Combined Anterior Cruciate Ligament, Medial Collateral Ligament, and Posterior Oblique Ligament Reconstruction Through Single Tibial Tunnel Using Hamstring Tendon Autografts

Posterior oblique ligament of the knee: state of the art

The posterior oblique ligament (POL) is the predominant ligamentous structure on the posterior medial corner of the knee joint. A thorough understanding of the anatomy, biomechanics, diagnosis, treatment and rehabilitation of POL injuries will aid orthopaedic surgeons in the management of these injuries.The resulting rotational instability, in addition to valgus laxity, may not be tolerated by athletes participating in pivoting sports. The most common mechanism of injury - accounting for 72% of cases - is related to sports activity, particularly football, basketball and skiing. Moreover, three different injury patterns have been reported: those associated with injury to the capsular arm of the semimembranosus (SM), those involving a complete peripheral meniscal detachment and those involving disruption of the SM and peripheral meniscal detachment.The hallmark of an injury related to POL lesions is the presence of anteromedial rotatory instability (AMRI), which is defined as 'external rotation with anterior subluxation of the medial tibial plateau relative to the distal femur'.In acute settings, POL lesions can be easily identified using coronal and axial magnetic resonance imaging (MRI) where the medial collateral ligament (MCL) and POL appear as separate structures. However, MRI is not sensitive in chronic cases.Surgical treatment of the medial side leads to satisfactory clinical results in a multi-ligamentous reconstruction scenario, but it is known to be associated with secondary stiffness.In young patients with high functional demands, return to sports is allowed no earlier than 9-12 months after they have undergone a thorough rehabilitation programme. Cite this article: EFORT Open Rev 2021;6:364-371. DOI: 10.1302/2058-5241.6.200127.

Controversies in acute multiligamentary knee injuries (MLKI)

Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.