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Multiligament knee injury

70 citationsUpdated Sep 2026

Overview

Multiligament knee injuries frequently present as part of a multisystem injury complex, where concomitant head, chest, abdominal, or lower limb fractures affect surgical timing and treatment results [3, 10, 13]. Patients with these injuries experience longer hospital stays compared to those with isolated ligamentous injuries [3], and high-energy mechanisms are associated with poor functional outcomes [6]. While a new five-class classification system has been proposed to aid surgical planning and clinical research [4], the optimal treatment strategy continues to evolve with ongoing controversy regarding the role of repair versus reconstruction [9]. Current literature supports surgical management, with reconstructions recommended over repairs due to higher failure rates of the latter [17]. Early operative treatment yields improved functional and clinical outcomes compared with nonoperative management or delayed surgery [5], and a reproducible single-stage strategy exists to restore stability across all planes and support functional recovery [2].

Surgical management of multiligament knee injuries confers a significant increased risk of 30-day post-operative minor or severe adverse events over arthroscopic ACL reconstruction [15]. Specific techniques, such as reconstruction with a combination tibial-inlay and two-femoral-tunnel technique, provide good results [29]. At intermediate- to long-term follow-up, patients older than 30 years undergoing reconstruction for knee dislocation have inferior IKDC and Lysholm scores compared to those 30 years or younger [12], suggesting that allograft reconstruction may have clinical utility in older patients [16]. In bicruciate reconstructions, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on posterior tibial slope were identified at midterm follow-up [30]. Furthermore, despite the type of injury, only minor differences in knee laxity and subjective outcome scores exist between isolated PCL and multiligament groups [14].

Most young athletes who sustained multiligament knee injury were able to return to play at some level, though a minority returned to their preinjury level [7]. Concomitant injury patterns show increased rates of cartilage injuries in the revision setting, specifically localized to the medial femoral condyle, medial tibial plateau, and lateral femoral condyle [19]. A small, randomized pilot study suggests a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies [23]. Future research, particularly large prospective studies evaluating surgical approaches and timing, will be critical in advancing treatment [1], and further work is needed to elucidate patient and surgical factors that may influence subjective outcomes [8].

Anatomy & Pathophysiology

Osseous Anatomy

The knee joint functions as a hinge incorporating both gliding and rolling motions essential to its kinematics [59]. The "screw-home" mechanism involves the tibia externally rotating 5 degrees in the final 15 degrees of extension [59]. The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral femoral condyle [58]. Conversely, the lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial femoral condyle [58]. The tibial articular surface slopes 7° to 10° in the sagittal plane [58]. The medial tibial plateau is larger than the lateral plateau and is concave in its frontal and sagittal planes [58]. The lateral tibial plateau is smaller and more circular than the medial plateau, concave in the frontal plane and convex in the sagittal plane [58]. The patella is the largest sesamoid bone in the body, averaging 2.5 cm in thickness [58]. Its articular surface contains a vertical central ridge separating the broader lateral facet from the medial facet, plus a smaller medial odd facet [58].

Ligamentous Anatomy

The anterior cruciate ligament (ACL) travels from the medial border of the lateral femoral condyle to its insertion site anterolateral to the medial tibial spine [37]. The ACL prevents anterior translation and rotation of the tibia on the femur [37]. It is composed of 90% type I collagen and 10% type III collagen [58]. The mean length of the ACL is 33 mm and the mean midsubstance width is 11 mm [58]. The femoral attachment of the ACL is a semicircular area (20 mm long and 10 mm wide) on the posteromedial aspect of the lateral femoral condyle [58]. The tibial attachment of the ACL is a broad, irregular, oval-shaped area (30 mm long and 10 mm wide) slightly medial and anterior to the midline [58]. The ACL anteromedial bundle is tight in knee flexion and the posterolateral bundle is tight in knee extension [63]. The ACL primarily resists anterior tibial translation relative to the femur [68].

