REVIEW ARTICLE

Surgical Treatment of Combined ACL, PCL,

and Lateral Side Injuries
James P. Stannard, MD,*† James T. Stannard, PhD,†‡
and James L. Cook, DVM, PhD*†

table with an angiogram and emergent vascular repair or

Abstract: A knee dislocation that involves at least 2 of the 4 major
ligament groups—such as the anterior cruciate ligament, the pos-
terior cruciate ligament, or the posterolateral corner—is a cata-
strophic event for an athlete or trauma patient. Careful evaluation
Downloaded from http://journals.lww.com/sportsmedarthro by BhDMf5ePHKbH4TTImqenVDiEotxSR1UHSri9UYeq731yPtyf3tcRlqPhYGQSu7tG on 08/09/2020
reconstruction.3–5 The vast majority of neurological injuries
associated with KDs involve the peroneal nerve. One recent
large case series documented a 19% incidence of peroneal
nerve injury associated with MLKIs with many involving a

of these patients is needed to avoid disastrous outcomes. Surgeons

must be cognizant of a number of key treatment concerns—such as significant PLC injury. Patients surgically treated for MLKI
tunnel crowding, controversies over graft fixation methods, and with concurrent peroneal nerve injuries had significantly lower
sparsity of level I clinical data—to make proper ligament repair postoperative knee range of motion compared with those who
decisions. This manuscript will review treatment principles that did not have a peroneal nerve injury and a lower rate of return
govern high-quality care of this complex injury. to work that was considered clinically but not statistically
significant. However, there was no difference between these 2
Key Words: knee dislocations, knee stability, anterior cruciate lig-
cohorts in terms of postoperative activity level, pain, or other
ament, posterior cruciate ligament, posterolateral corner
functional outcomes.7
(Sports Med Arthrosc Rev 2020;28:94–99) There are a number of other key treatment principles
regarding multiligament injured knees that are important
for the surgeon to consider. The first is that reconstruction
rather than repair is most often necessary, and for poster-
K nee dislocations (KDs) are being diagnosed with
increasing frequency in both high energy and low energy
(sports) situations. By definition, a KD involves at least 2 of
omedial (PM) corner and PLC injuries, reconstruction is
superior to repair in restoring knee stability.8–11 Con-
temporary reconstructions attempt to closely recreate the
the 4 major ligament groups of the knee and therefore
normal ligamentous anatomy. Fortunately, the use of ten-
termed a multiligament knee injury (MLKI).1 It is well
don allografts allows for anatomic reconstruction of the
established that surgical treatment yields superior outcomes
major knee ligaments and is associated with good results in
when compared with nonoperative treatment of KDs.2,3
countries where they are available. However, these anatomic
One of the important variants is the KD IIIL,1 which
reconstructions can lead to tunnel crowding, overlap, and
involves tears of the anterior cruciate ligament (ACL),
