Multiple Ligament Knee Injuries Research Articles

Do Age and Timing Influence the Outcomes of Single-stage Reconstruction of Multiple Ligament Knee Injuries? 5-10 Years Follow Up.

Multiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single-stage reconstruction of MLKIs. The patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF-36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann-Whitney U test or χ2 test. A total of 102 MLKI patients managed by single-stage multi-ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2-10.7 years). At the last follow-up, no significant difference was found in knee ROM, functional scores, and patient-reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%-80.4% of patients, and grade B in 11.8%-23.5% patients. The single-stage reconstruction of MLKIs can obtain comparative long-term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.

Outcomes of multiligament knee injury treated with versus without internal brace suture augmentation.

To compare the postoperative outcomes between Internal Brace (IB) and non-IB patients who underwent surgical management of multiple-ligament knee injuries (MLKI). Patients who underwent surgical management of MLKI at two institutions between 2010 and 2020 were identified and offered participation in the study via the collection of postoperative functional outcomes for MLKI; Lysholm Knee score, Multiligament Quality of Life (ML-QOL), Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT), Pain Interference (PI), Physical Function (PF), and Mobility instruments (MI). The postoperative outcomes and reoperation rates were compared between the IB group and non-IB group. One hundred and twenty-six patients were analyzed; 89 were included in the IB group (31.5% female; age 35.6 ± 1.4years), and 37 were included in the non-IB group (25.7% female; age 38.8 ± 2.4years). Mean follow-up time of the entire cohort was 37.9 ± 4.7months [IB: 21.8 + 1.63; non-IB: 76.4 ± 6.2, p < 0.001). The IB group achieved similar PROMIS CAT [PROMIS Pain (51.8 + 1.1 vs. 52.1 + 1.6, p = 0.8736), Physical Function (46.6 + 1.2 vs. 46.4 + 1.8, p = 0.9168), Mobility (46.0 + 1.0 vs. 43.7 + 1.6, p = 0.2185)], ML-QOL [ML-QOL Physical Impairment (36.6 + 2.5 vs. 43.5 ± 4.2, p = 0.1485), Emotional Impairment (42.5 + 2.9 vs. 48.6 ± 4.6, p = 0.2695), Activity Limitation (34.5 + 2.8 vs. 36.2 ± 4.3, p = 0.7384), Societal Involvement (39.1 + 3.0 vs. 41.7 + 4.2, p = 0.6434)] and Lysholm knee score (64.9 + 2.5 vs. 60.4 + 4.0, p = 0.3397) postoperatively compared the non-IB group, but the differences were not significant. In this cohort of patients with MLKI treated with versus without IB, outcomes and reoperation rates trended toward favoring IB, but the study was not sufficiently powered to reach statistical significance. Internal bracing could be useful in the management of MLKI.In the future, matched patient cohorts with more patients are warranted to further evaluate the clinical impact of the internal brace in MLKI.

Poster 257: Decreased time between injury and surgery and increased injury severity predict motion loss after multi-ligament knee injury, but are only part of the picture

