Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
Outcomes After Single-Stage Anatomic
Multiligament Knee Reconstruction
With Early Range of Motion
in Adolescents
S. Clifton Willimon,
*
MD, Jason Kim,
*
BS, and Crystal A. Perkins,
*
y
MD
Investigation performed at Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
Background: Multiligament knee injuries (MLKI), rare in adolescents, are challenging injuries that require complex surgical recon-
struction. Historically, nonanatomic reconstructions have been associated with prolonged immobilization and failure to restore
normal knee biomechanics, resulting in arthrofibrosis and high rates of graft failure.
Purpose: To describe the clinical and patient-reported outcomes (PROs) for adolescent patients treated with single-stage ana-
tomic multiligament knee reconstruction.
Study Design: Case series; Level of evidence, 4.
Methods: A single-center retrospective study was performed of patients 18 years old who underwent reconstruction of MLKIs
by a single surgeon between 2014 and 2019 using a single-stage anatomic technique, with protected weightbearing and early
range of motion. Complications were defined as infection, arthrofibrosis, deep vein thrombosis (DVT) or pulmonary embolus,
and secondary surgery. PROs, including the pediatric version of the International Knee Documentation Committee (Pedi-IKDC)
and the Tegner activity score, were obtained at a minimum of 2 years postoperatively.
Results: Included were 30 patients (21 male, 9 female; mean age, 15.4 years). The most common ligamentous reconstruction
types were anterior cruciate ligament (ACL) 1fibular collateral ligament (12 patients; 40%) and ACL 1medial collateral ligament
(9 patients; 30%). Three patients (10%) had secondary surgeries, including irrigation and debridement of a granuloma, a staged
osteochondral allograft transplantation to a lateral femoral condyle impaction fracture, and repair of a medial meniscal tear and
lateral femoral condyle fracture associated with new injuries 2 years after ACL 1fibular collateral ligament reconstruction. Two
patients (7%) developed arthrofibrosis and 1 patient (3%) developed DVT. PRO scores obtained at a mean of 37 months post-
operatively included a mean Pedi-IKDC of 87 (range, 52-92) and a median highest Tegner score at any point postoperatively of 9
(range, 5-10). Of the patients who were athletes before their injury, 70% returned to the same or higher level of sport
postoperatively.
Conclusion: Reconstruction of MLKI in this series of adolescents with single-stage anatomic techniques and early range of
motion resulted in low rates of secondary surgery, few complications, and good knee function as well as PRO scores at mean
3-year follow-up.
Keywords: multiligament knee injury; multiligament knee reconstruction; adolescent; anterior cruciate ligament; medial collateral
ligament; fibular collateral ligament; posterolateral corner; outcomes; adolescent
Multiligament knee injuries (MLKI) in adolescents are
challenging injuries that require complex surgical recon-
struction and lengthy rehabilitation. The complexity of lat-
eral and medial knee anatomy and injury patterns has
resulted in a multitude of described reconstruction techni-
ques. Historically, nonanatomic reconstructions and cruci-
ate and collateral repairs as the treatment of MLKI have
resulted in failure to restore normal knee biomechanics
and high rates of graft failure.
24,29
These reconstructions
have also been associated with the need for prolonged
immobilization protocols that increase rates of arthrofibro-
sis.
21,22
Thus, single-stage anatomic reconstructions are
preferred to allow for early range of motion (ROM), lower
The Orthopaedic Journal of Sports Medicine, 12(6), 23259671241252870
DOI: 10.1177/23259671241252870
ÓThe Author(s) 2024
1
This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (https://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are
credited. You may not alter, transform, or build upon this article without the permission of the Author(s). For article reuse guidelines, please visit SAGE’s website at
http://www.sagepub.com/journals-permissions.
Original Research
rates of graft failure, relatively shorter recoveries, and
superior outcomes.
13,15,21
Compared to isolated anterior cruciate ligament (ACL)
injuries, MLKIs account for a smaller proportion of acute
knee injuries, particularly among adolescents.
