MacDonald, Peter

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined ‘a priori’ if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

Purpose The purpose of this systematic review was to address the treatment of multiligament knee injuries, specifically ( 1 ) surgical versus nonoperative treatment, ( 2 ) repair versus reconstruction of injured ligamentous structures, and ( 3 ) early versus late surgery of damaged ligaments. Methods Two independent reviewers performed a search on PubMed from 1966 to August 2007 using the terms “knee dislocation,” “multiple ligament–injured knee,” and “multiligament knee reconstruction.” Study inclusion criteria were ( 1 ) levels I to IV evidence, ( 2 ) “multiligament” defined as disruption of at least 2 of the 4 major knee ligaments, ( 3 ) measures of functional and clinical outcome, and ( 4 ) minimum of 12 months' follow‐up, with a mean of at least 24 months. Results Four studies compared surgical treatment with nonoperative treatment. There was a higher percentage of excellent/good International Knee Documentation Committee (IKDC) scores (58% v 20%) in surgically treated patients, as well as higher rates for return to work (72% v 52%) and return to full sport (29% v 10%). Two studies compared repair with reconstruction of damaged structures, with similar mean Lysholm scores (88 v 87) and excellent/good IKDC scores (51% v 48%). However, repair of the posterolateral corner had a higher failure rate (37% v 9%). Similarly, repair of the cruciates yielded decreased stability and range of motion and a lower return to preinjury activity levels (0% v 33%). There were 5 studies comparing early surgery (≤3 weeks) with late surgery. Early treatment resulted in higher mean Lysholm scores (90 v 82) and a higher percentage of excellent/good IKDC scores (47% v 31%), as well as higher sports activity scores (89 v 69) on the Knee Outcome Survey. Conclusions Our review suggests that early operative treatment of the multiligament‐injured knee yields improved functional and clinical outcomes compared with nonoperative management or delayed surgery. Repair of the posterolateral corner may yield higher revision rates compared with reconstruction.