Objectives: Postoperative motion loss is the most common complication following multiple ligament knee injuries (MLKIs). MLKIs are often associated with concomitant musculoskeletal and neurovascular injuries and complex surgical treatment; however, factors that increase the risk of postoperative motion loss remain largely unknown. The purpose of this study was to identify predictors of motion loss following MLKI. We hypothesized that injury classification (Knee Dislocation [KD] grade), and shorter time between injury and surgery would be independent predictors of postoperative motion loss. Methods: This was a multicenter retrospective review of 773 MLKIs that occurred between 2011 and 2015. MLKI was defined as a complete tear of two or more ligaments where at least 1 ligament was repaired or constructed. Individuals with a MLKI defined as a complete tear (grade III tear) of two or more ligaments that underwent surgical repair or reconstruction of at least one ligament were included. Cases with loss of motion were identified from review of follow-up documentation or the need for subsequent manipulation under anesthesia and/or lysis of adhesions. A multivariable logistic regression with forward variable entry (p&lt;0.05) was performed to determine if any of the following variables were predictive of motion loss after MLKI: biological sex, KD grade, number of days between injury and surgery, graft type, use of external fixation, if staged procedures were performed, and associated vascular, nerve or tendon injury. Results: Of the 773 patients identified in the multicenter review, 562 (72.7%) had complete data for inclusion in the current analyses with 65 (11.6%) having postoperative motion loss (Table 1). Of the 562 patients (76.0% male, age=30.7±12.9 y, BMI=29±6.8 kg/m2), the median number of days between injury and surgery was 59 days (IQR=22-192 days). KD I injuries were the most common (59.6%) with 3.6% having KD II, 14.4% KD III-M, 13.9% KD III-L, 5.3% KD IV, and 3.2% KD V injuries. External fixation was used in 8.2% and 6.8% of the patients underwent staged procedures. Multiple graft combinations were used (all allograft = 37.5%, all autograft = 11.4%, combination = 48.9%, all repairs = 2.1%). Associated nerve injuries occurred in 19.8%, tendon injuries in 15.8%, and vascular injuries in 4.1%. Regression analysis identified decreased time between injury and surgery (OR=0.998, 95%CI[0.997-1.00]) and increased injury severity (KDIII OR=2.31, 95%CI[1.19-4.48], KDV OR=5.42, 95%CI[1.84-15.98]) as independent predictors of motion loss after MLKI (p &lt; 0.001, Nagelkerke R2=0.08). Conclusions: While KD grade and time between injury and surgery are predictive of motion loss after MLKI, these variables only explain 8% of the variability in motion loss. This confirms that clinicians should be cognizant that decreased time between injury and surgery and more severe injuries may increase this risk of motion loss; however, postoperative factors not measured in this secondary analysis might more heavily impact motion loss after surgical treatment for MLKI. Future studies are necessary to identify other factors such as pre-operative ROM, the postoperative inflammatory state of the knee, utilization of physical therapy and/or psychosocial factors that might influence motion loss after MLKI reconstruction to better inform postoperative care. [Table: see text]

Erratum: Presentation and Surgical Management of Multiple Ligament Knee Injuries.

Erratum: Presentation and Surgical Management of Multiple Ligament Knee Injuries.

Intra-articular administration of adrenaline plus an irrigation pump system for visibility during the arthroscopic reconstruction of multiple knee ligaments without a tourniquet.

Multiple ligament knee injuries (MLKIs) are rare but severe systemic trauma. Single surgery in the acute setting is preferred, although with an extended operation time. To avoid the complications associated with a tourniquet, we herein describe a method for visibility without a tourniquet: intra-articular administration of adrenaline plus an irrigation pump system. This is a cohort study with a level of evidence of 3. From April 2020 to February 2022, 19 patients with MLKIs were reviewed retrospectively. All patients got intra-articular administration of adrenaline plus an irrigation pump system for visibility without a tourniquet. The following parameters were assessed: visibility, range of motion, knee stability, visual analog scale (VAS) score, range of motion (ROM), Lysholm score, Tegner activity level, and International Knee Documentation Committee Subjective Knee Form (IKDC). All patients were followed up for at least 6 months. At the latest follow-up, the mean VAS score, ROM, Lysholm score, and IKDC were 1.79 ± 0.86, 121.21 ± 10.96, 88.16 ± 5.21, and 88.53 ± 5.06, respectively. The average Tegner activity level decreased significantly from preinjury to postoperation (5.16 ± 0.83 vs. 3.11 ± 0.88, P < 0.001). Of the 19 patients, 17 (89.47%) had good knee function, while only two patients (10.53%) had asymptomatic knees with positive Lachman tests. A total of 17 patients (89.47%) had good or excellent visualization during arthroscopy. Of the 19 patients, three (15.79%) required an increased fluid pressure to achieve a clear operative view. Two patients converted to tourniquet inflation due to persistent intra-articular bleeding after using shavers. The intra-articular administration of adrenaline plus an irrigation pump system is recommended as an alternative to a tourniquet to achieve a good visual field. Further evidence-based work with a larger sample is needed.

