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Multiligament Injury

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Other Names

  • Multiligament knee injuries (MLKI)
  • Multiligament Knee Injury

Background

History

Epidemiology

  • Estimated to represent 0.02% to 0.20% of all orthopedic injuries[1]
  • Likely underestimated as a high proportion are missed on initial evaluation

Pathophysiology

Etiology

  • High energy trauma
    • Examples include motor vehicle crash, ATV accident
    • Often associated with other injuries
  • Lower energy trauma
    • Sports-related trauma
    • Fall from standing

Associated Injuries

Risk Factors

  • Needs to be updated

Differential Diagnosis

Clinical Features

  • History
    • High energy or low energy trauma
    • If ambulation attempted, likely instability or buckling
  • Physical Exam: Physical Exam Knee
    • Dimple Sign: buttonholing of of medial femoral condyle through medial capsule
    • Very important to document a thorough vascular exam
    • Presence of peripheral pulses does not exclude vascular injury
    • Abnormal pedal pulse is only 79% sensitive, 91% specific for arterial injury[2]
    • Serial vascular exam is mandatory
    • Assess Peroneal Nerve, Tibial Nerve
    • Carefully examine compartments
  • Special Tests
    • Ankle Brachial Index: can be used to compare vascular flow to contralateral limb
    • Need to perform structural exam assessing ACL, PCL, MCL and LCL

Evaluation

Multiligament Knee Injury with Popliteal Artery Injury
Knee dislocation algorithim proposed by Ng et al[3]

Ankle Brachial Index

  • Excellent screening tool since arteriography is impractical in all patients
    • If ABI < 0.9, must pursue further vascular workup
  • Mills et al: ABI <0.9 has 100% sensitivity, specificity and PPD for vascular injuries in knee dislocations[4]

Radiographs

MRI

  • Indicated in most cases
    • After reduction, prior to surgical intervention if possible
  • Helpful to identify degree of soft tissue injury
    • Especially in the multi-ligament knee injury
  • Consider angiography

CT

  • Useful to evaluate for fracture patterns
  • Findings
    • Tibial eminence fracture
    • Tibial tubercle fracture
    • Tibial Plateau fracture
  • Consider angiography

Ultrasound

  • Duplex arterial sonography may be useful to evaluate arterial supply

Classification

Schenck Anatomic Knee Dislocation (KD) Classification

  • KD I: Knee dislocation with either cruciate intact
  • KD II: Bicruciate with collateral intact
  • KD III: Bicruciate injury with one collateral ligament injury
    • KD IIIM: Bicruciate + MCL injury
    • KD IIIL: Bicruciate + LCL injury
  • KD IV: Bicruciate with both colateral ligaments injured
  • KD V: Periarticular fracture dislocation

Management

Prognosis

  • Levy et al systematic review compared operative to nonoperative management[5]
    • Overall, operative treatment results in better functional outcome as compared to nonoperative treatment
    • Higher rates of return to work and pre-injury sports activities
    • International Knee Documentation Committee [IKDC] excellent/good results 58% operative vs 20% nonoperative
    • Return to sport is 29% in operative group vs 10% in nonoperative group
    • Range of motion (126° vs. 123°) and flexion (4° vs. 3°) loss were similar among groups
  • Timing of surgery
    • Levy looked at timing of surgery[6]
      • More likely to return to sport if surgery done within 3 weeks
      • No difference in functional outcomes between early and late surgery
  • Staged vs acute reconstruction/repair
    • Jiang et al: staged treatment yield best clinical results for KD III, with no difference between acute and chronic reconstruction[7]
    • Mook et al: staged procedures produced better outcomes, acute timeline was superior[8]

Acute

  • Follow ATLS protocol when appropriate, based on mechanism
  • Examination
    • Thorough structural examination
    • Examine soft tissue compartments
    • Confirm palpable dorsalis pedis, posterior tibia and popliteal artery pulses
  • Immobilization
  • Imaging
    • Pre and post-reduction radiographs
    • Consider CT (with angiography), emergent MRI
    • Vascular- consider ABI, duplex arterial sonography
  • Emergent surgery
    • Irreducible knee dislocation
    • Open knee dislocation
    • Vascular injury