1
Conse-
quently, outcome studies of multiligament reconstruction
in this population are limited.
8
The purpose of this study
was to describe the clinical outcomes and patient-reported
outcomes (PROs) of adolescent patients treated with
single-stage anatomic multiligament knee reconstruction.
METHODS
An institutional review board-approved, single-center ret-
rospective review was performed of consecutive patients
18 years old who underwent multiligament knee recon-
struction by a single surgeon using a single-stage anatomic
technique between January 2014 and December 2019, with
protected weightbearing and early ROM protocol. Multili-
gament reconstruction was defined as treatment of a combi-
nation of 2 or more of the following: ACL; posterior cruciate
ligament (PCL); medial collateral ligament (MCL); and fib-
ular collateral ligament (FCL). Depending on the injury
pattern and severity of the lateral knee injury, some or
all of the components of the posterolateral corner (PLC),
including the popliteus tendon and popliteofibular liga-
ment (PFL), were addressed. Patients with \24 months
of follow-up were excluded. Additional exclusion criteria
were staged surgery with the index surgery performed out-
side of the study institution, underlying metabolic bone
disease or connective tissue disorder, and incarcerated
patients.
Physical examination,
3
magnetic resonance imaging,
6
and validated stress radiographs
12,14
were utilized for
diagnosis and to guide treatment. Formal physical therapy
and home exercises to achieve terminal knee extension,
flexion, and quadriceps function were performed before
surgery. Achieving normal or near-normal knee ROM
was a prerequisite before proceeding with ligamentous
reconstruction. Modifications were made to avoid valgus
and varus stress in MCL and FCL injuries, respectively,
and to include the use of prone knee flexion in patients
with PCL injuries to avoid posterior tibial sag. Patients
with MLKI that included MCL injury were typically treated
with an initial 4 to 6 weeks in a hinged knee brace after
injury to allow for early protected ROM to minimize the
risk of postoperative arthrofibrosis. Similarly, PCL injuries
were treated in a dynamic PCL-specific brace for 4 to 6 weeks
after injury. Again, this bracing occurred concomitantly with
physical therapy to restore knee motion. In these patients,
valgus and PCL stress radiographs were repeated after
a period of 4 to 6 weeks of bracing and physical therapy to
assess for residual laxity and need for reconstruction.
The indication for FCL reconstruction was a side-to-side
difference of 2.2 mm on varus stress radiographs, while
a difference of 4 mm indicated a need for PLC reconstruc-
tions including FCL, popliteus, and PFL componenets.
10,14
Valgus stress radiographs with a side-to-side difference of
3.2 to 9.8 mm indicated a complete superficial MCL tear,
while a difference of .9.8 mm indicated a complete tear
of all medial knee structures and the need for MCL and
posterior oblique ligament reconstructions.
12
Indications
for PCL reconstruction included 8 to 11 mm of side-to-
side increased posterior translation on stress radiographs.
9
Surgical Technique
Graft options for adolescent multiligament knee recon-
structions are numerous. Our preference for grafts is as
follows: ACL reconstruction with quadriceps tendon or
bone–patellar tendon–bone autograft; double-bundle PCL
reconstruction with Achilles allograft with calcaneus bone
block for the anterolateral bundle and tibialis posterior allo-
graft for the posteromedial bundle; isolated FCL reconstruc-
tion with semitendinosus autograft; full PLC reconstruction
with a split Achilles allograft with calcaneus bone blocks for
both the FCL-PFL and popliteus; and MCL reconstruction
with semitendinosus autograft or allograft.
Reconstruction of the posterolateral corner was per-
formed as described in detail by Serra Cruz et al
27
and
included peroneal nerve neurolysis in all patients. In
patients with MLKI with a medial knee injury component
that failed to improve with bracing and had increased val-
gus laxity at 20°of flexion, augmented repair was performed
utilizing a semitendinosus autograft with suture anchor or
socket fixation at the tibial and femoral attachments.
