Multiligament Injury

Other Names

• Multiligament knee injuries (MLKI)
• Multiligament Knee Injury

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

• Emergent
  • Knee Dislocation
  • Popliteal Artery injury
  • Common Peroneal Nerve Injury
• Ligaments
  • Meniscus Injury
  • Osteochondral Defect
  • PCL Injury
  • MCL Injury
  • LCL Injury
  • ACL Injury
  • Posterolateral Corner Injury
• Other
  • Bone contusion, less commonly fracture

Differential Diagnosis

• Fractures
  • Distal Femur Fracture
  • Patellar Fracture
  • Tibial Plateau Fracture
• Dislocations & Subluxations
  • Patellar Dislocation (and subluxation)
  • Knee Dislocation
  • Proximal Tibiofibular Joint Dislocation
• Muscle and Tendon Injuries
  • Quadriceps Contusion
  • Iliotibial Band Syndrome
  • Quadriceps Tendonitis
  • Patellar Tendonitis
  • Popliteus Tendinopathy
  • Extensor Mechanism Injury
    • Patellar Tendon Rupture
    • Quadriceps Tendon Rupture
    • Patellar Fracture
• Ligament Pathology
  • ACL Injury
  • PCL Injury
  • MCL Injury
  • LCL Injury
  • Meniscal Pathology
  • Posterolateral Corner Injury
  • Multiligament Injury
• Arthropathies
  • Knee Osteoarthritis
  • Septic Arthritis
  • Gout
• Bursopathies
  • Prepatellar Bursitis
  • Pes Anserine Bursitis
  • MCL Bursitis
  • Infrapatellar Bursitis
• Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
  • Chondromalacia Patellae
  • Patellofemoral Osteoarthritis
  • Osteochondral Defect Knee
  • Plica Syndrome
  • Infrapatellar Fat Pad Impingement
  • Patellar Instability
• Neuropathies
  • Saphenous Nerve Entrapment
• Other
  • Bakers Cyst
  • Patellar Contusion
• Pediatric Considerations
  • Patellar Apophysitis (Sinding-Larsen-Johansson Disease)
  • Patellar Pole Avulsion Fracture
  • Tibial Tubercle Avulsion Fracture
  • Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)

Diagnosis

• History
  • High energy or low energy trauma
  • If ambulation is attempted, likely instability or buckling
• Physical Exam: Physical Exam Knee
  • Dimple Sign: buttonholing of medial femoral condyle through a medial capsule
  • Very important to document a thorough vascular exam
  • The presence of peripheral pulses does not exclude vascular injury
  • Abnormal pedal pulse is only 79% sensitive, 91% specific for arterial injury^[2]
  • A 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 the contralateral limb
  • Need to perform structural exam assessing ACL, PCL, MCL, and LCL

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

• Standard Radiographs Knee
• May be normal depending on mechanism
  • look for asymmetric, irregular or widening of joint space
  • Segund Fracture, Osteochondral Defect may be seen
• Post reduction or post splinting films are necessary

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 collateral ligaments injured
• KD V: Periarticular fracture-dislocation

Treatment

Prognosis

• Levy et al systematic review compared operative to nonoperative management^[5]
  • Overall, operative treatment results in the better functional outcomes 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 the 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 is done within 3 weeks
    • No difference in functional outcomes between early and late surgery
• Staged vs acute reconstruction/repair
  • Jiang et al: staged treatment yields best clinical results for KD III, with no difference between acute and chronic reconstruction^[7]
  • Mook et al: staged procedures produced better outcomes, the acute timeline was superior^[8]

Acute

• Follow ATLS protocol when appropriate, based on the mechanism
• Examination
  • Thorough structural examination
  • Examine soft tissue compartments
  • Confirm palpable dorsalis pedis, posterior tibia and popliteal artery pulses
• Immobilization
  • Full-extension in long Hinged Knee Brace or Posterior Long Leg Splint
  • If the posterior capsule is injured, may require 20° of flexion to avoid posterior subluxation
  • May require temporary external fixation
• 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

• Indications
  • Few, but consider in
  • Elderly
  • Poor surgical candidates, multiple comorbidities
  • Poor ambulatory function at baseline
• Hinged Knee Brace
• Physical Therapy

Operative

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