Functional outcomes following Multiligament Knee Reconstrcution

Nagraj Shetty

Volume 5 | Issue 1 | Jan – April 2020 | Page 53-57

Author: Nagraj Shetty [1,2,3]

[1] Department of Orthopaedics, Lilavati Hospital, Mumbai, India.
[2] Department of Orthopaedics, Hinduja Healthcare, Mumbai, India.
[3] Department of Orthopaedics, Nanavati Hospital, Mumbai, India.

Address of Correspondence
Dr. Nagraj Shetty
Consultant Arthroscopy Knee & Shoulder Surgeon
Lilavati hospital, Nanavati hospital, Hinduja Healthcare; Mumbai, India.


Purpose: The purpose of this descriptive review was to study the available literature on final functional outcomes of multiligament knee injury (MLKI) reconstructions. Specific study factors included 1) Surgical vs nonoperative treatment 2) Repair vs reconstruction vs combined procedure 3) early vs late surgery; Single stage vs two stage procedures.
Methods: A PubMed search was performed from 1966 until 2020. and search terminologies included multiligament Knee injury, multiple ligament knee injury, knee dislocation, multiligament knee reconstruction and functional outcomes. Study inclusion criteria were 1) Levels I to IV evidence 2) Multiligament knee injury being defined as disruption of minimum 2 of the 4 major knee ligaments. 3) Assesment of final outcome both based on subjective clinical, functional scores like return to sports, preinjury activity level and stability scores. 4) minimum of 12 month follow up.
Results: Four high level studies compared surgical with nonoperative treatment. There were higher Lysholm scores (85 vs 67) in surgically treated patients (pts) as well as higher IKDC scores (69% vs 64%) and return to sport (41% vs 18%).The four studies comparing repair with reconstruction of damaged ligaments showed similar mean Lysholm (84 vs 84) and excellent IKDC scores. Nevertheless repair of the posterolateral corner (PLC) had a higher failure rate (39% vs 8 %) and lower return to sport activities (25% vs 51%). Similarly repair of the cruciates achieved decreased stability and range of motion. Eight articles were studied comparing early (within 3 weeks ) with delayed surgery. Early treatment resulted in higher mean Lysholm scores (89 vs v82), higher percentage of excellent IKDC scores (57% vs 41%)as well as higher mean ROM (129 degree vs 124 degrees)
Conclusions: This review suggests that the best treatment guidelines for MLKI is still awaited, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. Surgery must be performed within first 3 weeks upto 6 weeks for better results.When feasible ACL reconstruction can be delayed thereby reducing rate of arthrofibrosis
Keywords: descriptive review, functional outcomes, multiligament knee injury, multiple ligament knee injury, knee reconstruction.