31
For those medial knee injuries with increased valgus laxity
in both flexion and full extension, anatomic MCL and poste-
rior oblique ligament reconstruction was performed.
5
This
technique utilizes 2 grafts, 4 separate closed-socket tunnels,
and suture anchors to restore the proximal attachment of
the superficial MCL. Double-bundle PCL reconstruction
was performed, as published by Chahla et al,
4
and utilized
a single transtibial tunnel and 2 sockets in the center of
the anterolateral and posteromedial bundle footprints.
Postoperative Protocol
Postoperative weightbearing was guided by the concomi-
tant meniscal and chondral procedures performed in
y
Address correspondence to Crystal A. Perkins, MD, Children’s Healthcare of Atlanta, 5445 Meridian Mark Road, Suite 250, Atlanta, GA 30342, USA
(email: crystalperkins11@gmail.com) (Twitter/X: @crystal_perkins).
*
Children’s Healthcare of Atlanta, Atlanta, Georgia, USA.
Final revision submitted November 16, 2023; accepted November 21, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: S.C.W. has received education payments from
Arthrex and United Orthopedics; nonconsulting fees from Arthrex, Smith+Nephew, and United Orthopedics; and consulting fees from Smith+Nephew and
Vericel. C.A.P. has received education payments from United Orthopedics and hospitality payments from Smith+Nephew. AOSSM checks author disclo-
sures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or
responsibility relating thereto.
Ethical approval for this study was obtained from Children’s Healthcare of Atlanta (ref No. STUDY00000803).
2Willimon et al The Orthopaedic Journal of Sports Medicine
addition to multiligament knee reconstruction, typically
including touch-down weightbearing for 6 weeks in
a hinged knee brace locked in extension, 50% weightbear-
ing for week 7, 1 crutch for week 8, and then weightbearing
as tolerated. The brace was unlocked to work on early
ROM: 0°to 90°for the first 4 weeks, with progression as
tolerated. If PCL reconstruction was performed, prone
ROM, or supine ROM in a dynamic PCL brace, was then
performed to prevent posterior tibial sag and potential
stretch of the PCL grafts in the early postoperative
period.
19
Aspirin 81 mg twice daily was used for deep
vein thrombosis (DVT) prophylaxis in postpubescent
patients for 4 weeks postoperatively, at which point
patients were typically highly mobile and had returned
to school.
A standard structured rehabilitation protocol beginning
2 to 3 days postoperatively was utilized and included ROM,
progressive strengthening, proprioception, and ultimately
endurance. A running progression was typically initiated
at around month 4, with side-to-side motions limited until
6 months. Functional testing guided the initiation of
a return-to-play progression, with full return to play no
sooner than 9 months for ACL 1collateral ligament
reconstruction and 12 months for knee dislocations requir-
ing bicruciate 6collateral ligament reconstruction.
Data Collection
Patient demographics, mechanism of injury, ligamentous
injury patterns, surgical treatment, outcomes, and compli-
cations were gathered from chart review. Complications
were defined as infection, arthrofibrosis, DVT or pulmo-
nary embolus (PE), and secondary surgery. Arthrofibrosis
was defined as the lack of 10°of flexion compared with
the contralateral knee and inability to achieve 0°of exten-
sion. PROs, including the pediatric version of the Interna-
tional Knee Documentation Committee (Pedi-IKDC) and
the Tegner activity score, were obtained via telephone
call a minimum of 2 years postoperatively.
RESULTS
A total of 39 patients met the inclusion criteria, 9 of whom
were excluded for the following reasons: \24 months of
follow-up (n = 5); staged surgery with index procedure per-
formed outside of the study institution (n = 2); metabolic
bone disease (n = 1); and patient incarcerated (n = 1).
