Acute Versus Delayed Surgical Intervention in Multiligament Knee Injuries: A Systematic Review

Abstract

Background: The optimal timing of surgical intervention for multiligament knee injuries remains controversial. Purpose: To review the clinical and functional outcomes after acute and delayed surgical intervention for multiligament knee injuries. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a search of the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to September 2020. Eligible studies reported on knee dislocations, multiligament knee injuries, or bicruciate ligament injuries in adult patients (age, ≥18 years). In addition to comparing outcomes between acute and delayed surgical intervention groups, we conducted 3 subgroup analyses for outcomes within isolated knee injuries, knee injuries with concomitant polytrauma/fractures, and high-level (level 2) studies. Results: Included in the analysis were 31 studies, designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n = 20). These studies reported on 2594 multiligament knee injuries sustained by 2585 patients (mean age, 25.1-65.3 years; mean follow-up, 12-157.2 months). At the latest follow-up timepoint, the mean Lysholm (n = 375), International Knee Documentation Committee (IKDC) (n = 286), and Tegner (n = 129) scores for the acute surgical intervention group were 73.60, 67.61, and 5.06, respectively. For the delayed surgical intervention group, the mean Lysholm (n = 196), IKDC (n = 172), and Tegner (n = 74) scores were 85.23, 72.32, and 4.85, respectively. The mean Lysholm (n = 323), IKDC (n = 236), and Tegner (n = 143) scores for our isolated subgroup were 83.7, 74.8, and 5.0, respectively. By comparison, the mean Lysholm (n = 270), IKDC (n = 236), and Tegner (n = 206) scores for the polytrauma/fractures subgroup were 83.3, 64.5, and 5.0, respectively. Conclusion: The results of our systematic review did not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes. Although previous evidence has supported acute surgical intervention, future prospective randomized controlled trials and matched cohort studies must be completed to confirm these findings.

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review

“…Several recent systematic reviews assessing MLKI define the term specifically as ‘disruption of at least two of the four major knee ligaments, comprising the ACL, PCL, MCL (and PMC) and LCL (and PLC)’ 1 4 15 23. Numerous original research studies and systematic reviews do not explicitly define their interpretation of MLKI, or do not define their interpretation of the ‘four primary knee ligaments’ 24–30. One recent systematic review defined MLKI as ‘three or more ligaments injured and/or knee dislocation’ 31.…”

“…Therefore, only 5/15 studies (33%) comprised original research assessing early versus delayed surgery. There is consensus for the demarcation in time point between ‘early’ and ‘late’ surgery for MLKI1 23 25 90–94; early being <3 weeks and late being >3 weeks; however, the evidence for this demarcation is unclear. Levy et al 1 noted that 3 weeks had been considered a critical time period following injury, when tissue planes can be identified and are of sufficient integrity to allow reapproximation and suture placement.…”

Vascular Injury After Knee Dislocation: A Meta-Analysis Update

“…A systematic review by Mardeer et al concluded that no clear difference was observed in outcomes in acute versus delayed surgical intervention. 34 Liow et al 35 4 Both prior studies found no cases of PA damage in KDI or KDII injuries. Classically, posterior and anterior dislocations are thought to directly compress and stretch the PA, respectively.…”

“…A systematic review by Mardeer et al concluded that no clear difference was observed in outcomes in acute versus delayed surgical intervention. 34 Liow et al 35 found that early surgical intervention within two weeks of presentation was superior to delayed treatment in multiligament knee injuries. Emergent open reduction is conducted in cases of known vascular injury.…”

Does Delayed Ligament Reconstruction Surgery Lead to Poor Outcomes in Patients With Multiligament Knee Injuries?

“…In their meta-analysis, Mook et al [ 16 ] noted that patients undergoing acute surgery had more flexion deficits. However, a more recent meta-analysis involving 2,585 patients showed no difference in clinical and functional outcomes when comparing acute and delayed surgical intervention [ 18 ]. In our study, there were no cases of knee stiffness needing manipulation under anesthesia or arthroscopic adhesiolysis.…”