Short to Mid-term Outcomes of Single-stage Reconstruction of Multiligament Knee Injury

Document Type : RESEARCH PAPER


1 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

2 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran.


Background: Multiligament knee injury (MLKI) is a complex orthopedic injury leading to the tear of at least two of
the major knee ligaments. However, there is no consensus on the optimal management of this debilitating condition.
Regarding this, the present study was performed to evaluate the outcomes of single-stage multiligament reconstruction
surgery in patients with MLKI.
Methods: This retrospective study was conducted on 41 consecutive MLKI patients who underwent surgical
reconstruction. Objective evaluation of the outcome included active extension and flexion. Furthermore, the subjective
evaluation of the outcome was accomplished using the Lysholm scoring scale and International Knee Documentation
Committee (IKDC) form in Persian. Postoperative complications were also recorded for all patients.
Results: The mean age of the participants was 31.95±7.82 years. In addition, the mean follow-up period and the
mean time interval between the injury and surgery were recorded as 36.9±17.8 and 11.5±8.9 months, respectively. The
mean Lysholm and IKDC scores were obtained as 86.9±11.5 and 70±18.7, respectively. The mean Lysholm and IKDC
scores were not statistically different between the patients who underwent surgery less than 6 months after the injury
and those subjected to reconstruction 6 months postinjury (P=0.07 and P=0.3, respectively). Seven patients showed
postoperative restricted range of motion, which was resolved with physiotherapy. The only surgical complication was
popliteal artery injury.
Conclusion: As the findings indicated, the single-stage reconstruction of MLKI provided an acceptable outcome.
However, several aspects of this reconstruction, such as the timing of the surgery, still remain to be resolved in future
Level of evidence: IV


Main Subjects

1. Riboh JC. Multiligament knee injuries. Singapore:
World Scientific Publishing Company; 2016. P. 359-67.
2. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC,
Stuart MJ, et al. Decision making in the multiligamentinjured
knee: an evidence-based systematic review.
Arthroscopy. 2009; 25(4):430-8.
3. Manske RC, Hosseinzadeh P, Giangarra CE. Multiple
ligament knee injury: complications. N Am J Sports
Phys Ther. 2008; 3(4):226-33.
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. Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe
G, Ziegler C, et al. Posterior cruciate ligament: current
concepts review. Arch Bone Jt Surg. 2018; 6(1):8-18.
6. Jones RE, Smith EC, Bone GE. Vascular and orthopedic
complications of knee dislocation. Surg Gynecol
Obstet. 1979; 149(4):554-8.
7. Rihn JA, Groff YJ, Cha PS, Harner CD. The acutely
dislocated knee: evaluation and management. J Am
Acad Orthop Surg. 2004; 12(5):334-46.
8. Hoover NW. Injuries of the popliteal artery associated
with fractures and dislocations. Surg Clin North Am.
1961; 41(4):1099-112.
9. James EW, Williams BT, LaPrade RF. Stress
radiography for the diagnosis of knee ligament
injuries: a systematic review. Clin Orthop Relat Res.
2014; 472(9):2644-57.
10. Barfield WR, Holmes RE, Slone H, Walton ZJ, Hartsock
LA. Acute versus staged surgical intervention in
multiligamentous knee injuries: a review of the
literature since 2009. Curr Orthop Pract. 2015;
11. Schenck RC Jr. The dislocated knee. Instr Course Lect.
1994; 43(1):127-36.
12. Negahban H, Mostafaee N, Sohani SM, Mazaheri M,
Goharpey S, Salavati M, et al. Reliability and validity of
the Tegner and Marx activity rating scales in Iranian
patients with anterior cruciate ligament injury. Disabil
Rehabil. 2011; 33(22-23):2305-10.
13. Ebrahimzadeh MH, Makhmalbaf H, Golhasani-Keshtan
F, Rabani S, Birjandinejad A. The international knee
documentation committee (IKDC) subjective short
form: a validity and reliability study. Knee Surg Sports
Traumatol Arthrosc. 2015; 23(11):3163-7.
14. Hadi H, Bagherifar A, Tayebi F, Ansari M,
Shahsavaripour A, Qomashi I, et al. Anterior cruciate
ligament reconstruction with hamstring tendons has
no deleterious effect on hip extension strength. Arch
Bone Jt Surg. 2019; 7(3):278-83.
15. Noyes FR, Barber-Westin SD. Posterolateral ligament
injuries: diagnosis, operative techniques, and
clinical outcomes. Noyes’ knee disorders: surgery,
rehabilitation, clinical outcomes. New York: Elsevier;2017. P. 527-77.
16. Moatshe G, Chahla J, LaPrade RF, Engebretsen L.
Diagnosis and treatment of multiligament knee
injury: state of the art. J ISAKOS. 2017; 2(3):152-61.
17. Peskun CJ, Whelan DB. Outcomes of operative and
nonoperative treatment of multiligament knee
injuries: an evidence-based review. Sports Med
Arthrosc Rev. 2011; 19(2):167-73.
18. Stannard JP, Brown SL, Farris RC, McGwin G, Volgas DA.
The posterolateral corner of the knee: repair versus
reconstruction. Am J Sports Med. 2005; 33(6):881-8.
19. Mariani PP, Santoriello P, Iannone S, Condello V,
Adriani E. Comparison of surgical treatments for knee
dislocation. Am J Knee Surg. 1999; 12(4):214-21.
20. Jari S, Shelbourne KD. Nonoperative or delayed
surgical treatment of combined cruciate ligaments
and medial side knee injuries. Sports Med Arthrosc
Rev. 2001; 9(3):185-92.
21. Karataglis D, Bisbinas I, Green MA, Learmonth DJ.
Functional outcome following reconstruction in
chronic multiple ligament deficient knees. Knee Surg
Sports Traumatol Arthrosc. 2006; 14(9):843-7.
22. Fanelli GC, Edson CJ. Combined posterior cruciate
ligament-posterolateral reconstructions with
Achilles tendon allograft and biceps femoris tendon
tenodesis: 2-to 10-year follow-up. Arthroscopy.
2004; 20(4):339-45.
23. Fanelli GC, Edson CJ. Arthroscopically assisted
combined anterior and posterior cruciate ligament
reconstruction in the multiple ligament injured
knee: 2-to 10-year follow-up. Arthroscopy. 2002;
24. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo
M. Arthrofibrosis in acute anterior cruciate ligament
reconstruction: the effect of timing of reconstruction
and rehabilitation. Am J Sports Med. 1991;
25. Shelbourne K, Baele J. Treatment of combined anterior
cruciate ligament and medial collateral ligament
injuries. Am J Knee Surg. 1988; 1(1):56-8.
26. Mook WR, Miller MD, Diduch DR, Hertel J, Boachie-
Adjei Y, Hart JM. Multiple-ligament knee injuries:
a systematic review of the timing of operative
intervention and postoperative rehabilitation. J Bone
Joint Surg Am. 2009; 91(12):2946-57.
27. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC,
Stuart MJ, et al. Decision making in the multiligamentinjured
knee: an evidence-based systematic review.
Arthroscopy. 2009; 25(4):430-8.
28. Skendzel JG, Sekiya JK, Wojtys EM. Diagnosis and
management of the multiligament-injured knee. J
Orthop Sports Phys Ther. 2012; 42(3):234-42.
29. Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament
injured knee: evaluation, treatment, and results.
Arthroscopy. 2005; 21(4):471-86.