disruption as the number of ligament reconstructions
posterior cruciate ligament (PCL), and posterolateral corner
increase, especially those involving double-bundle techni-
(PLC) comprised of the lateral collateral ligament (LCL),
ques and multipart ligaments. As such, careful attention is
popliteus tendon, and popliteofibular ligament (PLC).
required to orient tunnels in a direction that will minimize
KDs are limb-threatening injuries that must be carefully
tunnel overlap and disruption. Optimal graft fixation in
evaluated to avoid catastrophic outcomes. The vascular and
tunnels is still controversial but recent data from an animal
neurological condition of the limb must always be carefully
model has suggested that suspensory fixation may yield
checked and documented. There is strong evidence to support
superior graft to bone healing and mitigates concerns
the use of a screening vascular physical examination in all
regarding bone quality, that can be poor in trauma
cases of MLKI. Advanced imaging, such as magnetic reso-
patients.12 Currently, very little level I data is available
nance arteriography or a computed tomography angiogram,
regarding the treatment of KDs. However, a prospective
can then be added when positive examination findings are
randomized study of > 100 KDs documented significantly
found to employ a safe and effective strategy for vascular
improved stability and lower reconstruction failure rate with
assessment.3–5 The Ankle Brachial Index is a well-established
the use of a hinged external fixator in highly unstable
and successful screening tool in evaluation of these patients.
KDs.13 There is currently a level I multicenter trial enrolling
The standard protocol recommends advanced imaging in the
patients with a goal of resolving some of the ongoing con-
setting of an Ankle Brachial Index <0.9.3,4,6 Patients who do
troversies regarding the treatment of KDs.
not have a pulse on screening examination should be taken
KD IIIL dislocations require reconstruction of the
directly to the operating room and evaluated on the operating
ACL, PCL, and PLC. Current techniques for all 3 concen-
trate on replicating critical anatomy. The consensus
From the *Department of Orthopaedic Surgery; †Thompson Labo-
regarding ACL reconstruction is that autograft should be
ratory for Regenerative Orthopaedics, University of Missouri; and used for younger patients (below 40 y old) if possible, and a
‡University of Missouri School of Medicine, Columbia, MO. single bundle reconstruction can provide consistently out-
Disclosure: The authors declare no conflict of interest. standing results. Tendon allografts can provide consistently
Reprints: James P. Stannard, MD, Department of Orthopaedic Surgery,
Missouri Orthopaedic Institute, University of Missouri, 1100
successful outcomes for ACL reconstruction in patients over
Virginia Avenue, Columbia, MO 65212. 40 years of age. Tendons for allograft ACL reconstruction
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. should be nonirradiated or only low-dose irradiated

