Multiple ligament knee injuries: Clinical practice guidelines

Abstract

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.

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

“…The sequence of fixation in cases of MLKI is altered. It is generally recommended that PCL should be fixed first in MLKI 19. But in this case, because of the use of confluent tunnels, we have fixed the MCL first.…”

Chronic Irreducible Knee Dislocations: Outcomes following Open Reduction and Reconstructive Surgery

“…Our series also had a significantly large number of patients (38%) who had postoperatively missed knee dislocations (type 2), and this is a common phenomenon in the prior reported cases too. [5][6][7][8] Special attention should be paid to radiographically "normal" multiple ligament knee injuries which are notorious for being missed spontaneously reduced knee dislocations. An inexperienced surgeon may underestimate the complexity of the primary injury with resultant underdiagnosis or undertreatment of the knee instability.…”

“…Cases that have been reported have been described under two specific circumstances; either as a missed injury in a polytrauma patient [1][2][3][4] or as a neglected postoperative dislocation in a patient with multiple ligament knee injury having undergone periarticular surgery and immobilization in an inadvertent unreduced position. [5][6][7][8] There is no consensus on the treatment approach, and the limited cases reported have been treated with open arthrolysis with knee repositioning, 5 single stage open reduction with allograft ligament reconstruction and application of a skeletally fixed knee hinge, 6 staged surgery with reduction and ligament reconstruction, 9 gradual reduction with the Ilizarov external fixator, 7 or a combination of these techniques. 2,4 Knee arthrodesis 10 and arthroplasty 11,12 have also been reported as treatment options reserved for nonsalvageable and older patients.…”