Single Stage in Situ Suture Repair of a Multi-Ligament Knee Injury, an Observational Study

Objective: This study aims to observe the clinical outcomes associated with in situ single-stage suture repair for knee dislocation in patients suffering from multiple knee ligament injuries with the use of unabsorbable materials of the suture. Study design: A retrospective observational study Place and Duration this study was conducted in Gambat Medical College Pir Syed Abdul Qadir Shah Jellani Institute of Medical Science GIMS Gambat from May 2021 to May 2022. Methodology: In this study35 patients treated surgically with in situ suture repair were recruited. A retrospective analysis was done on 35 patients with a mean follow-up score of 3.8 ± 1.3 years. Patients were undergone in situ surgical procedures for all the ruptured ligaments followed by a proper rehabilitation protocol post-operatively. Outcome variables were assessed by Lysholm score, satisfactory score, Meyers functional rating score, VAS score, and Tegner score. Results: Results of the study states that the mean follow-up a score of VAS was recorded as 1.98 ± 0.4, Lysholm score was recorded as 82.5 ± 6.7, and the patient satisfaction score was recorded as 7.5 ± 0.9. Statistically, significant differences have been observed between the pre and post-scores of ranges of motion and Tegner activity scores with a p-value of &lt; 0.001 for both activity and ROM scores. Final follow-up of these patients reported that patients were left with no ligament laxity except for two patients who were unable to restore back to work. Among 35 patients, 5 were unable to achieve full ROM and had stiffness whereas two had infections at the surgical site. Conclusion: In situ suture repair of multiple ligaments had shown significant improvement in terms of ligament repair and early rehabilitation and therefore can be considered an effective treatment approach for the management of multiple ligament injuries. Keywords: Multiple ligament injuries, in situ repair, knee dislocation, cruciate ligament injury, single-stage repair.

Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries

PurposeMultiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions.MethodsTen cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations.ResultsThe median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels.ConclusionThe use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.

Accuracy of Magnetic Resonance Imaging in the Diagnosis of Multiple Ligament Knee Injuries: A Multicenter Study of 178 Patients

Background: Magnetic resonance imaging (MRI) has shown limited diagnostic accuracy for multiple ligament knee injuries (MLKIs), especially posterolateral corner (PLC) injuries. Hypothesis: The diagnostic accuracy of MRI for MLKIs will only be moderate for some knee structures. Patient-related factors and injury patterns could modify the diagnostic accuracy of MRI. Study Design: Cohort study; Level of evidence, 3. Methods: All patients with MLKIs surgically treated between January 2014 and December 2020 in the centers participating in the study were reviewed. We recorded sex, age, mechanism of injury, time from injury to MRI, and vascular and neurological associated lesions. Lesions to the anterior cruciate ligament (ACL), posterior cruciate ligament, medial collateral ligament, lateral collateral ligament (LCL), popliteus tendon, popliteofibular ligament, iliotibial band, biceps tendon, medial and lateral meniscus, and articular cartilage from MRI reports and surgical records were also collected. The sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, diagnostic odds ratio, positive and negative likelihood ratio, and intraclass correlation coefficient of MRI were calculated for each knee structure. With logistic regression, associations between patient and injury characteristics and MRI accuracy were assessed. Results: A total of 178 patients (127 male; mean age, 33.1 years) were included. High-energy trauma was the most common mechanism of injury (50.6%), followed by sports trauma (38.8%) and low-energy trauma (8.4%). The ACL was the structure with the best diagnostic accuracy, diagnostic odds ratio, and positive predictive value (94.4%, 113.2, and 96.8%, respectively). PLC structures displayed the worst diagnostic accuracy among knee ligaments (popliteus tendon: 76.2%; LCL: 80.3%) and diagnostic odds ratio (popliteus tendon: 9.9; LCL: 17.0; popliteofibular ligament: 17.5). MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. Logistic regression found that the diagnostic accuracy was affected by the Schenck classification, with higher Schenck grades having worse diagnostic accuracy for peripheral structures (iliotibial band, popliteus tendon, and biceps tendon) and improved diagnostic accuracy for the ACL and posterior cruciate ligament. Conclusion: The diagnostic accuracy of MRI for MLKIs largely varied among knee structures, with many of them at risk of a misdiagnosis, especially PLC, meniscal, and chondral lesions. The severity of MLKIs lowered the diagnostic accuracy of MRI for peripheral structures.

