Name: Treatment of Multiligament Knee Injuries
Uploaded: 2019-11-11T00:00:00Z
Channel: Arthrex
Description: George F. Rick Hatch III, MD (Los Angeles, CA), shares his philosophy and technique for managing multiligament knee injuries.

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George F. Rick Hatch III, MD (Los Angeles, CA), shares his philosophy and technique for managing multiligament knee injuries.

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VID1-000488-en-US | A | Treatment of Multiligament Knee Injuries

George F. Rick Hatch III

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Treatment of Multiligament Knee Injuries

So my name is Rick Hatch. I'm at USC and I'm also a part of my practice is in the Academic Center at Keck Medical Center, which also at LA County, USC, LA County. So with my my partners at my at the at the private practice, at the, at the academic center, we take care of the we take care of the help them take care of the teams. And at County I have a different type of athletic team population. And so this is makes up a lot of my is kind of what I'm passionate about. And this is what my practice really is at County. And it's, it's it's this team right here. So and this is my actual patient. He took a selfie of him. Well, he had the EMT take the selfie of him. And we're going to see him later in this talk. So this is the kind of this is the area that I really am interested in. I'm really passionate about studying multi ligament knees and the treatment of multi ligament knees. And so my as I said my practice it is at Keck where we have referred patients in for this, and then also a county where the cases can be also a little bit even more high energy. And one of the things that these cases, you know, they're tough. They take a long time. They're difficult. They don't happen that often. So you want a case that's safe, that's reproducible. One of the things I was tasked with was okay, do a multi ligament, how to treat it from start to finish and do it in ten minutes. So I'll try. This is a 50 year old male triathlete who is on a motorcycle dirt bike. He's not a dirt biker and he suffered an open posterior knee dislocation. So that's his femur in the dirt. And again his friend took a selfie. This is him eight weeks after. And I did not ask him to do this in clinic. All right. He has an internal brace, a PC with ACL reconstruction, a PCL repair and a all internal brace. So this is him at seven months postoperatively. All right. And I'm going to go on. This is a 45 year old recreational soccer player. It's a much lower velocity injury with a CD. Three l need this location. He is one year after his injury, so he had an ACL reconstruction with an allograft augmentation, a PCL brace repair, and a and a posterior corner and repair. And then finally, before we kind of go on, this is a 45 year old man who is a revision multi ligament in a wall collapsed on him at work. He had he had a CD4 with a peroneal palsy. He had a good surgeon who did his surgery. He had a double all-inside PCL double tunnel double bundle. He had a style reconstruction. And you can see from his you can see from his standing film on the far left that his is lax and you can see a severe varus deformity. So in this case, he had a high tibial osteotomy with an augmentation of his posterior lateral corner and then in a graft. And this is him in clinic on Thursday. So now he's two and a half years out. And what's more impressive at this is that that morning, this is his Strava post that he posted on his bike. Okay. So clearly he's a motivated individual. So the the optimal treatment for these is, is highly debatable. Okay. This is a rare injury. The populations are heterogeneous. So we can't we can't really have good studies. There's no high level evidence at all that exists here. So there are certain things that we that we can't we can agree that are non debatable. And that's that it's a life threatening injury that we demands that we, we document everything on that limb when we see it document neurovascular status. We always have to think about the vein, not just the not just the artery. Because these patients sit around, they get DVT. So they have to be they have to be Doppler. We have to rule out the concomitant injuries because many of these patients have fractures. They have other things. When it's such a high velocity injury, we also need to have a knee that is reducible. And we can maintain that reduction until the until the Definitiv treatment. So this for instance, the patient on these are both my patients. One had a bilateral knee dislocation and a vascular injury which resulted in him losing his leg. And he has two dislocations. And then the one on the bottom is when he was referred to me, who was who was eight months out of a treated non-operative knee dislocation. And that's a 23 year old. So Bruce, who you know, Bruce and Mike. Mike