Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment.

A detailed history, thorough examination, and a high index of suspicion for associated injuries together are the cornerstone for diagnosing and treating a knee with multiple ligament injuries. Acute surgery in patients with combined ligament injuries of the knee can lead to stiffness, primarily with medial-side injuries. Knee dislocations with lateral-side injuries require acute repair to achieve a good long-term result. All knee dislocations should not be grouped together because of the difference in healing potential between medial- and lateral-side injuries. Patients likely prefer a knee that is mildly lax but functional with full range of motion as opposed to a stiff, painful, stable knee. Treatment is based on the individual healing potential of the injured structures and the natural history of these injuries, along with the following principles: (1) medial-side injuries can heal with proper nonsurgical treatment; (2) posterior cruciate ligament (PCL) tears with grade II laxity or less can heal with similar long-term results as PCL tears with grade I laxity; therefore, surgery may not be indicated. As surgical techniques are developed and improved upon, a more aggressive approach to PCL reconstruction may be warranted; (3) PCL laxity greater than grade II and a soft end point should be considered for semiacute reconstruction; and (4) anterior cruciate ligament injuries in combination with medial collateral ligament and/or PCL injury can initially be treated nonsurgically and reconstructed later as dictated by patient symptoms and activity level.