Among the final cohort of 30 patients, the mean age was
15.4 61.6 years old (range, 12-18 years old), and the
mean body mass index was 24.9 65.2 kg/m
2
(range,
17.9-41.6 kg/m
2
). There were 21 (70%) male patients and
9 (30%) female patients. Six patients (20%) had open
physes, all of whom had less than 2 years of growth
remaining as calculated by hand bone age. The most com-
mon mechanism of injury was team sports (24 patients;
80%), followed by injuries secondary to a trampoline (2
patients; 7%), fall (1 patients; 3%), gymnastics (1 patient;
3%), wrestling (1 patient; 3%), and dirt bike crash (1
patient; 3%). Six patients (15%) sustained a knee disloca-
tion. Ligamentous reconstruction patterns are listed in
Table 1. All patients underwent a single surgery for their
multiligament reconstruction, and the median time from
injury to surgery was 56 days (range, 9-146 days).
One patient, a 16-year-old boy with a traumatic knee
dislocation and ACL, PCL, and posterolateral corner
injury, had a concomitant complete peroneal nerve palsy
at the time of injury. There were no acute vascular inju-
ries. A total of 12 (40%) patients had a meniscus injury
requiring treatment at the time of ligamentous reconstruc-
tion, with 7 of these patients treated with meniscus repair.
Of these 12 patients, 8 patients had a lateral meniscal tear
(including 1 posterior root avulsion and 1 complete radial
tear), 1 patient had a medial meniscal posterior root tear,
and 3 patients had combined medial and lateral meniscal
tears.
There was 1 intraoperative complication, which was
a sidewall injury to the peroneal vein in an 18-year-old
male patient who underwent ACL, FCL, and PLC recon-
structions. This was treated with peroneal vein ligation
after consultation with vascular surgery. The patient had
no postoperative sequelae related to this.
Patient-Reported Outcome Scores
PRO scores were obtained in all patients at a mean of 37
months postoperatively (range, 24-81 months). The mean
Pedi-IKDC score was 87 68.9 (range, 52-92). The median
preinjury Tegner score was 9 (range, 3-9), the median
highest Tegner score at any point after surgery was 9
(range, 5-10), and the median Tegner score at final
follow-up was 7 (range, 4-10). With the exception of 3
patients who were not involved in athletics before their
injury, all patients returned to sports. Of the 27 patients
who returned to sports, 19 (70%) returned to the same level
or higher. Of the 8 patients who did not return to the same
level of sport, 6 (75%) completed high school in the year
after their injury and had not intended to play collegiate
sports. One patient, a 14-year-old gymnast at the time of
TABLE 1
Patients According to Ligamentous
Reconstruction Type (N = 30 Patients)
a
Reconstruction Type n
ACL 1MCL 9
ACL 1FCL 12
ACL 1FCL 1POP 1PFL 3
ACL 1MCL 1FCL 1
b
ACL 1PCL 1MCL 1
b
ACL 1PCL 1FCL 1
b
PCL 1FCL 1POP 1PFL 2
b
ACL 1PCL 1MCL 1FCL 1POP 1PFL 1
b
a
ACL, anterior cruciate ligament; FCL, fibular collateral liga-
ment; MCL, medial collateral ligament; PCL, posterior cruciate
ligament; PFL, popliteofibular ligament; POP, popliteus tendon.
b
Knee dislocation.
The Orthopaedic Journal of Sports Medicine Adolescent Multiligament Knee Reconstruction 3
her ACL-MCL injury, elected not to pursue gymnastics
after missing a year at the elite level and transitioned to
track and cheer. The final was the 14-year-old male patient
previously described with an ACL graft tear who transi-
tioned from competitive to recreational basketball.
Complications
There were 5 secondary surgeries among 3 patients. One
patient, a 14-year-old boy who underwent ACL and FCL
reconstructions with lateral capsular repair, developed
a granuloma over the medial proximal tibial incision 3
months postoperatively that did not heal with local wound
care. He had an irrigation and debridement, removal of the
ACL tibial fixation, and revision wound closure 7 months
postoperatively. This same patient sustained a new injury
playing basketball 20 months after his index procedure
and represented the single patient (3%) with graft injury.
