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WORST CASE SCENARIO
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Magnetic Resonance Imaging (MRI) was consistent with complete disruptions of the ACL, Posterior Cruciate Ligament (PCL), Fibular Collateral Ligament (FCL) and the posterolateral corner (PLC) structures (Fig. 4).
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The patient then returned to the operating room 48 hours later for compartment irrigation and debridement at which point it was noted that all the muscles in all four compartments were necrotic (Fig. 5).
Our recommendation given the patient’s age was to get control of the infected wounds with debridements and eventual coverage, regain range of the motion (ROM) of the knee, stabilize the knee with multi-ligament reconstruction and then perform a delayed below knee amputation (BKA). We felt this would give him better overall function compared to an above knee amputation (AKA).
It’s important to note that the increase in energy expenditure for an AKA is roughly 65%, whereas for a BKA it’s only 25%. This has significant long-term ramifications whereby the ability to ambulate will depend on the patients cardio- pulmonary health.
We successfully gained control of the soft tissues, and four months post injury we performed ACL / PCL / FCL and PLC reconstructions. For the ACL, we used a tibialis anterior allograft, single bundle, with suspensory fixation on the femur and interference screw fixation on the tibia. For the PCL, we used an Achilles tendon allograft, single bundle, transtibial technique. Extreme care was taken when drilling the tibial tunnel as the bypass graft was in close proximity (Fig. 6a). Final arthroscopic views of the ACL / PCL reconstruction are shown (Fig. 6b).
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For the FCL and PLC, we performed the “Anatomic Technique” described by Laprade et al, using a split Achilles tendon allograft. This procedure necessitates a tibial tunnel and caution must be used as the bypass graft can be injured during this step (Fig. 7a). Intra-operative photos of the graft construct are shown (Fig. 7b).
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ISAKOS NEWSLETTER 2015: Volume II 43