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J Knee Surg 2023; 36(03): 236-245
DOI: 10.1055/s-0041-1731325
Original Article

Multiligamentous Knee Injuries: Current Concepts Review

Calvin Holloway
1   University of Chicago Pritzker School of Medicine, University of Chicago Medical Center, Chicago, Illinois
,
Andrew Rizzi 
2   Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medical Center, Chicago, Illinois
,
Jason Dickherber
2   Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medical Center, Chicago, Illinois
,
Aravind Athiviraham 
2   Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medical Center, Chicago, Illinois
› Author Affiliations Funding None.
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Abstract

Multiligamentous knee injuries (MLKI) are rare but devastating injuries that have a potential to cause long-term sequelae and significant morbidity. Frequently occurring concomitantly with knee dislocations (KD), MLKI have many risk factors that influence their incidence and treatment outcomes. Proper understanding of these risk factors can assist the surgeon with evaluation, surgical planning, and managing patient expectations both pre- and postoperatively. The purpose of this review is fourfold: (1) identify the risk factors and injuries associated with MLKI, (2) describe factors implicated in the treatment of MLKI, (3) report the effect of these risk factors on outcomes of MLKI, and (4) provide a brief insight into MLKI at our tertiary referral academic care center. This was a retrospective review of literature relevant to MLKI. Studies that described injuries, risk factors, treatment techniques, or outcomes associated with MLKI were included in our review. A total of 35 studies (consisting of level 3 and 4 evidence) published between 2009 and 2020 were found and included in our analysis. In addition, 25 patients who underwent treatment for MLKI at the University of Chicago Medical Center between December 2015 and December 2019 were included in our analysis. MLKI tend to occur in the younger male population. Increasing age, body mass index, and severity of the injury have been correlated with worse functional and patient-reported outcomes. Operative treatment is indicated for MLKI; however, timing and repair versus reconstruction is still debated, and is often decided on a patient by patient basis. Retrospective cohort studies have indicated that reconstruction may be favored; however, further more rigorous studies are needed to better characterize this finding. MLKIs are devastating injuries with significant variability in presentation, treatment, and outcome. Variations in these are largely attributable to the mechanism and severity of injury, timing, and surgeon preference. A holistic approach, and understanding of the present literature, is required to best optimize patient outcome.

Keywords

multiligamentous knee injury - knee dislocation - trauma

Note

This study was performed at University of Chicago Medical Center, Chicago, IL.




