Current concepts in the assessment and management of multiligament injuries of the knee

Abstract

Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

Incidence and type of meniscal tears in multilligament injured knees

“…Demographic populations and mechanisms of MLKI are also diferent, with high-energy injuries related to motor vehicle accidents and low-velocity injuries reported in obese patients. Ligament damage is frequently associated with neurovascular injuries and lower extremity fractures [23,25,[50][51][52].…”

“…In our institution, in the majority of MLKI cases, a surgical treatment was performed. According to the literature, operated patients were considered to have better outcomes than those treated without surgery [17, 52]. Second, mainly in chronic cases, some initial ligament and meniscal damage may have healed when the patient was cared for.…”

Surgical approach on combined chronic patellar tendon and bicruciate knee ligament injury

“…Combined patellar tendon and bicruciate ligaments rupture is an uncommon injury, resulting from high-energy trauma and involving tendon damage to the knee extensor complex (patellar tendon) and both cruciate ligaments [ 6 , 16 ].…”

Maximum outcome with minimal resources: report of a multiligamentous knee injury managed with ‘modified confluent tunnel technique’

“…Multiligamentous knee injuries (MLKIs) are rare, accounting for only 0.02–0.2% of all orthopaedic injuries 1 2. They are generally defined as injury to two or more of the four major ligaments of the knee—the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) with or without the posteromedial corner (PMC), and the lateral collateral ligament with or without the posterolateral corner (PLC) 3. The Schenck classification system is used to classify these injuries into five types depending on the structures involved 4.…”