This case describes a 23-year-old male who was struck by a motor vehicle. Upon arrival at our hospital, the patient had a GCS of 8. FAST exam, chest radiograph, and computed topography (CT) of the head and cervical spine were obtained and were negative.
Exam of the lower extremities revealed abrasions over the left knee and tenderness over the lateral joint line with an effusion. The right knee was diffusely tender to palpation without effusion. The patient had palpable pulses in both feet with well-perfused extremities. Ankle brachial indices were performed and found to be >0.9. He demonstrated guarding and pain with the attempted Lachman maneuver of the left knee and slight opening of the left knee joint with varus stress. Radiographs were obtained and revealed a left knee Segond fracture (Figure 1).
Magnetic resonance imaging (MRI) of both knees was performed to evaluate for ligamentous injury. Left knee imaging demonstrated the Segond fracture along with a grade III lateral collateral ligament (LCL) tear with retraction (Figure 2), a grade II tear of the popliteus tendon and anterior cruciate ligament (ACL) (Figure 3), and a grade I medial collateral ligament (MCL) injury (Figure 4), as well as partial thickness tears of the biceps femoris and vastus medialis. Right knee imaging revealed a grade III tear of the ACL and MCL (Figure 5), grade II tears of the posterior cruciate ligament (PCL) (Figure 6), LCL, and popliteus tendon, and a medial meniscus tear. The patient was placed in bilateral hinged braces with the left knee unlocked and the right knee in locked extension to aid with transfers from a bed to a wheelchair. The patient was also given a left foot drop boot for a foot drop discovered during a secondary exam. On hospital day three, the patient was discharged home.
Nine days after the accident, the patient presented to the clinic. He noted that the left-sided foot drop was improving. On that side, he had 5/5 strength of his extensor hallucis longus and tibialis anterior (TA), without any sensory deficits in the peroneal nerve distributions. On the physical exam of the left knee, the Lachman maneuver was grade 2B (ACL injury with 5-10 mm translation without an endpoint), the varus stress test grade 3 (complete LCL tear with >10 mm opening of the lateral joint), and the valgus stress test grade 2 (MCL injury with 6-10 mm opening of the medial joint). The right lower extremity was also neurovascularly intact, and the right knee exam revealed a grade 2A Lachman maneuver (ACL injury with 5-10 mm translation and a firm endpoint), a grade 3 posterior drawer test (complete tear of PCL with >10 mm posterior tibial translation), and a grade 3 valgus stress test (MCL injury with 11-15 mm opening of the medial joint), with a presumptive positive dial maneuver on the right side at 30 and 90 degrees (consistent with PCL and posterolateral corner (PLC) injury). However, given that the patient had bilateral PLC injuries, this physical exam finding was somewhat subjective without a reference point on the contralateral side. Subtle gapping with varus stress was also documented.
Multiligamentous reconstructions of both knees were recommended (Table 1). The left knee was addressed first in order to explore and decompress the common peroneal nerve. In regard to the right knee, preoperative physical therapy was performed to restore range of motion (ROM) before undergoing surgery.
Intraoperative findings of the left knee included a positive lateral gutter drive-through sign indicative of a PLC injury. The LCL was avulsed off the fibula, and the anterior lateral ligament (ALL) was also avulsed off the tibia. A greater than 50% disruption of the ACL was observed. Exam under anesthesia demonstrated a grade 2A Lachman maneuver, a grade 2 pivot shift, grade 3 varus instability, and instability on external rotation. The procedure included ACL reconstruction with a hamstring autograft augmented with an allograft, PLC reconstruction utilizing a TA allograft, and repair of the native avulsed LCL and ALL with suture anchors (Figure 7). First, the hamstrings were harvested and augmented with an allograft, and the tunnels for the ACL reconstruction were drilled. The PLC was then reconstructed using the anatomic technique described by Malanga et al.. The native LCL was repaired using suture anchors with the overlying allograft reconstruction used to supplement it. The posterolateral capsule was then reefed into the LCL allograft reconstruction. Finally, the ACL graft was passed and fixed. Postoperatively, the patient was placed in a hinged brace locked in extension and was made toe-touch weight bearing.
The decision was made to proceed with the right knee reconstruction one week later. Exam under anesthesia revealed a grade 2A Lachman maneuver, grade 3 posterior drawer test, a grade 3 varus stress test, and a grade 2 valgus stress test. Surgery included ACL reconstruction with a bone-tendon-bone (BTB) autograft, PCL reconstruction with an Achilles allograft, MCL primary repair with additional Achilles allograft reconstruction, PLC reconstruction with TA allograft, and repair of the posterior horn of the medial meniscus (Figure 8). The lateral exposure for the PLC reconstruction was performed first, and the blind-ended sockets and fibular tunnel were drilled. An open approach to the MCL was then performed, and the injured MCL was found and tagged for later repair. The BTB autograft was then harvested for the ACL reconstruction. At this point, the posterior horn of the medial meniscus was confirmed to be torn from its root so this was repaired using sutures passed through a tibial tunnel. Guide pins were then passed for the ACL and PCL tunnels to ensure there was no convergence. Both tunnels were then reamed and the grafts passed. The PCL was fixed first while the leg was flexed, and the ACL was then fixed with the leg in extension. The MCL repair and reconstruction with an allograft were completed using the surgical technique described by Sekiya et al., followed by the PLC reconstruction which was carried out utilizing the same method noted previously. Postoperative immobilization and weight bearing status were the same as those in the contralateral side.
Range of motion and physical therapy rehabilitation began at 1 week postoperatively. Early exercises included isometric activities to strengthen the quadriceps and patella mobilization exercises. Both knees were kept in a brace locked in extension with minimal weight bearing the first six weeks following surgery. Six weeks after the initial reconstruction, the patient was instructed to begin weight bearing with crutch assistance, starting in extension and then unlocking the straight leg brace to 90  of flexion. At eight weeks post-op, the patient was transitioned out of knee braces and then given clearance to return to work ten weeks after surgery.
At six months post-op, the patient completed physical therapy. On the physical exam, the patient's knees demonstrated full ROM bilaterally with a grade 1A Lachman maneuver in both knees. The right knee also had a grade 2A posterior drawer test without sag. At that time, clearance was given to begin straight running. At one year post-op, the patient had returned to jogging and playing basketball recreationally and was able to participate in strenuous work (Table 2, Figure 9).