SURGERY FOR MULTILIGAMENTOUS INJURIES
Surgery for multiligament injuries aims to to treat several knee ligaments injured during the same trauma. Depending on the structures affected, the surgeon can repair some ligaments and rebuild others using grafts.
The indication for and timing of the intervention depend on the clinical examination, associated injuries, tissue condition, and the patient's goals. Surgery is not decided solely on the basis of imaging: stability, circulation, nerve function, and overall condition are also assessed.
UNDERSTANDING ANTERIOR CRUCIATE LIGAMENT SURGERY
WHEN SHOULD SURGERY BE CONSIDERED FOR MULTILIGAMENTOUS INJURIES?
Surgery may be discussed when multiple ligaments are ruptured and knee instability compromises its function or cannot be controlled by non-surgical treatment.
- Significant instability
When the examination reveals instability in multiple directions, reconstruction or repair may be considered to achieve a more stable knee. - Complete tears of several ligaments
The combination of injuries, their location, and their functional impact are assessed together. The strategy depends on the precise profile of each injury. - Patient's functional needs
The patient's level of activity, work, sporting goals and expectations all contribute to the decision, along with a realistic assessment of recovery possibilities. - Injury requiring early repair
Some ligament avulsions or ruptures can be more easily repaired when treated within an appropriate timeframe. The timing is determined based on the condition of the tissues and other medical priorities.
Surgery is not automatic. It may be postponed if the knee is too swollen or stiff, if the tissues are not ready, or if other injuries need to be treated first. Vascular, nerve, bone, or skin damage may also alter the treatment plan.
PREPARE FOR THE INTERVENTION
Preparation allows for a precise assessment of the injuries, planning of necessary procedures, and organization of the return home. For complex traumas, the evaluation may also include blood circulation and nerve function.
PRE-OPERATIVE ASSESSMENT
The clinical examination is supplemented by a review of imaging studies and, depending on the situation, by further tests. An anesthesia consultation is scheduled before the procedure.
INTERVENTION PLANNING
The surgeon determines which ligaments can be repaired or need to be reconstructed, whether associated injuries require treatment, and whether the procedures will be performed in one or several stages. The choice of grafts and their fixation method depends on the injuries and the patient.
PHYSICAL PREPARATION AND PRACTICE
When possible, regaining satisfactory mobility and muscle activation before surgery can facilitate the subsequent recovery. Crutches, splints, and home care assistance are arranged according to the established protocol.
INSTRUCTIONS BEFORE THE OPERATION
The team will provide instructions regarding fasting, hygiene, and skin preparation. Regular medications should not be stopped without medical advice. Smoking and current treatments will be discussed during the preparation phase.
HOW DOES THE PROCEDURE WORK?
The procedure depends on the number and type of ligaments affected, the presence of associated injuries, and the chosen timeline. The intervention may combine arthroscopy and targeted incisions. It is generally performed under general anesthesia, sometimes supplemented by regional anesthesia. The duration and length of hospitalization vary depending on the complexity of the procedure.
INSTALLATION AND ANESTHESIA
After pre-operative checks, the patient is positioned to allow for examination and controlled mobilization of the knee. The team performs safety checks, prepares the skin, and applies sterile drapes.
Access to the knee
Small incisions are usually made to introduce the arthroscope and instruments into the joint. Additional incisions may be necessary to access or fix certain collateral ligaments.
Treatment of injured ligaments
The surgeon inspects the joint and confirms the injuries. Depending on their location and condition, some ligaments can be reinserted or repaired. Ligaments that cannot be reliably repaired are reconstructed using a graft, often taken from the patient or selected from available grafts. Bone tunnels are prepared to pass the graft through, and it is then fixed in place. Any associated meniscal, cartilage, or bone damage is assessed and treated as needed.
RESULT CONTROL
Knee stability is tested in several directions. The surgeon checks the tension of the grafts, their fixation, and the mobility achieved, taking care to avoid excessive tension that could limit movement.
CLOSURE AND END OF THE PROCEDURE
The incisions are closed and protected with a dressing. A splint may be applied. The patient is then transferred to the recovery room for monitoring.
The goal is to treat the ligaments responsible for the instability while preserving mobility compatible with rehabilitation.
A STRATEGY ADAPTED TO INJURED LIGAMENTS
Multiligament injuries do not require a single, identical surgical procedure. The surgical plan depends on the ligaments involved, their location, their condition, and any other observed injuries.
