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.
Highlights
A knee dislocation (KD) is defined as tibiofemoral disarticulation, but spontaneous reduction and KDs with intact cruciate ligaments have added complexity to this definition [1]
The initial assessment must abide by advanced trauma life support (ATLS) principles as Multiligament knee injuries (MLKIs) are frequently complicated by comorbid polytrauma [26]
A thorough neurovascular exam is always warranted, and an Ankle Brachial Index (ABI) should be performed [27] and serially monitored as the development of occlusive thromboses formed by intimal flap tears may only be revealed with time [28]
Summary
A knee dislocation (KD) is defined as tibiofemoral disarticulation, but spontaneous reduction and KDs with intact cruciate ligaments have added complexity to this definition [1]. In 1824, Sir Astley Cooper made the observation about knee dislocations: “Of this, I have only seen one instance, and I conclude it, to be a rare occurrence; and there are scarcely any accidents to which the body is more liable which more imperiously demand immediate amputation than these.” [5] KDs were historically associated with detrimental sequelae such as loss of life and limb, and initial management focused on conservative strategies [6,7,8,9] This has changed as surgical techniques and intricate anatomic and biomechanical knowledge evolved [10]. Some of these historical findings are still applicable in certain settings
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