He was treated with revision ACL reconstruction. A second
patient, a 15-year-old boy, sustained a large depressed lat-
eral femoral condyle impaction fracture in association with
ACL and MCL injuries. He was treated with a planned
staged 20-mm osteochondral allograft transplantation 6
months after multiligament reconstruction. The third
patient was a 13-year-old girl with ACL and FCL recon-
structions who sustained a new injury and bucket-handle
medial meniscal tear while playing basketball 22 months
after her index surgery and was treated with medial
meniscus repair. She returned to sports after her meniscus
repair and then had a subsequent injury with resultant
coronal plane fracture of the lateral femoral condyle trea-
ted with open reduction and internal fixation 7 months
later. She was found to be vitamin D deficient with
a 25(OH)-vitamin D level of 14 ng/mL at the time of her
fracture. Her vitamin D was supplemented to achieve nor-
mal levels, her fracture healed, and she had returned to
full sports at the most recent follow-up 4 years after her
multiligament knee reconstruction.
Arthrofibrosis was identified in 2 (7%) patients over the
course of a 16-month clinical follow-up. First was the 16-
year-old male patient with a concomitant peroneal nerve
injury whose final terminal flexion was 120°compared to
135°on the contralateral knee. This patient was offered
arthroscopic lysis of adhesions and manipulation but
declined further treatment, having returned to basketball
without functional limitations. Second was a 17-year-old
male patient who underwent ACL-PLC reconstruction
and was lacking 3°of terminal extension but had full
knee flexion. He was not an athlete, did not feel that he
had functional limitations, and did not want to pursue
any additional treatment. No patients required manipula-
tion under anesthesia or lysis of adhesions. One patient
developed a popliteal vein DVT postoperatively and was
treated uneventfully with enoxaparin. There were no
PEs. The single patient with the complete peroneal nerve
palsy initially used an ankle-foot orthosis postoperatively.
He ultimately had partial nerve recovery (4/5 strength
with testing of the extensor hallucis longus and extensor
digitorum longus in toes 2-4, intact but diminished
sensation to light touch in the first web space and dorsum
of the foot) at the time of the final follow-up of 34 months.
He returned to playing basketball recreationally and elec-
ted not to use any orthosis as he had adequate dorsiflexion
strength. No patient was noted to have cruciate nor collat-
eral graft laxity at the time of final clinical examination at
a mean of 16 months postoperatively.
DISCUSSION
Multiligament knee reconstruction in this series of adoles-
cents with single-stage anatomic techniques and early
ROM resulted in low rates of secondary surgery, few com-
plications, and good knee function and PROs at an average
follow-up of 3 years. Despite the severity of MLKI and high
rates of reported complications, the positive outcomes iden-
tified in this adolescent population further validate find-
ings by other authors that younger patients experience
superior outcomes compared to older adults.
8,23
Godin
et al
8
described 20 adolescents with MLKI treated with
single-stage anatomic reconstruction, highlighting signifi-
cant improvements in PROs from pre- to postoperatively
and excellent satisfaction. Furthermore, Levy et al,
23
in
a series of 125 MLKI treated with reconstruction, identi-
fied age \30 years as an independent predictor of
improved IKDC and Lysholm scores. The majority of
patients in the current series, in addition to these prior
studies, were 2-ligamentous injuries, which may have
influenced the superior outcomes compared with patients
with knee dislocations.
Anatomic multiligament knee reconstruction techni-
ques allow for reproduction of native knee biomechanics
as well as for early knee ROM without compromising graft
integrity.
11,16,20
All patients in this series were treated
with biomechanically validated reconstruction techni-
ques.
16,20,28
Early knee ROM with these techniques has
proven to decrease rates of arthrofibrosis and subsequent
surgery,
7,13,25
a finding confirmed by this current study
in adolescents. The biomechanical function of the cruciate
and collateral ligaments is interconnected, and their integ-
rity is critical for optimal knee function.
