An Evidence-Based Approach to Multi-Ligamentous Knee Injuries

Abstract

Multi ligament knee injuries (MLKIs) are highly complex injuries with associated complications and often present with difficult management strategies. MLKIs may affect the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (or posteromedial corner (PMC)), and lateral collateral ligament (or posterolateral corner (PLC)) in addition to other structures including the menisci, common peroneal nerve, and popliteal artery. MLKIs are highly associated with the male sex and are commonly seen in high-velocity motor vehicle accidents and low-velocity sports injuries. Given the multiple planes of movement in the knee and various primary and secondary stabilizers throughout those planes, there is great heterogeneity in an injury pattern and most involve the ACL and PCL. Initial evaluation of this injury includes assessment of lower extremity sensation, distal pulses, and ankle-brachial index (ABI). If vascular compromise is suspected, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are indicated to evaluate the vasculature. As opposed to CTA, MRA offers visualization of the soft-tissue structures that are commonly damaged in MLKIs. Initial management typically includes closed reduction of the knee with subsequent external fixation. Classification systems guide initial assessments; however, further management is unclear and leads the surgical team to decide the best, individualized management option for each patient. As a result, optimal surgical and postoperative treatment options remain complicated, and clinical outcomes remain difficult to predict. The purpose of this review is to consolidate the most up-to-date practices of the diagnostic workup, management, and treatment of MLKIs.

Outcomes of Operative Management of Multi-Ligament Knee Injuries in an Adolescent Population: A Retrospective Case Series

“…1 Commonly associated with a tibiofemoral joint dislocation, multi-ligament knee injuries typically result from high-energy mechanisms and may be associated with neurovascular injury, fractures, or periarticular soft tissue injury. [2][3][4][5] The incidence of multiligament knee injuries ranges between 0.02 and 0.20% of all adult orthopaedic injuries, though this may be an underestimation. 1 Historically, multi-ligament knee injuries resulted in high rates of persistent instability, loss of motion, and poor function or quality of life in adult patients.…”

“…[13][14][15][16][17][18][19][20][21] This may be due to challenges such as cohort heterogeneity with varying presentation and severity and the lack of surgical technique standardization. 5 Furthermore, the relatively low incidence of multi-ligament knee injuries typically results in studies with a low sample size.…”

Ultrasound With Stress for Assessing Injuries to the Medial and Lateral Collateral Ligaments of the Knee

“…These factors include the examiner’s expertise, patient tolerance, and the presence of concomitant injuries. 1 , 2 , 3 …”

Supine Lobenhoffer Approach Optimizes PCL Reconstruction with Tibial Inlay in Knee Dislocations

“…These injuries often give rise to significant complications, including impaired wound healing, arthrofibrosis, persistent pain and instability, and the development of posttraumatic osteoarthritis. Although surgical intervention has demonstrated the potential to enhance long-term outcomes, debates persist over the optimal surgical approach for MLKIs because of their rarity, accounting for only 0.02% to 0.2% of all orthopaedic surgeries 2 . Valgus stress test of the bilateral knees showing medial compartment opening of the left knee.…”