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Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020 Surgical Treatment of Combined ACL, PCL

(< 1.8 mrad) at low temperature and should not be

processed using harsh chemicals. Major topics in PCL
reconstruction involve the controversy of single versus
double-bundle techniques and the impact of codominance
with double-bundle reconstructions.14,15 Codominance is
the concept that by adding a second bundle to the PCL
reconstruction that is tensioned at full extension, the sur-
geon remarkably improves the strength and stability of the
anterolateral (AL) bundle that is tensioned at 90 degrees of
knee flexion. The most important concepts regarding PLC
reconstruction are that reconstructions yield a lower failure
rate than repairs and that the procedure should replicate the
anatomy by reconstructing the LCL, popliteus tendon, and
popliteofibular ligament.12

AUTHORS PREFERRED TECHNIQUES

PCL Reconstruction
In the first 15 years of the senior author’s (J.P.S.)
career, PCL reconstruction in KD cases was performed
using an Achilles tendon allograft double-bundle tibial inlay
technique. The procedure required an open exposure of the
posterior tibia with 4.5 mm cannulated screw and washer
fixation of a large bone block into a trough created in the
proximal tibia. Bioabsorbable interference screws were used
for fixation of the AL and PM bundle in 80 to 90 degrees
and 0 to 10 degrees of knee flexion, respectively. The tech-
nique yielded outstanding results and allowed early and
aggressive physical therapy without developing a 1+ to 2+
posteriorly unstable knee.16–18 Although the clinical out-
comes were outstanding, the procedure required a long
medial incision and a large dissection of the PM aspect of
the knee. In addition, this technique required full tunnels to
be drilled in the femur and interference screw fixation of the
AL and PM bundles. This does not allow for sequential
tensioning of the graft to reduce creep in the graft construct
and gain final desired tension and stability.
A careful review of the anatomy of the posterior tibia led
to the realization that the acute “killer turn” that frequently
results from transtibial arthroscopic PCL reconstructions can
be avoided if the tunnel placement on the back of the tibia is
placed 1 to 1.5 cm below the joint line. That started a research
pathway at our institution that led to designing and validating a
transtibial double-bundle PCL reconstruction technique with
suspensory fixation using Achilles tendon allograft without a
bone block. Biomechanical testing studies confirmed this new
PCL reconstruction technique performed at least as well as the
tibial inlay technique in all parameters tested while avoiding
associated undesirable components of the inlay technique.15,19
The all-soft-tissue PCL graft is created using an
Achilles tendon allograft to create a double-bundle con-
struct that allows for cortical suspensory fixation in sockets.
This graft also incorporates an “internal brace” in the form
of suture tape in a load sharing application. The Achilles
tendon is transected near its calcaneus insertion at the nar-
rowest point, which becomes the tibial end of the graft (10.5
to 12 mm final diameter). Beginning ∼15 mm from the tibial
end, the graft is divided into AL (10 mm) and PM (7 mm)
bundles. The AL band should be ∼150 mm in length, the
PM should be 140 mm. Three cortical suspensory fixation
devices (Tightrope; Arthrex, Naples, FL) are preplaced
within the “Y” of the graft and at the approximate midpoint
of each limb. Starting 15 mm from their ends, the 2 bands
are sutured together using a locking whipstitch pattern with
a #2 fiberloop suture (Arthrex). The suture tape (Fibertape
FIGURE 1. Posterior cruciate ligament graft created using Achilles
tendon allograft with cortical suspensory fixation devices and inter-
nally braced with suture tape. The suture tape is secured using #2
fiberloop routed through using an “M” pattern. The anterolateral band
is ∼150 mm, the posteromedial band should be 140 mm.
2 mm×36 inches; Arthrex) is then placed with its midpoint
sutured to ends of the 2 bands using #2 fiberloop and routed
through the 2 limb tightropes in an “M” pattern (Fig. 1).
The #2 fiberloop is then used to secure the sutured ends of
the bands and fibertape into the “Y” of the tibial end so that
the bands and fibertape are now doubled over. This should
yield an AL final diameter of 10 to 11 mm and final length
of 80 to 85 mm and a PM final diameter of 7 to 8 mm and
final length of 70 to 75 mm. The fiberloop is then used to
reinforce the tibial end using a mattress pattern followed by
a locking double whipstitch, which also incorporates the free
ends of the fibertape. The entirety of the graft is reinforced
at its junction and secured to the fibertape using #0 fiberwire
(Arthrex) and the doubled over portions of the bands are
sutured together, internalizing the fibertape, with 2-O
chromic suture (Fig. 2). Detailed graft preparation instruc-
tions are included in a prior publication on this technique.20
The graft implantation technique involves arthroscopic
debridement of ligament remnants from the notch, followed
by drilling the tibial tunnel with the aid of a PM portal. The
PCL guide designed by Bruce Levy (Arthrex) is used
because it can place the retrocutting drill/reamer 1 to 1.5 cm
FIGURE 2. Finished PCL allograft showing the doubled over por-
tions of the bands sutured together using #0 fiberwire to yield an AL
final diameter of 10 to 11 mm and final length of 75 to 85 mm and a
PM final diameter of 7 to 8 mm and final length of 70 to 80 mm and
internalizing the fibertape with 2-O chromic suture.

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Stannard et al Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020

