Multi-ligamentous injuries in the knee are quite common than the isolated ligament injury. Multiple-ligament injuries in the knee means at least two of main ligaments re torn with possible meniscal tear and cartilage and osseous compromise.
All isolated ligament injuries posts are these
Aetiology
Ligaments are to absorb the knee joint from excessive loads and prevention of dislocation. When the loads or mechanical stress exceeds the amount ligaments can take, dislocation or ligaments injuries occur.
·Increase the exercise level
·Sudden and excessive trauma (get tackled or car accident)
·Weakness of the muscle around the knee joint
·Fall
There are so many patterns of ligamentous injuries in the knee. There are some tendencies that some ligament injuries are accompanied by specific ligament injuries.
Anatomic classification of Knee Dislocations *2 Schenck
Class Injury
KD1 PCL or ACL intact knee dislocation (either one of them is injured)
Variable Collateral ligament involvement
KD2 Both cruciate ligaments get torn, collateral ligaments intact
KD3 Both cruciate ligaments torn, 1 collateral ligament torn
Subset M (medial) or L (lateral)
KD4 All 4 ligaments (ACL, PCL, MCL and LCL) torn
KD5. Knee fracture-dislocation
ACL: Anterior Cruciate Ligament. KD: Knee Dislocation. PCL: Posterior Cruciate Ligament
Sub type: C, arterial injury; N, neurologic injury
KD1 injuries are often seen in sports activities. KD2 is relatively rare as injuries are caused by hyper-extension of the knee without varus or valgus force whereas KD3 is the most prevalent injury pattern which involves bilateral cruciate ligaments tear and one of the collateral ligament injuries. KD 4 is that all 4 ligaments get torn by high energy trauma such as motor vehicle accident. KD 5 associates all ligamentous injuries with a fracture.
Injury pattern *1, 3
There are so many patterns of ligamentous injuries in the knee. There are some tendencies that some ligament injuries are accompanied by specific ligament injuries.
- Anterior cruciate ligament with MCL
- ACL, PCL and PLC
- ACL, PCL and MCL
- ACL, PCL and LCL
ACL is the most vulnerable ligament (31%), followed by MCL (29%), PCL (22%) and LCL (16%) .
Treatment
When it comes to debate surgical versus non-surgical and repair versus reconstruction, it is not transparent enough to say which one is better as the knee joint is complex, a few ligaments can be involved and severity of the injury.
Although it depends on severity of the injury, MCL is quicker to heal than any other ligaments as it has a better blood supply and does not get disrupted by joint fluid. Thus, MCL is often manageable with conservative treatment before the surgery for other ligaments unless MCL is torn from either side of the attachment.
Conservative or surgical
Although it depends on severity of the injury, MCL is quicker to heal than any other ligaments as it has a better blood supply and does not get disrupted by joint fluid. Thus, MCL is often manageable with conservative treatment before the surgery for other ligaments unless MCL is torn from either side of the attachment.
Surgical treatment is often utilized when the injury is severe or more than 2 ligaments get involved to restore ROM.
Early or delayed surgery
Some researches show that early surgeries which is less than 3 weeks give better scores and results in comparison to late surgeries. *2,11
However, there is no different outcome in terms of early (within 6 months) or late (after 6 months) ACL reconstruction. When ACL injury and medial meniscal injury occurred simultaneously, early surgery has better repair rate for meniscal injury and decreases the risk of developing osteoarthritis. Thus, ACL reconstruction and medial meniscal surgery should be executed within 6 months. *10
Repair or reconstruction *2,8,9
There were no differences in varus gapping at 0 and 20 degrees of knee flexion between repair and reconstruction of ACL and MCL. However, reconstruction gives more stability for rotation than repair. When it comes to PCL/LCL injury, repair surgery is prone to be failure in comparison to reconstruction. The repair is often performed when the ligament is avulsed and reconstruction is used when mid-fibre or mid substance are torn.
The research shows that if the repair is not successful, revision reconstruction gives similar results to patients who underwent the reconstruction.
Condition, severity and situation vary in injuries. No matter whether or not you go for surgical or conservative treatments, rehabilitation right after and before (if you have some time) is imperative.
References
- Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma. 2013;27:226–31
- Rebert C. Schenck, Dustin L. richater, Daniel C. Wascher Knee Dislocations 2014 Orthop J sports Med 2 (5)
- Zhang Y, Zhang X, Hao Y, Zhang YM, Wang M, Zhou Y, et al. Surgical management of the multiple-ligament injured knee: A case series from Chongqing, China and review of published reports. Orthop Surg. 2013;5:239–49
- Ankit Goyal, Milind Tanwar and Deepak Chaudhary Practice Guidelines for the Management of Multiligamentous injuries of the Knee Indian J orthope 2017 51 (5): 537-544
- Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30:718–27
- Justin Roe Combined ACL and MCL injury North Sydney Orthopaedic& sports medicine clinic
- Wilson WT, Deakin AH, Payne AP, Picard F, Wearing SC: Comparative analysis of the structural properties of the collateral ligaments of the human knee. J Orthop Sports Phys Ther 2012;42(4):345-351
- McCarthy M, Ridley TJ, Bollier M, Cook S, Wolf B, Amendola A. Posterolateral Knee Reconstruction Versus Repair. Iowa Orthop J. 2015;35:20–5
- Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med. 2010;38:804–809
- Krutsch W, Zellner J, Baumann F, Pfeifer C, Nerlich M, Angele P, et al. Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology. Knee Surg Sports Traumatol Arthrosc. 2017;25:418–25.
- Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25:430–438
