Complex Knee Ligament Injuries
Other popular names
- Knee multi-ligament injury
Who does it affect?
Normally people involved in serious accidents or high impact sport.
Why does it happen?
A complex ligament injury of the knee implies that more than one of the major knee ligaments have been damaged. The major knee ligaments are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL) and the lateral collateral ligament (LCL). The LCL has important associated structures grouped together and is referred to as the postero-lateral corner.
Patients who sustain a complex knee injury will usually have experienced a major accident or high energy twisting injury and often have associated meniscal, articular cartilage injures and sometimes associated fractures.
A combination of pain, swelling, instability and tenderness which may be localised or extended depending upon the injury.
The diagnosis of complex knee ligament injuries is made from the knowledge of the accident and an understanding of the mechanism of injury. This will be ratified during your clinical examination by the orthopaedic consultant.
It is often necessary to take x-rays of the knee sometimes using multiple views. In addition you may be asked to undergo an MRI scan to provide a detailed injury analysis. An angiogram (special X-ray involving injection of dye) may be required to evaluate the circulation in the leg as the blood vessels around the knee can be seriously injured in association with multi-ligament injuries.
Fortunately, complex ligament injuries of the knee are quite rare and as would be expected, treatment is more complicated and is different for each patient and their individual pattern of injury.
Sometimes surgery is required as soon as possible after the injury. However, sometimes no surgery is required immediately but surgery is planned for a later date when the patient has recovered from the acute injury.
Surgery usually involves multiple ligament reconstruction and the rehabilitation process is usually longer and more complex than individual repair techniques.
The results of surgery for such injuries is, as one would expect are more unpredictable and tends to depend on the specific injuries sustained.
The techniques described for ACL, PCL, MCL and LHL will be combined. It is difficult to give details of the exact procedure to be performed as this will depend on the specific injury.
This surgery will be performed under general anaesthetic and could take anything from 30 – 90 minutes.
You are likely to stay in hospital 1-3 days. All patients will need someone to take them home.
The anaesthetic will wear off after approximately 6 hours. Simple analgesia (pain killers) usually controls the pain and should be started before the anaesthetic has worn off.
Patients need to use crutches for the first 2 weeks following surgery although they can fully weight-bear - the crutches are mainly to prevent falls until good muscle control has been regained to the leg.
The large bandage around the knee is normally removed 24-48 hours after surgery and a tubigrip to supply gentle compression to reduce post-operative swelling.
The non-stick sterile dressings on the wounds are replaced with clean waterproof dressings . The larger incision over the site of the hamstring tendon harvest site is closed using dissolving stitches and the paper butterfly sutures overlying this can be peeled away easily after 10 days.
Return to normal routine
Bathing and showering
The wounds should be kept clean and dry until the wound has sealed. Showering is fine and the waterproof dressings can be changed afterwards. Bathing is best avoided until the wounds are sealed, typically 10 days after surgery.
In summary, whilst the wounds are wet - keep them dry and when the wounds are dry, you can get them wet!
Surgery is followed by a prolonged course of physiotherapy. This requires a commitment to undertake this rehabilitation in order to achieve the best possible result (at least half an hour per day for 6 months). It is vitally important to stay within the post-operative activity restrictions an physiotherapy guidelines to avoid damaging stretching your reconstructed ligament.
Return to work
The timing of your return to work depends on the type of work and your access, however, the following is a general guide:
- Desk work: as soon as pain allows and you can travel easily to and from work (2 weeks)
- Light duties: if the job allows partial use of crutches or limited walking (2-5 weeks). If the job involves standing for prolonged walking, bending, lifting, stairs but no squatting (7-8 weeks)
- Heavy duties: full squatting, heavy lifting, digging, in and out of heavy machinery, ladder work etc (3-4 months)
When you can walk without crutches or a limp and be in control of your vehicle (about 3-6 weeks).
Ligament reconstruction is an extremely safe and reliable operation. However there is a risk of problems or complications with any surgery.
These risks include:
- Infection, which can occur with any operation. Special precautions are taken during surgery to diminish this risk, however, the risk still exists but there is <1% chance of developing a serious infection (major wound breakdown, septic arthritis or osteomyelitis).
- Injury to blood vessels or nerves. Major injuries to these structures are extremely rare, although it is not uncommon to develop some reduced sensation around the shin wound, this rarely causes a problem
- Deep vein thrombosis / pulmonary embolus (DVT/PE) (blood clots) can also occur as with all operations (<0.2% of a serious clot). This does pose a definite but miniscule risk to life (<1:10000).
- Stiffness of the knee joint after ligament surgery can result from a number of causes. Fortunately these are rare. Some individuals are predisposed to form excessive and thick scar tissue. This is treated by surgical excision of the scar tissue (0.5%)
- Re-rupture can happen if excessive force occurs to the knee in the early post-operative period (performing the wrong activities too early). Rupture can also occur at a later stage by another injury (4-5%). If this occurs then the options remain the same - that is to either live around ongoing instability symptoms or to undergo revision ligament reconstruction.
All these risks are uncommon and in total, the chance of you or your knee being worse off in the long term is about or less than 1%.