Presentation and Surgical Management of Multiple Ligament Knee Injuries

Abstract

Background:Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system.Methods:This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively.Results:A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range [IQR], 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved menisci (55.6%), nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication.Conclusions:A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up

“…2,22 Given that MLKI and KD are often intertwined, it is becoming even more apparent that 2 distinct entities exist along the progressive spectrum of ligamentous knee injuries. 8,20,23 Sustaining a traumatic KD with radiographic evidence of tibiofemoral disarticulation or clinical documentation of a manual reduction of a tibiofemoral KD has been shown by our multi-institutional data to be associated with a poorer clinical outcome and reduced activity capacity at a mean of 6.5 years after injury. Documented KDs likely represent a greater insult to the soft tissue envelope than a nondislocated 3-ligament knee injury.…”

“…23 It has been shown throughout multiple large, multicenter studies that KD3 is the most common subset of disarticulations encountered. 19,23 The authors of the current study believed that a frankly dislocated knee joint would present as a more severe injury than a nondislocated MLKI, and this was supported by the higher rates of neurovascular compromise identified at presentation and inferior clinical results and activity levels reported at a mean follow-up of 6.5 years among those in the KD group.…”

“…The authors support the anatomic classification system for MLKIs proposed by the Surgical Timing and Rehabilitation Trial for MLKIs Network, based on that of Schenck, allowing for a more reliable tool encompassing all soft tissue knee injuries that exist along the progressive spectrum extending from nondislocated 2-ligament injuries to frank traumatic open dislocations with neurovascular compromise. 23 It has been shown throughout multiple large, multicenter studies that KD3 is the most common subset of disarticulations encountered. 19,23 The authors of the current study believed that a frankly dislocated knee joint would present as a more severe injury than a nondislocated MLKI, and this was supported by the higher rates of neurovascular compromise identified at presentation and inferior clinical results and activity levels reported at a mean follow-up of 6.5 years among those in the KD group.…”

“…4,6 The knee dislocation-3 (KD3) injury pattern of MLKI consists of tears to both cruciate ligaments and one of the collateral ligaments, is subdivided based on medial (KD3-M) or lateral (KD3-L) involvement, and is the most common pattern of ligamentous injury associated with KD. 5,9,17,23,29 While KD3-M injuries have been shown to present more often with a documented dislocation, KD3-L injuries occur more often in higher-energy and polytraumatized settings. 4,14 Posterolateral corner (PLC) injuries in the setting of MLKI are more likely than medial injuries to require surgical intervention in an effort to restore knee stability and optimize clinical outcomes.…”

An examination from 1990 to 2019: investigating the burden of knee dislocation on a global scale

“…Given that the disease burden of knee dislocation has not lessened, its rehabilitation is also a point that needs attention. Loss of motion is not uncommon after surgery for multiple knee ligament injuries ( 44 ). Unfortunately, the rehabilitation of knee dislocation remains full of unknowns ( 45 ).…”