This current-concepts review by Fanelli et al. covers the evaluation and surgical management of the multiple-ligament injured knee, including knee dislocation. It presents the authors' systematic approach to vascular assessment, ligament reconstruction timing, graft selection, and posterolateral corner classification. Outcomes from the authors' 2- to 10-year series of arthroscopic combined ACL/PCL reconstructions are included.
When a patient walks into your trauma bay after a high-energy knee injury, vascular status is the first decision — not ligament reconstruction. The popliteal artery is an end artery tethered at the adductor hiatus and soleus arch; geniculate collaterals cannot compensate if it is disrupted. Normal pulses after reduction give false reassurance: intimal injury can thrombose hours later, so serial neurovascular checks are mandatory for any suspected dislocation.
Once the limb is perfused and stable, the ligament pattern drives your timing algorithm. Posterolateral corner injuries need attention within 2-3 weeks — beyond that window, primary repair is no longer possible and outcomes worsen. Low-grade MCL tears combined with ACL/PCL injury are the one situation where bracing first (4-6 weeks) is appropriate before cruciate reconstruction.
This paper also establishes that failing to address the collateral structures when reconstructing the cruciates produces inferior results — incomplete treatment of all injured structures is the most common technical error in multiligament knee surgery.
This current-concepts review by Fanelli et al. covers the evaluation and surgical management of the multiple-ligament injured knee, including knee dislocation. It presents the authors' systematic approach to vascular assessment, ligament reconstruction timing, graft selection, and posterolateral corner classification. Outcomes from the authors' 2- to 10-year series of arthroscopic combined ACL/PCL reconstructions are included.
When a patient walks into your trauma bay after a high-energy knee injury, vascular status is the first decision — not ligament reconstruction. The popliteal artery is an end artery tethered at the adductor hiatus and soleus arch; geniculate collaterals cannot compensate if it is disrupted. Normal pulses after reduction give false reassurance: intimal injury can thrombose hours later, so serial neurovascular checks are mandatory for any suspected dislocation.
Once the limb is perfused and stable, the ligament pattern drives your timing algorithm. Posterolateral corner injuries need attention within 2-3 weeks — beyond that window, primary repair is no longer possible and outcomes worsen. Low-grade MCL tears combined with ACL/PCL injury are the one situation where bracing first (4-6 weeks) is appropriate before cruciate reconstruction.
This paper also establishes that failing to address the collateral structures when reconstructing the cruciates produces inferior results — incomplete treatment of all injured structures is the most common technical error in multiligament knee surgery.