The posterior cruciate ligament (PCL) runs from the lateral aspect of the medial femoral condyle to the posterior aspect of the tibia, just below the joint line [37]. The PCL prevents posterior subluxation of the tibia on the femur [37]. It is the largest of the intra-articular ligaments, with an average length of 38 mm and a mean diameter at the midpoint of 13 mm [71]. The PCL cross-sectional area is approximately 120% to 150% greater than that of the ACL [71]. The PCL has two distinct bundles defined by their insertion on the femur: an anterolateral (AL) bundle and a posteromedial (PM) bundle [71]. The AL bundle of the PCL is larger and comprises 85% of the PCL's cross-sectional area [71]. The PCL inserts onto a midline depression on the tibia, 10 to 15 mm below the level of the medial and lateral tibial plateaus [71]. The PCL anterolateral bundle is tight in knee flexion and the posteromedial bundle is tight in knee extension [63]. The PCL primarily resists posterior tibial translation relative to the femur [68]. The meniscofemoral ligaments are present in at least one form in 93% of knees [71]. These ligaments connect the posterior horn of the lateral meniscus to the intercondylar notch and contribute a mean of 17.2% to the PCL footprint and cross-sectional area [71].

The medial collateral ligament (MCL) has superficial and deep portions that stabilize the knee to valgus stresses [37]. The MCL resists valgus stress [68]. The superficial MCL proximal division resists valgus tibial translation and tibial external rotation [59]. The superficial MCL distal division resists tibial external rotation in knee extension and tibial internal rotation [59]. The deep MCL resists valgus translation and tibial internal and external rotation [59]. The posterior oblique ligament resists tibial internal rotation, especially in knee extension [59]. The posteromedial corner (PMC) resists valgus stress [68].

The lateral collateral ligament (LCL) runs from the lateral femoral condyle to the head of the fibula and is the main stabilizer against varus stress [37]. The LCL is part of the posterolateral "complex" or "corner" of the knee that also resists external rotation [37]. The fibular collateral ligament (FCL) resists varus stress [68]. The lateral collateral ligament resists varus tibial translation and tibial external rotation, especially at 30 degrees of knee flexion [59]. The popliteus tendon resists tibial external rotation, especially in knee flexion [59]. The popliteofibular ligament, present in 90% of knees, runs from the tendon of the popliteus muscle to the styloid on the posterior fibular head [37]. It resists tibial external rotation, especially in knee flexion, and posterior tibial displacement [59]. The oblique popliteal ligament resists knee hyperextension and varus tibial translation [59]. The posterolateral corner (PLC) resists posterior translation, external rotation, and varus angulation of the tibia [68].

Meniscal Anatomy

The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase congruency between joint surfaces, enhance joint stability, and aid in distribution of synovial fluid [37]. They consist of type I collagen fibers arranged obliquely, radially, and vertically [63]. Vascular supply to the menisci is derived from the geniculate arteries, which penetrate into 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [63]. The medial meniscus is crescent-shaped and attaches more anterior and posteriorly [63]. It is firmly attached to the joint capsule along its entire peripheral edge [37]. The medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [37]. The lateral meniscus is circular in shape and covers a larger proportion of the tibial plateau [63]. It is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [37]. The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [37].

Vascular and Neural Anatomy

The blood supply to the knee is formed from an anastomosis around the knee derived from the descending geniculate artery, medial and lateral superior geniculate arteries, medial and lateral inferior geniculate arteries, middle geniculate artery, and anterior tibial recurrent arteries [58]. The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [58]. The inferior geniculate arteries pass deep to their respective collateral ligaments [58]. The popliteal artery travels through the adductor hiatus, where it is relatively immobile, and distally through the fibrous arch deep to the soleus muscle [68].

The knee is innervated by branches of the femoral nerve (L2, L3, L4), obturator nerve (L2, L3, L4), and sciatic nerve (L4, L5, S1, S2) [58]. The largest nerve providing innervation of the intra-articular knee is the posterior articular branch of the tibial nerve [58]. This branch supplies the infrapatellar fat pad, the synovial covering over the cruciate ligaments, and the periphery of the meniscus [58]. Nerves to the cruciate ligaments contain vasomotor and pain fibers as well as mechanoreceptors that may be involved in proprioception [58]. The common peroneal nerve travels along the posterior edge of the biceps femoris and continues distally around the fibular neck [68]. The tibial nerve, after branching from the sciatic nerve, courses distally through the center of the popliteus fossa [68].