1. Moatshe G., etal. Demographics and Injuries Associated With Knee Dislocation: A prospective review of 303 patients”. Orthopaedic Journal of Sports Medicine 5.5 (2017):232596711770652.
2. Wascher DC, Dvirnak pc, DeCoster TA. Knee dislocation:Initial assessment and implications for treatment . J Orthop Trauma 1997;11(7):525-529
3. Medina O, Arom GA, Yeranosian MG, ,Petrigliano FA , McAllister DR. Vascular and Nerve injury after knee dislocation: a systematic review . Clin OrthopRelat Res 2014;472:2621-9
4. Engebretsen L, Robertson B, Ludvigsen TC. Outcome after knee dislocations : a 2-9 years follow up of 85 consecutive patients . Knee Surg Sports TraumatolArthrosc 2009; 17(9):1013-26
5. Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries : an evidence based review .Sports Med Arthrosc 2011; 19(2):167-173
6. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports TraumatolArthrosc 1993;1(3-4):226-234
7. Wascher DC , Becker JR, Dexter JG, Blevins FT. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation, Results using fresh noniradiated allografts . Am J Sports Med 1999;27(2):189-196
8. Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R.ACL reconstruction : a meta analysis of functional scores . Clin OrthopRelat Res 2007; 458:180-187
9. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries . Clin OrthopRelat Res 1985;(198):43-49
10. Wright RW.Knee injury outcome measures. J Am AcadOrthop Surg 2009;17(1) 31-39
11. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 2001; 29(2):213-218
12. Wong CH, Tang JL, Chang HC, Khin LW, Low CO. Knee dislocations -a retrospective study comparing operative vs closed immobilization treatment outcomes . Knee Surg Sports TraumatolArthrosc 2004; 12(6):54-544
13. Rios A, Villa A, Fahandezh H, de Jose C, Vaquero J. Results after treatment of traumatic knee dislocations : a report of 26 cases. J Trauma 2003;55(3):489-494
14. Richter M, Bosch U, Wippermann B, Hoffman A, KrettekC.Comparison of surgical repair or reconstruction of the cruciate ligament versus non surgical treatment in patients with traumatic knee dislocations. Am J Sports Med 2002;30(5):718-727
15. Plancher KD, Siliski J. Long term functional results and complications in patients with knee dislocations . J Knee Surg 2008;21(4) 261-268
16. Dedmond BT, Almekinders LC. Operative vs nonoperative treatment of knee dislocations : a metaanalysis. Am J Knee Surg 2001; 14(1):33-38
17. Fanelli GC, Stannard JP, Stuart MJ, etal. Management of complex knee ligament injuries. J Bone Joint Surg Am 2010;92(12):2235-2246
18. Laprade RF, Chahla j, DePhillipoNN..etal.Single -stage Multiple-ligament Knee Reconstructions for Sports related injuries.Am J Sports Med 2019:1-9
19. Hirschmann MT, Zimmermann N, Rychen T, etal. Clinical and radiological outcomes after management of traumatic knee dislocation by open single stage complete reconstruction /repair. BMC MusculoskeletDisord2010;11:102
20. Tzurbakis M, Diamantopoulos A, Xenakis T, GeorgoulisA.Surgical treatment of multiple knee ligament injuries in 44 pts:208 years follow up results.Knee Surg Sports TraumatolArthrosc 2006;14(8): 739-749
21. 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;18(7):703-714
22. Karataglis D, Bisbinas I, Green MA, Learmonth DJ.Functional outcome following reconstruction in chronic multiple ligament deficient knees. Knee Surg Sports TraumatolArthrosc 2006; 14(9):843-847
23. Hua X, Tao H, Fang W, Tang J.Single stage in situ repair of multi-ligament knee injury: a retrospective study of 17 patients. BMC Musculoskeletal disorders 2016;17(41)
24. Vermeijden HD, Jonkergouw A, Van der list AP, DiFeliceGS.The multiple ligament -injured knee. When is primary repair an option .The Knee 2019
25. Frosch K, Preiss A, Heider S, Stengel D, Wohlmuth P, Hoffmann M.Primary ligament sutures as a treatment option of knee dislocations:a meta-analysis.Knee Surg Sports TraumatolArthrosc 2013;1502-9
26. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ.Repair vs reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament injured knee.Am J Sports Med 2010;38:804-9
27. Stannard JP. The posterolateral corner of the knee: repair vs reconstruction.Am J Sports Med 2005;33:881-8
28. Mariani PP, Santoriello P, Iannone S, Condello V, AdrianiE.Comparison of surgical treatments for knee dislocation. Am J Knee Surg 1999;12:214-21
29. Liow RYL, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and knee reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br 2003;85B:845-85
30. Harner CD, WaltripRL, Bennett CH, Francis KA, Cole B,IrrgangJJ.Surgical management of knee dislocation. J Bone Joint Surg Am 2004;86A:262-73
31. Subbiah M, Pandey V, Rao SK, Rao S.Staged reconstructive arthroscopic surgery for multiple ligament injuries of the knee. J Orthop Surg 2011;19(3):297-302
32. Li X, Liu T. Surgical management of multiple knee ligament injuries. Eur J OrthopTrauamatol2013;23:691-7.
33. Zhang Y, Zhang X, Hao Y, Zhang YM, Wang M, Zhou Y.Surgical management of the multiple-ligament injured knee: a case series.Orthop Surg2013;5:239-49
34. Wajsifisz A, BjardPlaweski S, DijianP,DemeyG,etal.Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears:OrthopTraumatol Surg Res 2014;100S:S379-83
35. Vicenti G, Solarino G, etl.Major concern in the multiligament-injured knee treatment:A systematic review.Injury 2019;:S89-S94
36. Black BS, Stannard JP. Repair vs reconstruction in acute posterolateral instability of the knee .Sports Med Arthrosc 2015;23:22-6
37. Gwathmey FW, ShafiqueDA,MillerMD.Our approach to the management of the multiple-ligament knee injury.Oper Tech Sports mED.2010;18(4):235-44.
38. Van der Wal WA, HeesterbeekPJC..etal.Anatomical reconstruction of posterolateral corner and combined injuries of the knee.Knee Surg Sports TraumatolArthrosc 2014;3369-7
39. Fanelli GC, Harris JD.Surgical treatment of acute medial collateral ligament and posteromedial corners of the knee.Sports Med Arthrosc Rev 2006;14(02):78-83
40. Moatshe G, Getgood A, LaPrade RF, EngebretsenL.Medial-sided injuries in the multiple ligament knee injury.J Knee Surg 2020:02-19
41. Fanelli GC.Evaluation and treatment of medial instability of the knee. Sports Med Arthrosc Rev 2015;23(02):61-62
42. Owens BD, Neault M, Benson E, BusconiBD.Primary repair of knee dislocations :results in 25 patients at a mean follow up of four years. J Orthop Trauma 2007;21(2):92-96
43. Stannard JP, Black BS, Azbell C, VolgasDA.Posteromedial corner injury in knee dislocations . J Knee Surg 2012;25:429-34
44. Twaddle BC, Bidwell TA, Chapman JR.Kneedislocations:where are the lesions ?A prospective evaluation of surgical findings in 63 cases. J Orthop Trauma 2003;17(3):198-202.