Management of Multiligament Knee Injury

Multiligament knee injuries are defined as injuries to at least two of the four major ligaments in the knee: anterior cruciate ligament, posterior cruciate ligament, lateral collateral ligament (and posterolateral corner) and medial collateral ligament (and posteromedial corner). Multiple ligament knee injuries that results from high energy trauma, may have nerve and vascular injuries, therefore neurovascular examination with clear documentation of capillary refill time, distal pulses, function of all lower limb compartments and common peroneal and tibial nerve function should be performed. Before definitive treatment performed, we have to classified the multiligament injury according to the energy of the injury and the anatomic injured structures. MRI still recommended to know about the ligaments injury. The goal and our priority treatment is to obtain functional stability of the knee without the loss of motion or stiffnes that can lead to longterm pain, weakness, and the subsequent osteoarthritis.

Supine Lobenhoffer Approach Optimizes PCL Reconstruction with Tibial Inlay in Knee Dislocations: A Case Report.

A 47-year-old man suffered a knee dislocation while skiing with associated damage to the anterior cruciate, posterior cruciate, medial collateral, and medial patellofemoral ligaments. The patient underwent a multiple-ligament knee reconstruction using the supine Lobenhoffer approach, which resulted in remarkable outcomes that persisted throughout the 56-month follow-up period. The utilization of this approach can prevent inappropriate graft tension and iatrogenic damage, reduce surgical time, and minimize airway complications by eliminating the need for the prone position. Optimizing these factors enhances the patient's chances for long-term outcomes; thus, surgeons should consider this approach in managing multiple-ligament knee injuries.

Common peroneal nerve rupture with multiple ligament knee injury: A case report

In peroneal nerve palsy with closed knee injury, most of the case improves by follow‐up. We present a case of peroneal nerve rupture with closed multiple ligament knee injury, requiring nerve transplantation. In multiple ligament knee injury, it is necessary to consider the possibility of peroneal nerve rupture.

Surgical Principles for Medial and Posteromedial Knee Injuries

Injuries to the medial side of the knee are among the most common knee ligament injuries. Treatment of these injuries require a thorough clinical workup and an intricate knowledge of the anatomy and biomechanics involving this region of the knee. Low grade injuries and isolated injuries to the medial collateral ligament (MCL) are treated nonoperatively with bracing and functional rehabilitation. Surgical treatment is recommended for high grade (Grade III) posteromedial corner injuries, distal MCL tears, including Stener lesions, knee dislocations and multiple ligament knee injuries involving the posterolateral corner (PLC) because of high risk of residual instability if treated non-operatively. When indicated, surgical treatment should be performed in the acute phase followed by early protected range of motion and functional rehabilitation. Preoperative planning should include stress radiographs and MRI. Important considerations for surgical technique include avoiding graft tunnel convergence in the setting of multiple ligament reconstruction and anatomic placement of the tunnels to recreate the native kinematics of the medial compartment. Postoperative rehabilitation focusing on quadriceps activation and protected range of motion is recommended beginning postoperative day one to minimize the risk of arthrofibrosis. Anatomic reconstruction of the superficial medial collateral ligament and posterior oblique ligament have been shown to produce good subjective and objective patient outcomes. Further level one studies are recommended to reinforce these findings.

High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes.