17,18,26,30
Staged
ligament surgery not only increases the number of anes-
thetic exposures and lengthens the patient’s postoperative
rehabilitation but also risks the reconstructed grafts
stretching out due to nonphysiologic loading in the absence
of secondary stabilizers. An additional benefit of a single-
stage reconstructive procedure unique to adolescents is
the reduced impact on time away from school.
Primary ligament repair is a treatment option that
should be reserved for very select injuries, most notably
acute avulsion injuries within the first 3 weeks after
injury.
7
In the pediatric population, repair may be consid-
ered for acute bony avulsions without midsubstance tear-
ing or attenuation. Otherwise, numerous studies have
illustrated inferior repair outcomes compared to recon-
struction, particularly of the posterolateral corner, as it
is less likely to restore native knee stability and results
in higher rates of failure.
2,7,15,21,31
4Willimon et al The Orthopaedic Journal of Sports Medicine
Historically, early surgical treatment has been shown to
result in higher outcome scores and sports activity scores
compared to delayed treatment.
22
Multiple factors, how-
ever, can impact surgical timing, including concomitant
neurovascular injuries, avulsion injuries amenable to early
repair, and MCL and PCL injuries treated with an initial
phase of bracing. In reality, the authors feel that performing
a single-stage anatomic reconstruction after achieving near
normal preoperative ROM, as was done in this case series at
a median of 8 weeks, is likely more critical to optimal out-
comes than reconstruction within a specific timeframe.
The rate of arthrofibrosis after MLKI reconstruction in
adolescents was found to be 3% in this series, which is
lower than has been reported for MLKI in adult popula-
tions.
13
We believe the greatest contributors to this low
rate is achieving normal or near normal preoperative
motion; anatomic reconstructions to permit early postoper-
ative ROM; use of physical therapists experienced in
achieving early motion, motivated athletic patients; and
patient and family education on the importance of early
terminal knee extension and progressive flexion.
All patients in this series who had FCL reconstruction,
with or without PLC reconstruction, underwent peroneal
nerve neurolysis. This is a critical initial step in posterolat-
eral reconstruction and is done to allow for safe drilling of
an anatomic FCL tunnel in the fibula and minimize the
risk of peroneal nerve neurapraxia postoperatively. The
neurolysis extends from posteromedial to the long head
of biceps proximally to the peroneal fascia distally, extend-
ing a few millimeters into the peroneal fascia to avoid com-
pression of the nerve at this level in the setting of
postoperative swelling. In patients with a preoperative
peroneal nerve palsy, including 1 patient in this series,
and significant posterolateral corner injury, the peroneal
nerve is typically in continuity but can be significantly
enlarged and encased in adhesions. In these patients,
meticulous peroneal nerve neurolysis and decompression
can be followed by a nerve wrap to prevent further adhe-
sions and compression. Aside from the single patient
with a preoperative peroneal nerve palsy, no patient in
this series with FCL and PLC reconstruction developed
a postoperative peroneal nerve palsy.
In those patients with a peroneal nerve palsy, serial
examinations should be performed to monitor for changes
in motor and sensory function. The most distal extent of
a Tinel’s sign over the peroneal nerve can be monitored
in reference to the distance from the fibular head to gauge
nerve recovery. In the absence of nerve recovery, an elec-
tromyography and nerve conduction study can be per-
formed to assess for signs of electrical response. Patients
should be encouraged to perform stretching of the gastro-
csoleus complex to prevent an equinus contracture, and
the use of an ankle-foot orthosis aids in ambulation.
Limitations
This study is not without limitations. Compared to isolated
ACL reconstruction, MLKI occurs at a significantly lower
frequency. As a result, the study cohort was relatively
small and injury patterns were diverse. This is, however,
a larger series compared to the only previously published
isolated adolescent cohort.