below the joint surface. Adjustable flipping reamers are now

available from > 1 manufacturer (Arthrex or DePuy Mitek,
Raynham, MA), which allow for all-inside socket drilling
for diameters from 6 to 12 mm with 1 device to improve
efficiency and reduce costs associated with the use of 3
separate reamers. The cutting portion is flipped to reamer
position in the posterior knee only after confirming its
appropriate and safe location using fluoroscopy or direct
arthroscopic visualization using the PM portal. A 40 to
45 mm socket is then reamed from posterior to anterior and
a passing suture is placed. The AL and PM sockets are
placed in the normal anatomic positions20 ∼10 mm from the
articular cartilage and reamed to a depth of 25 mm if pos-
sible. Passing sutures are passed to allow the graft to be
pulled into the knee. The tibial end is pulled into its socket
first with the cortical button being flipped on the ante-
romedial cortex of the tibia and initially tightened. The PM
bundle is then pulled into its socket and the button is flipped
on the medial femoral cortex. The graft is pulled to a depth
of 15 mm. The AL bundle is then pulled into its socket, the
cortical button flipped, and the graft pulled to a depth of
15 mm. The knee is then placed in 90 degrees of flexion and
the common tibial bundle is tightened followed by the AL
bundle on the femur. Finally, the PM bundle is tightened on
FIGURE 3. A 3 to 4 cm preincision drawing ending ∼2 cm prox-
the femur with the knee in 0 degrees of flexion. The knee is
imal to the insertion of the quadriceps tendon into the proximal
then placed through a range of motion at least 10 times, the pole of the patella.
grafts are stressed, and then the tightening sequence is
repeated. This is done at least 2 additional times, effectively
eliminating the creep from the graft until desired tension and by 4 double whipstitch passes back toward the end of the graft.
stability are achieved. Each free end of fibertape is passed through a hole in the sus-
pensory fixation button and the needles are removed from the
ACL fiberloops, which are left long to be incorporated in the final
Our preferred ACL reconstruction technique combines implanted construct. The graft is retensioned in the graft station
cortical suspensory fixation, suture tape (Fibertape; Arthrex) and tubularized, internalizing the fibertape, using 2-0 chromic
internal bracing in a load sharing application, and a quad- suture in a simple continuous pattern such that the final construct
riceps tendon autograft or allograft that is all-soft-tissue soft has diameter of 9 to 11 mm and a length of 65 to 70 mm (Fig. 5).
tissue. This technique was developed and validated in pre-
clinical animal model studies21–23 to assess the safety and
efficacy of suture tape augmentation.24 Advantages of our
preferred technique include a graft source with minimal
morbidity from harvest when using autograft, a large graft
cross-sectional area, collagen fiber characteristics, synthetic
augmentation for desirable material properties, improved
graft to bone integration, capabilities for sequential tensioning
of the graft to gain stability and relative ease of graft
implantation by eliminating difficulties associated with plac-
ing large bone blocks into femora and/or tibial tunnels.
For autograft harvest, a 3 to 4 cm incision is made over the
anterior leg ending ∼2 cm proximal to the insertion of the
quadriceps tendon into the proximal pole of the patella (Fig. 3).
A #10 blade or an 11 mm graft knife (Arthrex) is used to harvest
a quadriceps tendon graft (Fig. 4) that is 70 to 75 mm in length.
The graft is then prepared on a graft preparation station for
cortical button suspensory fixation (Tightrope; Arthrex) on both
ends. Collagen coated fibertape (2 mm×7 inches; Arthrex) is
looped through each tightrope with the free ends secured in
opposite ends of the graft station so that loop-to-loop length is 65
to 70 mm (based on patient size). The quadriceps tendon graft is
trimmed to match this length with a width of 10 to 12 mm. A #2
fiberloop is placed through the tightrope suture loop and then
through the fibertape and respective end of the graft, such that
the graft is attached to the fibertape and tightropes under tension.
The free ends of the fibertape are not incorporated in the fiber-
loop suture. The fiberloop is then passed through graft and FIGURE 4. A 70 to 75 mm in length quadriceps tendon harvested
fibertape 3 more times away from each end of the graft, followed using a #10 blade or 11 mm graft knife.