How to Cite this article: Shetty N | Functional outcomes following Multiligament Knee Reconstruction | Asian Journal Arthroscopy | January-April 2020; 5(1): 53-57.

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Complications of Multiple Ligament Knee Injury Surgery : Prevention and Salvage

Dinshaw N. Pardiwala, Kushalappa Subbiah, Nandan Rao, Vicky Jain

Volume 5 | Issue 1 | Jan – April 2020 | Page 58-65

Author: Dinshaw N. Pardiwala [1], Kushalappa Subbiah [1], Nandan Rao [1], Vicky Jain [1]

[1] Department of Orthopaedics, okilaben Dhirubhai Ambani Hospital, Mumbai, India.

Address of Correspondence
Dr. Dinshaw Pardiwala,
Kokilaben Dhirubhai Ambani Hospital
Four Bungalows, Andheri (W), Mumbai 400053, India.


Multiple ligament injuries of the knee are a complex group of injuries with diverse presentations, varying treatment options, and the potential for an array of significant complications. These include iatrogenic neurovascular injuries, fluid extravasation with compartment syndrome, intraoperative technical complications related to tunnel placement and graft tensioning, tourniquet complications, wound problems and infection, venous thromboembolic events, arthrofibrosis with loss of motion, residual knee instability, heterotopic ossification, and missed postoperative knee dislocations. Prevention of these complications is based on a comprehensive knowledge of knee ligament anatomy and biomechanics, understanding the unique and complex nature of these uncommon injuries, detailed preoperative clinico-radiological evaluation, astute surgical planning, careful operative execution, close postoperative monitoring, and a proper rehabilitation program. Early recognition of complications with appropriate and immediate management is critical for satisfactory functional outcomes.
Keywords: Multiple ligament knee injury, Knee dislocation, Complications, Prevention, Salvage, Surgical reconstruction


