ACL reconstruction in the multiligament knee

ACL reconstruction in the setting of the multiligament knee injury is a complex clinical problem, and the failure to diagnose and treat properly can lead to devastating outcomes. Currently, there is limited high-quality evidence available on which to base treatment decisions. The decisions of nonoperative versus operative, timing of surgery, allograft versus autograft, surgical technique, fixation choice, and rehabilitation remain controversial and should be individualized to each patient. There is no consensus in the literature on optimal timing to ACL reconstruction, as timing is dependent on vascular status of the extremity, degree of instability, status of collateral ligaments, condition of skin, and presence of open wounds, among other issues. A lower incidence of arthrofibrosis has been reported following delayed or staged reconstruction. The use of ACL autograft versus allograft has potential advantages and disadvantages, and this should be discussed with the patient before surgery. While the use of autograft for isolated ACL reconstruction is favored for young patients, allograft use for the three and four ligament injured knee is advantageous due to reduced operative time and less donor site morbidity. Our surgical technique and treatment algorithms for ACL reconstruction in the patient with a multiligament knee injury are presented in this chapter. In conclusion, surgical management should be centered on each patient’s clinical presentation, with their individual baseline and future functional goals in mind.