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Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
FIGURE 5. Anterior cruciate ligament allograft prepared using
cortical suspensory fixation with a suture tape internal brace and
tubularized using 2-O chromic suture. Final graft has diameter of
9 to 11 mm and length of 65 to 70 mm.
ACL socket preparation is completed using a femoral
guide and drilling an adjustable flip reamer from “inside
out”. The femoral socket is drilled to a depth of 25 mm if the
anatomy allows. A passing suture is passed through the
socket to aid in graft docking. The process is repeated with a
tibial guide placed in the middle of the insertion footprint,
aligned with the anterior horn of the lateral meniscus, to
create a tibial socket to a depth of 30 mm if the anatomy
allows. The graft is then pulled into the knee and into the
femoral socket with the cortical suspensory button being
FIGURE 6. Anterior cruciate ligament reconstruction using cortical suspensory fixation with a suture tape internal bracing load sharing
application and an all-soft-tissue autograft or allograft. Produced with permission from The Curators of the University of Missouri
(Copyright 2019 by The Curators of the University of Missouri).
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Surgical Treatment of Combined ACL, PCL
flipped on the lateral femoral cortex. The tibial end is pulled
into the tibial socket with the cortical button flipped on the
tibial cortex. At least 15 mm of the graft should be pulled
into each socket. The knee is then placed in full extension
and the graft is tensioned. After tensioning, the knee is
placed through a range of motion multiple times to elimi-
nate creep, stressed, and then retensioned until desired ten-
sion and stability are achieved (Fig. 6).
PLC
When evaluating the PLC, it is critical to determine if
the injury is primarily instability of the LCL or if it also
involves rotatory instability and an injury to the popliteus
muscle. The key physical examination maneuver used to
determine the presence and degree of rotatory instability is
the dial test. If there is an asymmetry on the dial test that is
> 5 mm, the test is considered positive and treatment must
address both varus instability and rotatory instability. There
are a number of anatomic reconstructions described in the
literature that can be used to reconstruct the popliteus,
popliteofibular ligament, and the LCL.25
Graft preparation for the PLC involves 1 graft if the
dial test is normal and 2 grafts if the patient has rotatory
instability. The grafts are created on a graft preparation
station. The graft for the LCL is prepared using an anterior
tibialis or semitendinosus tendon allograft that is at least
6.5 mm in width and 215 mm in length. Fibertape (2 mm×36
inches) is placed in the graft preparation station under ten-
sion. The allograft tendon is sutured to one end of the
fibertape using #0 fiberwire in a Ford interlocking pattern
over 15 mm. The allograft is then tensioned, measured, and
cut to 210 to 220 mm length (based on patient size) and
www.sportsmedarthro.com | 97
Stannard et al
FIGURE 7. Posterior lateral corner reconstruction of lateral col-
lateral ligament and popliteus tendon using cortical suspensory
fixation with a suture tape internal bracing load sharing applica-
tion and all-soft-tissue allograft. Reproduced with permission from
The Curators of the University of Missouri (Copyright 2019 by The
Curators of the University of Missouri).
sutured to the opposite end of the fibertape in the same
manner. Then, 3 mattress sutures of #0 fiberwire are placed
to secure the graft to the fibertape at equal intervals along its
length. The graft for the popliteus tendon is prepared using a
semitendinosus or anterior tibialis tendon allograft that is
5.5 to 7 mm in width and at least 170 mm in length. #2
fiberloops are used to place double whipstitch sutures over
15 mm at each end of the graft. (Fig. 7).
LCL and Popliteofibular Ligament
Our preferred technique for reconstruction of the LCL
and popliteofibular ligament involves the identification of
the isometric point on the lateral femoral condyle.26 The
isometric point is located at the intersection of a line from
the anterior portion of the posterior femoral condyle and
Blumensaat’s line. A spade tipped guide wire is drilled from
that point toward the medial femoral diaphysis aimed ∼30
degrees proximally and 30 degrees anteriorly. A socket is
drilled to a depth of at least 50 mm. A 3.2 mm drill bit is
used to drill across the proximal aspect of the fibula from
AL to PM. A guide wire is placed in the hole and sequential
