL tear). MRI assists preoperative planning by revealing ligament tear repairability, meniscal and cartilage injuries.<br /><br />Surgical Timing and Approach:<br />Emergent surgery is indicated for arterial injuries, compartment syndrome, open/irreducible dislocations. Acute interventions within 1-2 weeks address extensive medial disruption, displaced meniscal tears, or distal MCL “Stener” lesions. Reconstruction is generally preferred, with early repair easing anatomic restoration. Large grafts (e.g., BPTB for ACL, Achilles allograft for PCL) are used.<br /><br />Surgical Principles:<br />Anatomic repair/reconstruction with stable fixation promotes early motion. Complex cases benefit from a team approach. External fixation is reserved for vascular repair, open injuries, loss of reduction, and patient comorbidities like morbid obesity.<br /><br />Posterolateral Corner (PLC) Injuries:<br />Indications for repair vs reconstruction depend on injury severity; acute repairs typically yield better outcomes than delayed reconstructions. Anatomic reconstructions restore knee stability and function, focusing on LCL and popliteus tendon restoration.<br /><br />Clinical Case:<br />A trampoline park injury illustrating severe multi-ligament instability managed with staged surgical repair and arthroscopic evaluation demonstrates practical application of these principles.<br /><br />In summary, MLI knees require urgent vascular assessment, timely surgical intervention based on injury pattern, anatomic repair whenever possible, and coordinated multidisciplinary care to optimize patient outcomes.

Keywords

multi-ligament injured knees

MLI knee management

knee ligament classification

Schenck classification

neurovascular assessment

vascular injury in knee trauma

stress X-rays in ligament injury

MRI in knee surgery planning

surgical timing for MLI knees

posterolateral corner injury repair