Nonoperative or Delayed Surgical Treatment of Combined Cruciate Ligaments and Medial Side Knee Injuries

The combination injury of anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament is a rare injury and occurs in less than 1% of all knee ligament injuries. Assessment of a patient with multiligamentous knee instability requires a high index of suspicion for a knee dislocation. Acute ligament surgery is not indicated and, if surgery is required, it can be performed on a semiacute (> 2+ posterior cruciate ligament laxity) or elective basis. A treatment approach is described here for dislocated knees that is based on the healing potential of each individual ligament structure. The medial collateral ligament can be allowed to heal in a 20° flexed cylinder cast with weekly assessment of clinical medial collateral ligament healing. The posterior cruciate ligament can heal and posterior laxity of 2+ or less may not need surgical treatment. If initial posterior cruciate ligament laxity is greater than 2+, then semiacute posterior cruciate ligament reconstruction may be needed. The knee should be fully rehabilitated once the medial collateral ligament and posterior cruciate ligament have healed, and the decision to reconstruct the anterior cruciate ligament can then be discussed with the patient depending on the patient's occupation, lifestyle, and sporting activities. This method of treatment of the patient with a posterior cruciate ligament/posterior cruciate ligament/medial collateral ligament–injured knee, in the authors' experience, has given patients a good result with predictable return to function.