8
No preinjury PROs, aside
from self-reported Tegner score before injury, were avail-
able on the patient population, and therefore, changes in
preinjury to postinjury knee function could not be deter-
mined. Postoperative stress radiographs and instrumented
knee laxity were not routinely obtained, and assessment of
postoperative knee stability was therefore based on the
physician’s clinical exam. Radiographs were routinely
obtained 2 to 3 weeks and 1 year postoperatively in skele-
tally immature patients, but they were not routinely
repeated unless there was clinical concern for new injury.
Thus, this study was not designed to assess for radiographic
changes of arthritis, and longer-term follow-up is necessary
to determine whether this finding in select adults after
MLKI occurs similarly in the adolescent population.
CONCLUSION
Reconstruction of MLKI in this series of adolescents with
single-stage anatomic techniques and early ROM resulted
in low rates of secondary surgery, few complications, and
good knee function and PROs at average 3-year follow-up.
ORCID iD
Crystal A. Perkins https://orcid.org/0000-0003-4599-6844
REFERENCES
1. Arom GA, Yeranosian MG, Petrigliano FA, Terrell RD, McAllister DR.
The changing demographics of knee dislocation: a retrospective
database review. Clin Orthop Relat Res. 2014;472(9):2609-2614.
2. Black BS, Stannard JP. Repair versus reconstruction in acute pos-
terolateral instability of the knee. Sports Med Arthrosc Rev.
2015;23(1):22-26.
3. Bronstein RD, Schaffer JC. Physical examination of knee ligament
injuries. J Am Acad Orthop Surg. 2017;25(4):280-287.
4. Chahla J, Nitri M, Civitarese D, et al. Anatomic double-bundle poste-
rior cruciate ligament reconstruction. Arthrosc Tech. 2016;5(1):e149-
e156.
5. Coobs BR, Wijdicks CA, Armitage BM, et al. An in vitro analysis of an
anatomical medial knee reconstruction. Am J Sports Med.
2010;38(2):339-347.
6. Geeslin AG, Geeslin MG, LaPrade RF. Ligamentous reconstruction of
the knee: what orthopaedic surgeons want radiologists to know.
Semin Musculoskelet Radiol. 2017;21(2):75-88.
7. Geeslin AG, LaPrade RF. Outcomes of treatment of acute grade-III
isolated and combined posterolateral knee injuries: a prospective
case series and surgical technique. J Bone Joint Surg Am.
2011;93(18):1672-1683.
8. Godin JA, Cinque ME, Pogorzelski J, et al. Multiligament knee injuries
in older adolescents: a 2-year minimum follow-up study. Orthop J
Sports Med. 2017;5(9):2325967117727717.
9. Jackman T, LaPrade RF, Pontinen T, Lender PA. Intraobserver and
interobserver reliability of the kneeling technique of stress radiogra-
phy for the evaluation of posterior knee laxity. Am J Sports Med.
2008;36(8):1571-1576.
10. Kane PW, Cinque ME, Moatshe G, et al. Fibular collateral ligament:
varus stress radiographic analysis using 3 different clinical techni-
ques. Orthop J Sports Med. 2018;6(5):2325967118770170.
The Orthopaedic Journal of Sports Medicine Adolescent Multiligament Knee Reconstruction 5
11. Kennedy NI, LaPrade RF, Goldsmith MT, et al. Posterior cruciate lig-
ament graft fixation angles, part 2: biomechanical evaluation for ana-
tomic double-bundle reconstruction. Am J Sports Med. 2014;
42(10):2346-2355.
12. Laprade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA.
Correlation of valgus stress radiographs with medial knee ligament
injuries: an in vitro biomechanical study. Am J Sports Med. 2010;
38(2):330-338.
13. LaPrade RF, Chahla J, DePhillipo NN, et al. Single-stage multiple-
ligament knee reconstructions for sports-related injuries: outcomes
in 194 patients. Am J Sports Med. 2019;47(11):2563-2571.
14. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. The reproducibility
and repeatability of varus stress radiographs in the assessment of
isolated fibular collateral ligament and grade-III posterolateral knee
injuries. An in vitro biomechanical study. J Bone Joint Surg Am.