who spoke, who spoke here, and Bruce Levy and has given so much to the just the overall information about this and Doctor Stannard and Doctor Finlay, these are kind of the gods in my mind of multi ligament surgery and what they've been able to kind of piece together because this information is not there's not great studies is it. Surgical treatment does provide better outcomes. There's a trend if you look at the acutely treated 3 to 6 weeks versus versus chronically treated after that, that they tend to do a little bit better when treated acutely. However, however, Bruce found that there's really no difference in the range of motion when you look at whether they're treated acutely or not. And many of these patients have such issues that they can't show up. You can't take them to the operating room immediately. This is probably the best study that there is on multi ligament knee surgery that Doctor Stannard did and that he randomized it was it was it was it was nonrandomized. It was prospective trial but it was level two. And that's about as good as it gets in this group. And repairs failed and reconstructions did well. And Bruce showed this in the Mayo experience as well that repairs failed. Reconstructions did well when dealt with posterolateral corner. By the way, that patient is actually supine. It's mine. The. He also has a dislocated knee. Bruce also found in their group that with regards to the medial side, whether you're repairing or reconstructing, they couldn't really figure out which one is better, but that was better than treating them non-operatively so this isn't an MCL. We had a great talk at MCL today, and a great talk about not ignoring the MCL in this particular case when we've injured other ligaments. This is this is a really big issue if we ignore the MCL in these In these cases. So I've always favored the lapradd and ingwersen technique with the all-inside the with the anatomic reconstruction. This is one of my patients who had a double bundle ACL. And now they're three years out from that technique. And this is a this is a good surgery. This is a patient who is four years out from a CD three L. And he actually has that, that braces because he has a foot drop from his peroneal nerve palsy. But they both have very good results with using a reconstruction and a double bundle PCL. But I would say that I do think that there is clearly a role for repairs. And as we were talking about, as the panel was talking about up there, that we need to look into this, this was a study with doctor with doctor, and they couldn't even get this published in the sports literature. In 2007. It was actually published in the actually published in trauma. And if you look at the Lyceum scores, they had 28 knees. Now he has he has follow up of nine years in these patients. Their Lyceum scores were 89. If you look at Doctor Watson's study, again, one of the gods of this field that this subspecialty there on their fault there. 8083 so I'm not saying one is better than the other, I'm just saying that they're horrible injuries, and we need to look at a whole wide range of treatment options for these injuries. Doctor Frosch did a meta analysis and found that whether you repaired or you reconstructed, there was really no significant difference in the treatments. The only really thing that predicted the outcome was the classification. Higher grade, worse outcome. And so, you know, we've talked about the InternalBrace today. It's it protects your repair while it heals. It's not we're not trying to make a new ligament, but I feel it's a it's a check rein that allows us to give early range of motion. And it stops. It's a leash. It's stopping that failure. Doctor McKay and his group have shown that a that a brace was better than repair alone, and that it acted similar to a lapradd type reconstruction in a biomechanical setting. And the doctor Dugas demonstrated that when you look at this at Ucls, this was also when they did a brace. It was very similar to a job reconstruction with much less dissection. So it's very it's very attractive. So to an extent I am drinking the Kool-Aid a little bit on this, but my algorithm currently is that if I have a multi ligament knee injury and there's adequate soft tissue healing, I would like to go to or in between somewhere between 2 to 6 weeks to allow the tissues to heal. No more. No sooner than two weeks I'm going to look at the MRIs. And if there's an avulsion proximally or distally, those are ideal for a repair type situation if there's good tissue. But I'm prepared to reconstruct everything in the operating room, the actual Definitiv what gets fixed in the Or is going to be based upon what is lax under fluoro compared to the contralateral extremity, regardless of what it looks like under the under on the MRI study. So that's gonna actually make the final determination. And then I'll reconstruct with an internal brace