The purpose of the study is to assess return to play rate and timing of elite athletes treated for multi-ligament knee injuries with modern surgical techniques. A retrospective review was performed of all professional or national/international level athletes treated for a multi-ligament knee injury by the senior author in the period from February 2001 to October 2019, with a minimum of 2-year follow-up. The study cohort consisted of 136 elite athletes who underwent surgery of two or more knee ligaments. Outcomes measures were return to play (RTP), defined as return to elite level sport, return to play time, and further surgical procedures. One hundred and twenty (88.2%) athletes returned to elite level sport at an average of 12.8months from operation. In unicruciate injuries, ACL and PCL-based injuries had similar return to play rates (89.1% vs. 87.5% respectfully, n.s.) although mean RTP time was longer in those with PCL-based injuries (15.2 vs. 11.9months, p < 0.01). Bicruciate injuries had longer RTP times compared to unicruciate injuries (mean RTP 16.0vs. 12.4months, p < 0.05) but were able to return at a similar rate (83.3% vs.88.9%, n.s.). Medial and lateral sided injuries had similar RTP rates (89.3% vs. 87.9%, n.s.) though lateral sided injuries took longer before returning to play (13.4 vs. 11.6months, p < 0.05). Further surgery was required in 54 (39.9%) patients including 25 (18.4%) manipulations under anaesthesia. Four (2.9%) of the athletes underwent revision ligament surgery. Modern surgical techniques used in the treatment of multi-ligament knee injuries can lead to high return to play rates in elite athletes. IV.

The accuracy of MRI in diagnosing and classifying acute traumatic multiple ligament knee injuries

BackgroundMagnetic resonance imaging (MRI) is widely used for the evaluation of knee injuries, however, the accuracy of MRI in classifying multiple ligament knee injuries (MLKIs) remains unknown. This study aimed to investigate the accuracy of MRI in diagnosing and classifying acute traumatic MLKIs, we hypothesize that MRI had high accuracy in detecting and classifying MLKIs.MethodsThe clinical data of 97 patients who were diagnosed with acute traumatic MLKIs and managed by multi-ligament reconstruction between 2012 and 2020 were retrospectively reviewed. The MR images were read by two experienced radiologists and results were compared with intraoperative findings, which were considered as the reference for the identification of injured structures. The value of MRI in detecting injuries of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), and meniscus was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and kappa coefficients analysis. The value of MRI in classifying MLKIs was evaluated by calculating the agreement between MRI and intraoperative findings.ResultsFor detecting the specific injured structures in MLKIs, MRI had high sensitivity (90.7% for ACL, 90.4% for PCL, and moderate specificity (63.6% for ACL, 50% for PCL) in detecting cruciate ligament injuries, moderate sensitivity (79.1% for MCL, 55.6% for LCL) and specificity (46.7% for MCL, 68.4% for LCL) in detecting collateral ligament injuries, fair sensitivity (61.5%) and low specificity (39.4%) in the diagnosis of injuries to the meniscus. For classifying the MIKIs, MRI had a moderate agreement with intraoperative findings in classifying KD-V (kappa value = 0.57), poor agreement in the KD-I (kappa value = 0.39) and KD-IIIM (kappa value = 0.31), meaningless in the KD-II and KD-IIIL (kappa value < 0). The overall agreement between MRI and intraoperative findings in classifying MLKIs was poor (kappa value = 0.23).ConclusionsMRI is valuable in early detection and diagnosis of acute MLKIs, however, the accuracy of MRI in classifying MLKIs is limited. The management of MLKIs should be based on intraoperative findings, physical examinations, and comprehensive imaging results.

Multiple ligament knee injuries: Clinical practice guidelines

Multiple ligament knee injuries involve tears of two or more of the four major knee ligament structures, and are commonly noted following knee dislocations. These devastating injuries are often associated with soft-tissue trauma, neurovascular deficit, and concomitant articular cartilage or meniscus tears. The complexity of presentation, and spectrum of treatment options, makes these injuries unique and extremely challenging to even the most experienced knee surgeons. A high level of suspicion, and a comprehensive clinical and radiological examination, is required to identify all injured structures. The current literature supports surgical management of these injuries, with cruciate reconstructions, and repair/augmented repair/ reconstruction of collateral ligaments. This review article analyses management principle of multiple ligament knee injuries, and formulates clinical practice guidelines with treatment algorithms essential to plan individualized management of these complex heterogeneous injuries.