reaming is performed over the guide wire to achieve a final
tunnel diameter of 7 mm. A Hewson suture passer is used to
pull the allograft into the fibular tunnel to its midpoint. The
end of the graft exiting the AL aspect of the fibula is used to
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Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
reconstruct the LCL. The end of the graft exiting the PM
aspect of the fibula is used to reconstruct the popliteofibular
ligament. Each end of the graft is passed deep to the soft
tissues and the 2 limbs and fibertape ends are passed through
the suture loop of cortical button suspensory fixation device
(Tightrope; Arthrex) and sutured together (final dia-
meter = 8.5 to 9.5 mm) using a #2 fiberloop. The graft is
then pulled into the femoral socket and the cortical button is
flipped on the medial femoral condyle. The lateral com-
partment is reduced and the suspensory fixation is tightened.
The knee is then placed through a range of motion and the
graft is stressed to remove creep that might lead to laxity in
the reconstruction. The graft is then tensioned again. The
process of knee motion and stressing the graft with repeat
tightening is performed 2 to 3 additional times.
If the patient has rotatory instability of the PLC, a
separate popliteus reconstruction is performed before
tightening the LCL graft. To do this, a Kelly clamp or
hemostat is used to dissect around the head of the fibula
proximally to expose the posterolateral proximal tibia.
A finger is placed on the tibia where the popliteus tendon is
located, and a 3.2 mm drill bit is used to drill through a stab
incision from anterior to posterior aiming for the finger. The
finger is withdrawn when the drill bit hits the posterior
cortex to avoid injury, and the drill then penetrates the
posterior cortex. This technique is very accurate and is our
preferred method. An alternate technique is to use a liga-
ment guide. Following this step, a guide pin is inserted by
hand and a 6 mm cannulated reamer is used to drill a tunnel
from anterior to posterior over the guide wire. This tunnel is
then tapped to 7 mm. A Hewson suture passer is used to pull
the allograft into the tunnel from posterior to anterior.
The next step is to identify the insertion point of the
popliteus tendon on the lateral femur at the proximal end of the
popliteus hiatus. This point is normally 18 to 20 mm anterior to
the isometric point that has already been identified. A guide pin
is drilled into the femur at this point and a 6 mm cannulated
reamer is used to create a socket to a depth of at least 21 mm.
A 5.5-mm swivel lock screw (Arthrex) is used to secure the
allograft into this socket. At this point the popliteus graft is
tensioned from the anterior tibia with the knee flexed 20 to 30
degrees and a 7 mm interference screw is inserted to secure the
graft. It is very important not to internally rotate the leg while
tensioning the graft or the knee may be over-constrained.
CONCLUSIONS
Treatment of patients with a KD IIIL dislocation is a
challenge that requires reconstruction of the ACL, PCL, and
PLC. It is critical to identify the full scope of the injury (vas-
cular, neurological, articular cartilage, meniscus, and ligament)
before developing a treatment plan. Excellent results can be
obtained using the anatomic reconstructions described above,
with failure rates of the PCL between 4% and 8%16–18,20 and of
the PLC between 7% and 9%.9,11,12 Tunnel crowding is an
issue that must be considered and addressed with careful
placement of tunnels and sockets to avoid convergence. Sus-
pensory fixation provides superior fixation regardless of bone
quality and allows 4 zone healing of the ligament to bone in
animal models.8 It also allows repeat tensioning after placing
the knee through multiple ranges of motion and graft stressing
manipulations, eliminating creep that can cause ligament lax-
ity. Finally, the addition of suture tape augmentation for load
sharing “internal bracing” of grafts provides additional pro-
tection to the reconstructions during the crucial graft
Sports Med Arthrosc Rev  Volume 28, Number 3, September 2020
incorporation and remodeling phases of healing while allowing
more aggressive rehabilitation protocols to minimize arthro-
fibrosis and optimize functional outcomes.19,20,22,24 The
application of these principles to KD IIIL KD patients can
yield a stable knee with outstanding function despite the
severity of the original injury.
ACKNOWLEDGEMENTS
The authors thank Stacy Cheavens, MS, CMI, Certified
Medical Illustrator, for the illustrations used in this article.
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