1. Pardiwala DN, Soni S, Raut A. Knee dislocations : classification and treatment algorithm. In: Marghereritini F et al, editors. Complex knee ligament injuries. Springer; 2019. p 3-18.
2. Natividad TT, Wascher CD. Complications associated with the treatment of the multiple ligament injured knee. In: Fanelli GC, editor. The multiple ligament injured knee: a practical guide to management. New York: Springer; 2013. p. 443–50.
3. McDonough EB Jr, Wojtys EM. Multi-ligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156–9.
4. Kaufman SL, Martin LG. Arterial injuries associated with complete dislocation of the knee. Radiology 1992;184:153–5.
5. Pardiwala DN, Rao NN, Anand K, Raut A. Knee dislocations in sports injuries. Indian J Orthop. 2017;51(5):552-562.
6. Matava MJ, Sethi NS, Totty WG. Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796–804.
7. Tay AK, MacDonald PB. Complications associated with treatment of multiple ligament injured (dislocated) knee. Sports Med Arthrosc 2011;19(2):153–61.
8. Woodmass JM, Romatowski NPJ, Esposito JG, Mohtadi NGH, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2992–3002.
9. Krych AJ, Giuseffi SA, Kuzma SA, Stuart MJ, Levy BA. Is peroneal nerve injury associated with worse function after knee dislocation? Clin Orthop. 2014 Sep;472(9):2630–6.
10. Luo H, Yu JK, Ao YF, et al. Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction. Chin Med J (Engl) 2007;120:1127–30.
11. Poehling GG, Pollock FE Jr, Korman LA Reflex sympathetic dystrophy of the knee after sensory nerve injury. Arthroscopy 4:31-35, 1988.
12. Figueroa D, Calvo R, Vaisman A, et al. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study. Knee 2008;15:360–3.
13. Zazanis GA, Kummell BM: Preservation of infrapatellar branch of saphenous nerve J Surg 140:186, 1980 9:135-140, 1995.
14. Bomberg BC, Hurley PE, Clark CA, et al. Complications associated with the use of an infusion pump during knee arthroscopy. Arthroscopy 1992;8:224–8
15. Ekman EF, Poehling GG. An experimental assessment of the risk of compartment syndrome during knee arthroscopy. Arthroscopy 1996;12:193–9
16. Amendola A, Faber K, Willits K, et al. Compartment pressure monitoring during anterior cruciate ligament reconstruction. Arthroscopy 1999;15:607–12.
17. Konan S, Haddad FS. Femoral fracture following knee ligament reconstruction surgery due to an unpredictable complication of bioabsorbable screw fixation: a case report and review of literature. J Orthop Traumatol 2010;11:51–5.
18. Athanasian EA, Wickiewicz TL, Warren RF. Osteonecrosis of the femoral medial condyle after arthroscopic reconstruction of a cruciate ligament: Report of two cases. J Bone Joint Surg. 1995; 77A:1418-1422.
19. Moatshe G, Brady AW, Slette EL, et al. Multiple ligament reconstruction femoral tunnels: intertunnel relationships and guidelines to avoid convergence. Am J Sports Med 2017;45(3):563–9.
20. Moatshe G, Slette EL, Engebretsen L, et al. Intertunnel relationships in the tibia during reconstruction of multiple knee ligaments: how to avoid tunnel convergence. Am J Sports Med 2016;44(11):2864–9.
21. Hegyes MS, Richardson MW, Miller MD. Knee dislocation: Complications of operative and non operative management. Clin Sports Med. 2000;19:519-543.
22. Moore MR, Garfin SR, Hargens AR Wide tourniquets eliminate blood flow at low infiltration pressures. J Hand Surg 12:1006-1011, 1987.
23. Almekinders LC, Logan TC: Results following treatment of traumatic knee dislocations of the knee joint. Orthop Clin North Am 284:203-207, 1992.
24. Graf B, Uhr F: Complications of intra-articular anterior cruciate reconstruction. Clin Sports Med 7935-842, 1988.
25. Hughston J: Complications of anterior cruciate ligament surgery. Orthop Clin North Am 16:237-245, 1985.
26. Engebretsen L, Risberg MA, Robertson B, et al. Outcome after knee dislocations: a 2-9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc 2009;17:1013–26.
27. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86: 910–915.
28. Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations. J Bone Joint Surg Am 2004;86-A:262–73.
29. Harner CD, Irrgang JJ, Paul J, et al. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med 1992;20:499–506.
30. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292–9.
31. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991;19:332–6.
32. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of motion following anterior cruciate ligament reconstruction. A case-control study. Am J Sports Med 1991; 19:620–5.
33. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy 1996;12: 521–30.
34. Fu FH, Irrgang JJ, Sawhney R, et al: Loss of knee motion following anterior cruciate ligament reconstruction. Am J Sports Med 18:557-562, 1990.
35. Shapiro MS, Freedman EL Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation. Am J Sports Med 23:580-587, 1995
36. Thomas P, Rud B, Jensen U: Stability and motion after traumatic dislocation of the knee. Acta Orthop Scand 55:278-283, 1984
37. Stannard JP, Wilson TC, Sheils TM, et al. Heterotopic ossification associated with knee dislocation. Arthroscopy 2002;18:835–9.
38. Patton WC, Tew WM. Periarticular heterotopic ossification after multiple knee ligament reconstructions. A report of three cases. Am J Sports Med 2000;28(3): 398–401.
39. Whelan DB, Dold AP, Trajkovski T, Chahal J. Risk factors for the development of heterotopic ossification after knee dislocation. Clin Orthop Relat Res. 2014 Sep;472(9):2698-704.
40. Simonian PT, Wickiewicz TL, Hotchkiss RN, et al. Chronic knee dislocation: reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med. 1998;26:591–596.

How to Cite this article: Pardiwala DN, Subbiah K, Rao N, Jain V | Complications of Multiple Ligament Knee Injury Surgery : Prevention and Salvage | Asian Journal of Arthroscopy | January-April 2020; 5(1): 58-65.

(Abstract)      (Full Text HTML)      (Download PDF)