Nonoperative

Operative

  • Indications
    • Virtually all cases
  • Technique
    • Repair
    • Reconstruction

Rehab and Return to Play

Rehabilitation

  • Overall, there is a paucity of evidence guiding rehabilitation of repaired MLKI
  • General consensus is protected non-weight bearing for 4-6 weeks
    • Followed by active mobilization, progressive weight bearing, avoid passive stretching[9]
  • Mook et al showed early mobilization resulted in better range of motion, stability[8]

Return to Play

  • Needs to be updated

Complications

  • Popliteal Artery injury
    • Reported in 18 to 64% of knee dislocations[10]
    • Approximately 80% are repaired, 12% require amputation
    • Lower risk in sports-related injuries than high-velocity injuries[11]
    • Early interventions within 8 hours (11%) is associated with lower rates of amputation than beyond (86%)[12]
    • Highest risk with KD IV injuries
    • McDonough case series on popliteal artery injuries following MLKI[13]
      • 4/12 identified by physical exam, 5/12 identified with arteriography and 3/12 identified in OR with vascular exam and arteriography
  • Peroneal Nerve Injury
    • Most commonly the Common Peroneal Nerve, however Superficial Peroneal Nerve, Deep Peroneal Nerve also affected
    • Injured in between 25% and 33% of dislocations, particular posterior and lateral[14][15]
    • As high as 41% in posterlateral corner injuries[16]
    • Among sports, skiing and football are most commonly associated[17]
    • Approximately 30% have a complete palsy, with only 38.4% of them having a functional recovery
    • Approximately 70% have an incomplete palsy, 87.3% of them have a functional recovery[18]
  • Inability to return to sport
  • Chronic instability
  • Chronic pain

See Also

References

  1. ↑ Howells NR , Brunton LR , Robinson J , Porteus AJ , Eldridge JD , Murray JR . Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury 2011;42:1198–1204.
  2. ↑ Barnes CJ , Pietrobon R , Higgins LD . Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma 2002;53:1109–1114
  3. ↑ Ng, Jimmy Wui Guan, Yulanda Myint, and Fazal M. Ali. "Management of multiligament knee injuries." EFORT Open Reviews 5.3 (2020): 145-155.
  4. ↑ Mills WJ , Barei DP , McNair P . The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004;56:1261–1265.
  5. ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
  6. ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
  7. ↑ Jiang W , Yao J , He Y , Sun W , Huang Y , Kong D . The timing of surgical treatment of knee dislocations: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015;23:3108–3113
  8. ↑ 8.0 8.1 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;91:2946–2957.
  9. ↑ Lynch AD , Chmielewski T , Bailey L , et al.; STaR Trial Investigators. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr Rev Musculoskelet Med 2017;10:328–345
  10. ↑ Medina, Omar, et al. "Vascular and nerve injury after knee dislocation: a systematic review." Clinical Orthopaedics and Related Research® 472.9 (2014): 2621-2629.
  11. ↑ Shelbourne KD, Klootwyk TE. Low-velocity knee dislocation with sports injuries. Treatment principles. Clin Sports Med. 2000;19:443–56
  12. ↑ Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–9.
  13. ↑ McDonough EB Jr , Wojtys EM . Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156–159
  14. ↑ Meyers MH, Harvey JP. Traumatic dislocation of the knee joint: a study of eighteen cases. J Bone Joint Surg Am 1971;53:16-29.
  15. ↑ Samson D , Ng CY , Power D . An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2017;1:362–367
  16. ↑ Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87:664–7.
  17. ↑ Cho D, Saetia K, Lee S, Kline DG, Kim DH. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus. 2011;31:E11.
  18. ↑ Woodmass JM, Romatowski NP, Esposito JG, Mohtadi NG, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2015;23:2992–3002.
Created by:
John Kiel on 18 December 2020 22:31:21
Authors:
Last edited:
4 October 2022 15:51:12

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