Publication History

Received: 14 July 2020

Accepted: 01 May 2021

Article published online:
02 July 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Tardy N, Boisrenoult P, Teissier P, Steltzlen C, Beaufils P, Pujol N. Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc 2017; 25 (02) 524-531
    CrossrefPubMedGoogle Scholar
  • 2 Sundararajan SR, Sambandam B, Rajagopalakrishnan R, Rajasekaran S. Comparison of KD3-M and KD3-L multiligamentous knee injuries and analysis of predictive factors that influence the outcomes of single-stage reconstruction in KD3 injuries. Orthop J Sports Med 2018; 6 (09) 2325967118794367
    CrossrefPubMedGoogle Scholar
  • 3 Levy BA, Dajani KA, Whelan DB. et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy 2009; 25 (04) 430-438
    CrossrefPubMedGoogle Scholar
  • 4 Moatshe G, Dornan GJ, Løken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and injuries associated with knee dislocation: a prospective review of 303 patients. Orthop J Sports Med 2017; 5 (05) 2325967117706521
    CrossrefPubMedGoogle Scholar
  • 5 Darcy G, Edwards E, Hau R. Epidemiology and outcomes of traumatic knee dislocations: isolated vs multi-trauma injuries. Injury 2018; 49 (06) 1183-1187
    CrossrefPubMedGoogle Scholar
  • 6 Vaidya R, Roth M, Nanavati D, Prince M, Sethi A. Low-velocity knee dislocations in obese and morbidly obese patients. Orthop J Sports Med 2015; 3 (04) 2325967115575719
    CrossrefPubMedGoogle Scholar
  • 7 Peskun CJ, Chahal J, Steinfeld ZY, Whelan DB. Risk factors for peroneal nerve injury and recovery in knee dislocation. Clin Orthop Relat Res 2012; 470 (03) 774-778
    CrossrefPubMedGoogle Scholar
  • 8 Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma 2013; 27 (04) 226-231
    CrossrefPubMedGoogle Scholar
  • 9 Krych AJ, Giuseffi SA, Kuzma SA, Stuart MJ, Levy BA. Is peroneal nerve injury associated with worse function after knee dislocation?. Clin Orthop Relat Res 2014; 472 (09) 2630-2636
    CrossrefPubMedGoogle Scholar
  • 10 Kaeding CC, Pedroza AD, Parker RD, Spindler KP, McCarty EC, Andrish JT. Intra-articular findings in the reconstructed multiligament-injured knee. Arthroscopy 2005; 21 (04) 424-430
    CrossrefPubMedGoogle Scholar
  • 11 Schenck R. Classification of knee dislocations. Oper Tech Sports Med 2003; 11: 193-198
    CrossrefPubMedGoogle Scholar
  • 12 Sherman SL, Chalmers PN, Yanke AB. et al. Graft tensioning during knee ligament reconstruction: principles and practice. J Am Acad Orthop Surg 2012; 20 (10) 633-645
    CrossrefPubMedGoogle Scholar
  • 13 Bedi A, LaPrade RF, Burrus MT. Radiographic and anatomic landmarks of the major knee ligaments. J Bone Joint Surg Am 2018; 100 (14) 1241-1250
    CrossrefPubMedGoogle Scholar
  • 14 Chahla J, Moatshe G, Dean CS, LaPrade RF. Posterolateral corner of the knee: current concepts. Arch Bone Jt Surg 2016; 4 (02) 97-103
    PubMedGoogle Scholar
  • 15 McCarthy M, Ridley TJ, Bollier M, Cook S, Wolf B, Amendola A. Posterolateral knee reconstruction versus repair. Iowa Orthop J 2015; 35: 20-25
    PubMedGoogle Scholar
  • 16 Geeslin AG, Geeslin MG, LaPrade RF. Ligamentous reconstruction of the knee: what orthopaedic surgeons want radiologists to know. Semin Musculoskelet Radiol 2017; 21 (02) 75-88
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Lundquist RB, Matcuk Jr GR, Schein AJ. et al. Posteromedial corner of the knee: the neglected corner. Radiographics 2015; 35 (04) 1123-1137
    CrossrefPubMedGoogle Scholar
  • 18 Levy NM, Krych AJ, Hevesi M. et al. Does age predict outcome after multiligament knee reconstruction for the dislocated knee? 2- to 22-year follow-up. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 3003-3007
    CrossrefPubMedGoogle Scholar
  • 19 Johnson JP, Kleiner J, Klinge SA, McClure PK, Hayda RA, Born CT. Increased incidence of vascular injury in obese patients with knee dislocations. J Orthop Trauma 2018; 32 (02) 82-87
    CrossrefPubMedGoogle Scholar
  • 20 Werner BC, Hadeed MM, Gwathmey Jr FW, Gaskin CM, Hart JM, Miller MD. Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes?. Clin Orthop Relat Res 2014; 472 (09) 2658-2666
    CrossrefPubMedGoogle Scholar
  • 21 Godin JA, Cinque ME, Pogorzelski J, Moatshe G, Chahla J, LaPrade RF. Multiligament knee injuries in older adolescents: a 2-year minimum follow-up study. Orthop J Sports Med 2017; 5 (09) 2325967117727717
    CrossrefPubMedGoogle Scholar
  • 22 Barrow AE, Sheean AJ, Burns TC. Return to duty following combat-related multiligamentous knee injury. Injury 2017; 48 (04) 861-865
    CrossrefPubMedGoogle Scholar
  • 23 Werner BC, Gwathmey Jr FW, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med 2014; 42 (02) 358-363
    CrossrefPubMedGoogle Scholar
  • 24 King AH, Krych AJ, Prince MR, Sousa PL, Stuart MJ, Levy BA. Are meniscal tears and articular cartilage injury predictive of inferior patient outcome after surgical reconstruction for the dislocated knee?. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 3008-3011
    CrossrefPubMedGoogle Scholar
  • 25 Sanders TL, Johnson NR, Levy NM. et al. Effect of vascular injury on functional outcome in knees with multiligament injury: a matched-cohort analysis. J Bone Joint Surg Am 2017; 99 (18) 1565-1571
    CrossrefPubMedGoogle Scholar
  • 26 Krych AJ, Sousa PL, King AH, Engasser WM, Stuart MJ, Levy BA. Meniscal tears and articular cartilage damage in the dislocated knee. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 3019-3025
    CrossrefPubMedGoogle Scholar
  • 27 Worley JR, Brimmo O, Nuelle CW, Cook JL, Stannard JP. Incidence of concurrent peroneal nerve injury in multiligament knee injuries and outcomes after knee reconstruction. J Knee Surg 2019; 32 (06) 560-564
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Chahla J, Dean CS, Matheny LM, Mitchell JJ, Cinque ME, LaPrade RF. Outcomes of inside-out meniscal repair in the setting of multiligament reconstruction in the knee. Am J Sports Med 2017; 45 (09) 2098-2104
    CrossrefPubMedGoogle Scholar
  • 29 Fanelli GC, Edson CJ. Surgical treatment of combined PCL-ACL medial and lateral side injuries (global laxity): surgical technique and 2- to 18-year results. J Knee Surg 2012; 25 (04) 307-316
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 King AH, Krych AJ, Prince MR, Pareek A, Stuart MJ, Levy BA. Surgical outcomes of medial versus lateral multiligament-injured, dislocated knees. Arthroscopy 2016; 32 (09) 1814-1819
    CrossrefPubMedGoogle Scholar
  • 31 Stannard JP, Bauer KL. Current concepts in knee dislocations: PCL, ACL, and medial sided injuries. J Knee Surg 2012; 25 (04) 287-294
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Freychet B, Kennedy NI, Sanders TL. et al. No difference between single and staged posterolateral corner surgical procedures in the multiligament injured/dislocated knee. Knee Surg Sports Traumatol Arthrosc 2020; 28 (07) 2170-2176
    CrossrefPubMedGoogle Scholar
  • 33 Buyukdogan K, Laidlaw MS, Miller MD. Surgical management of the multiple-ligament knee injury. Arthrosc Tech 2018; 7 (02) e147-e164
    CrossrefPubMedGoogle Scholar
  • 34 Hanley J, Westermann R, Cook S. et al. Factors associated with knee stiffness following surgical management of multiligament knee injuries. J Knee Surg 2017; 30 (06) 549-554
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Schenck Jr RC, Hunter RE, Ostrum RF, Perry CR. Knee dislocations. Instr Course Lect 1999; 48: 515-522
    PubMedGoogle Scholar