Diagnosis and treatment of multiligament knee injury: state of the art

Multiligament knee injuries constitute a complex and challenging entity, not only because of the diagnosis and reconstruction procedure itself, but also because of the rehabilitation programme after the index procedure. A high level of suspicion and a comprehensive clinical and radiographic examination are required to identify all injured structures. Concomitant meniscal, chondral and nerve injuries are common in multiligament injuries necessitating a detailed evaluation. Stress radiographs are valuable in evaluating patients preoperatively and postoperatively. The current literature supports surgical management of multiligament injuries, and reconstructions are recommended because repair of ligaments has higher failure rates. Reconstruction of all injured ligaments in one stage is advocated (if possible) in order to achieve early mobilisation and to avoid joint stiffness. Using biomechanically and clinically validated anatomic ligament reconstructions improves outcomes. In the setting of multiligament knee reconstructions, several technical aspects that require consideration are vital, such as the graft choice, the sequence of ligaments reconstruction, tunnel position and orientation to avoid tunnel interference and graft tensioning order. This review article discusses the use of stress radiographs in diagnosing ligament injuries and evaluating postoperative stability. Tunnel convergence and tensioning sequence are potential problems, and guidelines to address these are also discussed. Recovery after a multiligament reconstruction surgery typically requires 9 to 12 months of rehabilitation prior to returning to full activities. The purpose of this article is to review the specific principles of multiligament injuries, classification, diagnosis, treatment options and rehabilitation guidelines for addressing these complex injuries. InTroduCTIon The definition of a multiligament knee injury is commonly recognised as a tear of at least two of the four major knee ligament structures: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the posteromedial corner (PMC) and the posterolateral corner (PLC).1 2 The terms knee dislocation and multiligament knee injuries are often used interchangeably. Knee dislocations often result in multiligament knee injuries, but some multiligament knee injuries are not knee dislocations. A knee dislocation is typically characterised by rupture of both cruciate ligaments, with or without an associated grade III medial or lateral-sided injury.2 3 However, knee dislocations with one of the cruciate ligaments intact have been reported.4 5 Multiligament injuries are heterogeneous, and a thorough diagnostic workup and treatment plan is mandatory when dealing with these injuries. The purpose of this article is to review specific focused principles of multiligament knee injuries, classification, diagnosis, treatment options and rehabilitation guidelines for addressing these complex injuries. Key information and articles on these injuries can be found in box 1 and box 2 respectively. Classification Schenck described the most widely used classification system for the dislocated knee in 1994, which is based on the anatomical patterns of the torn ligaments (table 1).3 6 The advantage of this classification is that it allows for identification of the torn ligaments and planning of treatment. In addition, it makes it possible to compare the different studies in the literature using the same classification system of knee dislocations. Aetiology Multiligament knee injuries can be caused by both high-energy trauma,7 such as motor vehicle accidents and fall from heights, and low-energy trauma,8 including sporting activities. In a cohort of 85 patients with knee dislocations, Engebretsen et al reported that 51% were high-energy injuries, and 47% were sports-related injuries.9 In a review of 303 patients with knee dislocations, Moatshe et al10 reported equivalent rates of highand low-energy trauma, with 50.3% and 49.7%, respectively. Miller et al reported on multiligament knee injuries in obese individuals as a result of ultra-low velocity trauma.11 Evaluation Multiligament knee injuries are not uncommon. Only 28% of PLC injuries occur in isolation.12 The clinician should have a high level of suspicion, and a detailed knee examination should be performed including assessment of the limb’s neurovascular status. PLC injuries are associated with both common peroneal nerve injuries and vascular injuries (Moatshe et al,10). When both cruciate ligaments are torn, the risk of vascular and neurological injuries is very high and vascular assessment is often needed.2 Magnetic resonance imaging (MRI) is performed to evaluate all the injured structures (figure 1). For both acute and chronic injuries, stress radiographs are essential, but can be difficult to carry out in the acute phase (tables 2 and 3, figures 2 and 3).13–15 Acute multiligament knee injuries For high-energy injuries, Advanced Trauma Life Support principles apply. Foot pulses and skin 1 Moatshe G, et al. JISAKOS 2017;0:1–10. doi:10.1136/jisakos-2016-000072. Copyright © 2017 ISAKOS Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine Publish Ahead of Print, published on March 8, 2017 as doi:10.1136/jisakos-2016-000072 Copyright 2017 by International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. group.bmj.com on December 21, 2017 Published by http://jisakos.bmj.com/ Downloaded from