augmentation for the PCL. But if I can repair it I'll repair it. Especially those those stretched out PCL which are there. But we all know that they're lax and that running a brace is kind of a really, really interesting alternative for the posterior lateral corner. The lateral ligaments I'll reconstruct with a brace or I'll repair if I have a good sleeve of tissue. And I'll do the same thing with an MCL. Here's an example of a patient who's a motorcycle who had a motorcycle injury with a hip. He has a fragment in his hip. He underwent a hip, open removal of that fragment. He had a big laceration. That general surgery washed out and closed. So he's got a soft tissue issue. He has a high grade PCL and he's got an MCL. So if we waited on this, if we wait on this guy, we know his knee is going to get really slack. So doing kind of a minimal technique where we could put a brace in and then repair the MCL and then just let him go. He needs to be he needs to be ambulatory. He needs to walk. He needs to get his hip better. He needs to get his strength back. And then I ordered an MRI at six months. Didn't tell the radiologist what we did. And the radiologist read this as a healed reconstruction. And this is him at two and a half years after his surgery. And here's his motion. The gentleman we talked about earlier who had the knee neatest location. This big tibia lack this ankle dislocation. So he had a repair of his ACL, his PCL. He had a posterior lateral corner. I just felt like I needed more tissue. And this is him at a year and a half postoperatively now he has a little hitch in his gait. If you look, his right ankle is basically fuzed, but he has he has good motion of his knee and he has a stable knee. So kind of finish off with the indication for what this is kind of the ultimate indication in my mind. So this is a 35 year old male mountain climber. He and a lawyer. Great combination. And he has a he has a fall. He has a traumatic BC and a left calcaneal fracture malunion. And he becomes this kind of he has this little internet following because he does all these crazy things now with his BC wakeboard surfs and he does he's he's into skiing and extreme skiing. He does, he does ski stunts And even if he, you know, even if he crashes, he keeps on doing these kind of things. He's very determined. And he's going to make it on this one. But unfortunately, his lifestyle catches up with him and he dislocated his left knee. And so this is his the injured knee. And this is his stress film in the in the O.R.. And he has a PCL and a and a lateral ligament complex. And so he essentially he wondered what a PCL reconstruction with a brace and repair his posterior corner and with braces, because I really felt like this guy is not complying, although he's very smart and he's going to start walking right away. And he also has a PCA. And so seven months he disappears, which is unusual. And he shows up in clinic seven months later and says he's doing CrossFit. And I expressed my concern about him doing CrossFit. And he says he'll stop doing CrossFit. I'm especially concerned about the fact that if you look at his, if you look at his tunnels, how much Osteolysis is on his tunnels. And if you look closely on his tunnels, especially on this HPV, you realize his brace is the only thing that's probably really been holding him in. And it's recessed now. He's basically pulled that brace. He's pulled that brace into the bone. So that's really holding this. So I tell him he needs to slow down. So he sends me this picture of him climbing and by waterfalls. Then he tells me he's going to go skiing. And I said, you can just enjoy the process of skiing on blue slopes. And he does this. And he's at nine months after his knee dislocation. Which. Completely terrifies me. And then so he sends me another one where he does this. This is a ten month. This is a ten months now. And now he is. Now he is completing them. So at 11 months, he says that he was hiking in the sequoias in a three day hike, where they go to Chalet Chalet with a 60 pound pack. He says, his knees sore, but he uses his brace. So I think that that is a patient that that it needs some kind of extra fixation. Obviously we want compliant patients who listen to us, but this patient would have clearly failed unless we did a some kind of other augmentation on him. I would say that this is a check rein. I'm not we're not trying to replace anything. It allows less surgical dissection. Importantly, it allows range of motion, getting the range of motion back and a healthy joint with full with a full range of motion and ligaments that a little bit lax are going to do well then. Arthrofx probiotic joint this is I think it's I think it's not applicable to all multi multi ligament knees. But I certainly think that that we have a new tool for the box. And I think that we need to look into this further. [00:13:46] So thank you.