Multiple ligament anatomic-based reconstructions of the knee: State- of-the-art

Multiple knee ligament injuries are defined as a disruption of any combination of the four main ligament complexes; the cruciate ligaments, posterolateral corner, and posteromedial corner. Evaluation requires consideration of the entire clinical picture, including injury to associated structures, directions and degree of instability, neurovascular compromise and appropriate imaging, and physical examination. Reconstruction is favored over repair and anatomic- based reconstruction techniques have been validated to restore the native biomechanics of the knee and lead to successful patient-reported and objective outcomes. Anatomic-based reconstruction of many knee ligaments simultaneously requires precise knowledge of the relevant anatomical landmarks, careful planning of reconstruction tunnel positions, and orientations to avoid tunnel convergence, and employment of immediate early motion in the post-operative rehabilitation regimen to provide the patient the best chance for relatively normal use of the affected limb.

Intervention Strategy Applied ICF Checklists for Sitting Cross-Legged in Patient with Multiple Ligament Knee Injury: Single Subject Study

Other SectionsAbstractINTRODUCTIONPATIENT INFORMATIONCLINICAL FINDINGSDIAGNOSTIC ASSESSMENTTHERAPEUTIC INTERVENTIONOUTCOMESDISCUSSIONReference

Finding an Association Between Congenital Talipes Equinovarus (CTEV) and Developmental Dysplasia of Hip (DDH): Role of Early Ultrasonography

A multiple-ligament knee injury (MLKI) is a devastating injury most commonly due to an acute knee dislocation [1-3]. This high energy injury leads to disruption of the major stabilizing ligaments. Sequela of these injuries included compromised knee stability and pain [4].

Reconstruction and/or Repair of The Multi-Ligament Knee Injury: A Systematic Review

A multiple-ligament knee injury (MLKI) is a devastating injury most commonly due to an acute knee dislocation [1-3]. This high energy injury leads to disruption of the major stabilizing ligaments. Sequela of these injuries included compromised knee stability and pain [4].

External fixation increases complications following surgical treatment of multiple ligament knee injuries.

The purpose of this study was to review post-operative complications after surgical intervention of MLKIs within the first 6 months to be better able to counsel patients before surgical intervention. All patients who underwent surgical reconstruction for a MLKI at one institution from 2009 to 2018 were included in this study. A retrospective review was performed of all patients and post-operative complications were recorded, including motion loss (which included > 10 degree flexion loss or > 3 degree extension loss), hematoma formation, infection, iatrogenic vascular or nerve injury, deep vein thrombosis (DVT), pulmonary embolism (PE), skin lesions, symptomatic hardware, recurrent ligamentous laxity, and need for additional surgery. Knee ligament injuries were classified based on the Schenck Knee Dislocation (KD) Classification. A total of 136 patients were included in this study, 83 with KD I injuries, 40 with KD III injuries, 9 with KD IV injuries, and 4 with KD V injuries. Of these total patients, 48 (35.5%) sustained a post-operative complication: 11 out of 133 (8.3%) from 0 to 1week, 46 out of 132 (34.8%) from 1week to 1month, 28 out of 124 (22.6%) from 1 to 3months, and 26 out of 121 (21.5%) from 3 to 6months. Out of the total complications, 99 (78.5%) occurred at 1week-3months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common complication was motion loss in 39 (28.6%) patients. There was a significant difference in mean number of complications between the KD I and KD III groups, as well as the KD III and KD IV-V groups. There was no significant difference in the overall prevalence of post-operative complications or occurrence of motion loss with KD grade. The main finding of this study was 48 (35.5%) patients sustained a complication after surgical treatment of MLKIs, with 99 (78.5% of all complications) complications occurring at 1week-3months post-operation. Patients who had an external fixator placed at initial injury were more likely to sustain a post-operative complication. The most common post-operative complication was motion loss in 39 (28.6%) patients. The KD grade was not associated with post-operative development of motion loss, but KD III had a significantly greater mean number of complications than KD I or KD IV-V grades. IV.