2008;90(10):2069-2076.
15. LaPrade RF, Johansen S, Agel J, et al. Outcomes of an anatomic
posterolateral knee reconstruction. J Bone Joint Surg Am. 2010;
92(1):16-22.
16. LaPrade RF, Johansen S, Wentorf FA, et al. An analysis of an ana-
tomical posterolateral knee reconstruction: an in vitro biomechanical
study and development of a surgical technique. Am J Sports Med.
2004;32(6):1405-1414.
17. LaPrade RF, Muench C, Wentorf F, Lewis JL. The effect of injury to
the posterolateral structures of the knee on force in a posterior cru-
ciate ligament graft: a biomechanical study. Am J Sports Med.
2002;30(2):233-238.
18. LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of grade III
posterolateral knee complex injuries on anterior cruciate ligament
graft force. A biomechanical analysis. Am J Sports Med. 1999;
27(4):469-475.
19. LaPrade RF, Smith SD, Wilson KJ, Wijdicks CA. Quantification of
functional brace forces for posterior cruciate ligament injuries on
the knee joint: an in vivo investigation. Knee Surg Sports Traumatol
Arthrosc. 2015;23(10):3070-3076.
20. Laprade RF, Wijdicks CA. Surgical technique: development of an
anatomic medial knee reconstruction. Clin Orthop Relat Res.
2012;470(3):806-814.
21. Levy BA, Dajani KA, Morgan JA, et al. Repair versus reconstruction of
the fibular collateral ligament and posterolateral corner in the
multiligament-injured knee. Am J Sports Med. 2010;38(4):804-809.
22. Levy BA, Dajani KA, Whelan DB, et al. Decision making in the
multiligament-injured knee: an evidence-based systematic review.
Arthroscopy. 2009;25(4):430-438.
23. Levy NM, Krych AJ, Hevesi M, et al. Does age predict outcome after
multiligament knee reconstruction for the dislocated knee? 2- to 22-
year follow-up. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):
3003-3007.
24. Mariani PP, Santoriello P, Iannone S, Condello V, Adriani E. Compar-
ison of surgical treatments for knee dislocation. Am J Knee Surg.
1999;12(4):214-221.
25. Mook WR, Miller MD, Diduch DR, et al. Multiple-ligament knee inju-
ries: a systematic review of the timing of operative intervention and
postoperative rehabilitation. J Bone Joint Surg Am. 2009;91(12):
2946-2957.
26. Moorman CT 3rd, LaPrade RF. Anatomy and biomechanics of the
posterolateral corner of the knee. J Knee Surg. 2005;18(2):137-145.
27. Serra Cruz R, Mitchell JJ, Dean CS, et al. Anatomic posterolateral
corner reconstruction. Arthrosc Tech. 2016;5(3):e563-e572.
28. Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and combined
grade-III posterior cruciate ligament tears treated with double-bundle
reconstruction with use of endoscopically placed femoral tunnels and
grafts: operative technique and clinical outcomes. J Bone Joint Surg
Am. 2011;93(19):1773-1780.
29. Stannard JP, Brown SL, Farris RC, McGwin G, Jr., Volgas DA. The
posterolateral corner of the knee: repair versus reconstruction. Am
J Sports Med. 2005;33(6):881-888.
30. Svantesson E, Hamrin Senorski E, Alentorn-Geli E, et al. Increased
risk of ACL revision with non-surgical treatment of a concomitant
medial collateral ligament injury: a study on 19,457 patients from
the Swedish National Knee Ligament Registry. Knee Surg Sports
Traumatol Arthrosc. 2019;27(8):2450-2459.
31. Wijdicks CA, Michalski MP, Rasmussen MT, et al. Superficial medial
collateral ligament anatomic augmented repair versus anatomic
reconstruction: an in vitro biomechanical analysis. Am J Sports
Med. 2013;41(12):2858-2866.
6Willimon et al The Orthopaedic Journal of Sports Medicine
