In this clinical case involving a 24-year-old patient, we explore the various physical examination tests used to assess a multiligament knee injury. What is the most appropriate surgical treatment, and how should post-operative rehabilitation be managed?
I am an orthopedic surgeon specialized in knee surgery. I practice at the University Hospital of Toulouse in the University Sports Clinic located in the Pierre Paul Riquet Hospital.
In addition to teaching at the Faculty of Medicine, I participate in courses for the professional societies to which I belong such as the SFA, ESSKA and SOFCOT.
My clinical activity (more than 800 surgeries per year) is exclusively focused on knee surgery. An important part of my surgeries is related to sports traumatology, in particular anterior cruciate ligament injuries (350+ ACL reconstructions per year).
My research activity is also focused on the knee. I have contributed to more than 110 publications in international journals. I am developing an à la carte approach in order to propose a personalized surgery to the patient. In the context of degenerative activity, the aim is to better analyze the variability of the anatomy in order to be able to propose prostheses adapted to the patient's anatomy. In the context of sports traumatology, it is a question of improving the dismemberment of all the lesions in order to propose an adequate therapy.
Since May 2022, I am a member of the board of ESSKA (European Society of Sports Traumatology Knee Surgery and Arthroscopy) as treasurer.
- Patient : 24-year-old male patient , farmer
- Mechanism of injury: High-Energy trauma ( Motorcycle Accident)
- Initial Injury: knee sprain without associated fractures
- Initial treatment: Knee Brace Immobilization for 6 weeks, followed by physiotherapy
- The patient presented to our hospital 6 months later with persistent daily knee joint instability
Pre-op Testing
- Varus Stress Test: varus laxity at 0° and 30°of knee flexion
- Valgus Stress Test: Absence of valgus laxity at 0° and 30° of knee Flexion
Pre operative MRI
- Knee X-ray: No fractures or bony avulsion
- Knee MRI Findings:
- Rupture of the PCL, PLC and LCL
- Intact ACL
- No meniscal tear
- No cartilage injury
Which test(s) should be positive at the physical examination?
- ✔️Dial Test
- ✔️Hughston
- ✔️Posterolateral Rotatory Drawer Test
- ✔️Posterior Drawer Test
What is a positive dial test and what structure is affected when positive?
- ✔️>10° external rotation asymmetry at 30° of flexion, PLC lesion
- ✔️>10° external rotation asymmetry at 90° of flexion, PCL lesion
One stage reconstruction of chronic PCL , PLC and LCL ruptures
- Arthroscopic reconstruction of the PCL and PLC is performed via a trans-septal approach, using a pedicled semitendinosus autograft for the PCL and an extensor hallucis longus allograft for the PLC
- LCL reconstruction is performed using a percutaneous technique with a gracilis tendon autograft
- Graft Tensioning sequence:
- Tighten the PCL graft with the knee in 90° flexion and maximum anterior drawer.
- Tighten the PLC graft with the knee in 90° flexion, maximum anterior drawer, and internal rotation.
- Tighten the LCL graft at 30° of flexion with moderate valgus stress.
Post-op X-rays
Post-operative Rehabilitation
- Immobilization using hinged PCL dynamic brace for 12 weeks with no weight bearing for the first 6 weeks.
- Full knee range of motion exercises was allowed immediately post operatively
- Early activation of the vastus medialis muscle was initiated to support quadriceps function
- No hamstring strengthening exercises for the first 12 weeks
References
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Ali Alayane M.D., David Zhu M.D., Dany Mourbes M.D., Leo Estivols M.D., Etienne Cavaignac M.D., Ph.D. Knee - Percutaneous Lateral Collateral Ligament Reconstruction
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