The surgeon also takes into account the condition of the tissues, swelling, knee mobility, risks associated with the trauma, and the patient's functional goals.
Ligament repair
When a ligament is torn near its insertion and the tissues are of sufficient quality, it can sometimes be reinserted or repaired. This option is not suitable for all tears and depends on their configuration.
Reconstruction by grafting
A graft can replace a ligament that cannot be reliably repaired. The choice between a graft taken from the patient and another graft depends on the surgical strategy and the context.
Intervention in one or more stages
When the condition of the knee and tissues allows, several procedures can be performed during the same operation. A multi-stage surgery may be considered if the medical context, tissue condition, or knee stiffness warrants it. Current data do not allow for a standardized schedule to be imposed on all patients.
Fixation and associated gestures
The grafts are fixed in bone tunnels using devices chosen according to the technique. Additional procedures may be necessary to treat other lesions or improve stability. Their indication is determined on a case-by-case basis.
No single technique is suitable for all knees: the choice depends on the examination, the lesions observed, and the recovery goals.
AFTER THE PROCEDURE: THE FIRST STEPS
After the procedure, the team monitors the knee, pain, and overall condition. The length of hospital stay depends in particular on the complexity of the operation and the level of mobility achieved.
Instructions for support, mobilization, and use of the splint are specific to the procedures performed. They are detailed by the surgeon and the physiotherapy team.
WAKE-UP AND PAIN ROOM
Monitoring focuses on pain, nausea, and recovery after anesthesia. Drinking and eating are resumed when the team gives the go-ahead.
Support, walking and splint
Weight-bearing may be limited or permitted depending on the repairs and reconstructions performed. Crutches and a splint may be necessary. Initial mobilizations are supervised by the healthcare team or physiotherapist.
RETURN HOME AND MONITORING
Return to activity is permitted once medical and functional criteria are met. Instructions include dressing changes, knee protection, and follow-up care. Severely worsening pain, fever, unusual swelling, shortness of breath, or changes in sensation or foot color require immediate contact with a medical team.
REHABILITATION AND RESUMPTION OF ACTIVITIES
Rehabilitation is progressive and follows the guidelines related to the repaired or reconstructed ligaments. The initial priority is to protect surgical procedures while avoiding excessive stiffness.
Initially, the physiotherapist assists with managing swelling, progressively restoring permitted mobility, and muscle activation. The ranges of motion and exercises are adapted to the chosen protocol.
The progression then includes strengthening, balance, movement control, and regaining limb function. Exercises are adjusted according to healing progress and medical check-ups.
Walking, driving, and work resume at varying times. They depend on the permitted weight-bearing, mobility, strength, pain, and the demands of the activity.
Resuming sports activities requires a specific progression. It may necessitate strength, balance, and functional control tests, as well as medical clearance before activities involving pivoting or contact.
Recovery depends on stability and restored functional capacities, not solely on the time elapsed.
EXPECTED RESULTS, LIMITATIONS AND RISKS
The decision is based on an individualized comparison between the expected functional benefit, the constraints of rehabilitation and the operative risks.
OBJECTIVES AND EXPECTED RESULTS
Surgery aims to improve knee stability and enable functional recovery tailored to the patient's goals. The outcome depends on the severity of the trauma, associated injuries, the recovery of mobility, and rehabilitation.
Boundaries
Reconstruction does not guarantee a return to previous athletic performance. Residual stiffness, weakness, or discomfort may persist, and certain cartilage or nerve damage may influence the outcome.
Risks and complications
Like any surgery, this procedure carries risks, including infection, bleeding, thrombosis, stiffness, persistent pain, nerve or vascular damage, poor wound healing, residual instability, or further graft rupture. The surgeon explains the risks specific to the patient's situation.
AN INTERVENTION TAILORED TO EACH PATIENT
Surgery for multi-ligament injuries is planned on a case-by-case basis for each knee. The number of ligaments involved is not enough to determine the treatment: their location, condition, associated injuries, and the state of the tissues are also important factors.
The patient's functional age, activities, work, medical history, and expectations are taken into account when choosing the procedures, timeline, and recovery protocol. The strategy can be adjusted according to clinical progress.
FREQUENTLY ASKED QUESTIONS
A SPECIALIST ADVICE TO DEFINE THE STRATEGY
Each multi-ligament injury has its own specific characteristics. A specialized evaluation allows for the analysis of the ligaments involved, associated injuries, and treatment options.
