TREATMENTS
Multi-ligament injury to the knee
Whilst rupture of the anterior cruciate ligament is very common, a major multiple ligament injury to the knee is relatively rare. It is however not uncommon to have a minor injury to another ligament, particularly to the medial collateral ligament, associated with cruciate ligament rupture. This is common from skiing. The majority of these medial collateral ligament sprains will heal well without surgery. If there is an excessive laxity in the ligaments bracing from early on is beneficial.
When two or more ligaments (of the total 4) have a serious injury then the knee joint has usually dislocated at the time of injury. Usually it immediately spontaneously springs back ‘into joint’ although many patients with such an injury will distinctly remember the feeling of thigh and shin bones parting company.
These major injuries can be limb threatening. If the artery adjacent to the knee is torn emergency surgery is required to re-establish blood supply to the leg below the knee. In addition, it is not uncommon for the major nerves that cross the knee to be damaged. It was thought that approximately 50% of knee dislocations were associated with damage to nerve and/or artery. With the realisation that knee dislocation is more common than thought the true instance is somewhat less. Never-the-less it is significant. I have found that the chance of the nerve injury spontaneously recovering is around 50%.
Traditionally, these dreadful injuries were treated non-surgically with initial application of a cast. The long term result was usually poor with marked instability of the knee, poor function, and rapid progression to arthritis being usual. This lead to a move towards surgical repair/reconstruction of the ligament injuries. Old techniques often required periods in plaster after operation and the results were poor. Modern treatment of these injuries have however greatly improved. There is debate as to whether surgery should be undertaken early (within the first 2 to 3 weeks from injury) or delayed several weeks. Very few specialists would however advocate a ‘wait and see policy’ beyond this. It is not known whether the results of early but delayed surgery are worse than very early surgery in the first few weeks.
Our philosophy, based on experience however, is that very early surgery is advantageous in that it offers the opportunity for repairing ligaments rather than having to reconstruct them with tendon grafts either harvested from the injured person or from donated cadaveric tissue. It also allows rehabilitation to start before muscles are wasted and the joint becomes stiff. In truth, the long term results are awaited and the correct management of these injuries in the early phase remains controversial. Very early surgery is certainly more risky than delayed surgery and therefore should be undertaken by highly specialist surgeons. Although I aim to undertake the surgery arthroscopically (i.e. using keyholes) as much as possible, significant scars are often required.
Many of these injuries, if treated early, and if satisfactory repair/reconstruction can be achieved, can result in a good level of function. The joints are, in truth, never normal and whilst some patients do get back to sport my belief is that this is associated with an increased risk of early arthritis. Our advice is therefore that these patients should avoid running sports to help protect the knee for the longer term. The risk of relatively minor complications such as stiffness is high and many patients will require either a manipulation under anaesthetic for stiffness or an arthroscopy. The time to achieve a final result is also very prolonged. It takes approximately 18 months to 2 years to achieve final status. The most arduous period is in the first 3 to 6 months. The knee will require bracing for 6 to 12 weeks and an intensive physiotherapy work. The level of injury is many times greater than a simple anterior cruciate ligament rupture and it is not surprising that the recovery period is so prolonged.