Pathophysiology and Injury Patterns

Multiligament knee injuries (MLKIs) involve complete injury to a combination of at least 2 of the 4 major ligaments: ACL, PCL, MCL, and/or PLC [125]. The incidence of MLKIs is reported as 0.002% to 0.2% per year [125]. MLKIs are most commonly the consequence of a knee dislocation due to high-energy trauma, such as motor vehicle accident or sports injury [125]. A combination of 1 cruciate tear with a medial or lateral side injury is the most frequent injury pattern in MLKI [125]. Knee dislocations represent less than 0.2% of all orthopaedic injuries [68]. The incidence of knee dislocations is likely underrepresentative of the true incidence because 20% to 50% of knee dislocations spontaneously reduce in the field [68]. High-energy mechanisms for knee dislocation include motor vehicle collisions, falls from a height, and industrial accidents [68]. Low-energy mechanisms for knee dislocation include sports-related injuries, often with a rotatory component [68]. Ultra-low-energy injuries include those occurring from seemingly trivial trauma in morbidly obese patients [68].

Patients with ligamentous knee injuries often had multi-system injuries with resulting longer hospital stay when compared to those without ligamentous knee injuries [3]. Patients with traumatic simultaneous bilateral knee multiligamentous knee injuries are at high risk of concomitant head, chest and abdominal injuries compared to unilateral MLIs with similar mechanisms [13]. Functional outcomes in polytraumatic multi-ligament knee injuries are influenced by factors other than the knee, including concomitant injuries and psychosocial factors [18]. Associated trauma to local joint and limb structures other than ligaments is the rule in knee dislocations [115]. The rate of an associated fracture in knee dislocations is 57%, with multiple fractures at 41% and open fractures at 27% [115]. Damage to the cartilage and menisci occurs in at least one-third of patients with traumatic dislocation [115].

The popliteal artery is at particular risk with knee dislocations because of its "tethered" position behind the joint between the adductor hiatus proximally and the soleus arch distally [115]. Estimates for how often the popliteal artery is compromised following multiligament knee injury range as high as 50% [115]. Vascular compromise was identified in 14.4% of dislocations at initial presentation [36]. Vascular compromise was more prevalent with multitrauma dislocations (17.3%) than isolated dislocations (10.5%) [36]. Peroneal nerve palsy complicated knee dislocations at a frequency of approximately 25% in several large series [115]. Neurological compromise was identified in 14.4% of patients at the time of presentation [36]. Recovery is observed in about half of peroneal nerve palsy cases, most of which are partial peroneal nerve palsies [115]. Only 38% of patients who sustained a complete peroneal nerve palsy in the setting of a multiligament knee injury recovered antigravity ankle dorsiflexion strength, compared with 83% of those with a partial peroneal nerve palsy [115]. Risk factors for associated peroneal nerve injury with knee dislocation include male sex, high body mass index, and concomitant fibular head fracture [115]. 27% of patients with a high-energy knee dislocation sustained life-threatening injuries to the head, chest, and/or abdomen [115].

Meniscal damage was identified in 53% of traumatic knee dislocations [36]. The medial meniscus was affected in 19% of dislocations, the lateral meniscus in 15%, and both menisci were damaged in 19% of cases [36]. Damage to the extensor mechanism, including the patellar and quadriceps tendons, was present in 51% of dislocations [36]. Injury to at least one structure within the posteromedial corner was observed in 81% of high-grade multiligament knee injuries [121]. Superficial MCL injury was observed in 63% of patients with high-grade multiligament knee injuries [121]. The posterior oblique ligament (POL) was injured in 64% of patients with documented posteromedial corner injury [121]. The semimembranosus and its expansions were injured in 64% of patients with documented posteromedial corner injury [121]. Injury to the meniscotibial ligament was observed in 50% of patients with documented posteromedial corner injury [121]. Injuries to the posterior horn of the medial meniscus were associated with a tear of the meniscotibial ligament in 100% of patients [121].

The pathoanatomy of posterolateral corner ligamentous disruption in multiligament knee injuries is predictive of peroneal nerve injury [22]. There is a relationship between peroneal nerve and anterior cruciate ligament involvement in multiligamentous knee injury [22]. Increased neurovascular morbidity is seen in documented knee dislocation versus multiligamentous knee injury [22]. Rupture of the cruciate ligaments or disruption of the tibiofemoral surface, including the menisci, causes a major change in the path of the instant center, leading to articular dysfunction [74]. Progressive damage to translational and rotational knee soft-tissue restraints occurs with increasing knee hyperextension [96]. Patients with multiligament knee reconstruction display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery [97]. Multiligament knee reconstruction patients display significant alterations in knee kinematics and spatiotemporal gait characteristics not identified in healthy controls during walking [125].

Classification

Schenck: The Schenck classification is currently the most frequently used anatomically based classification system for multiligamentous knee injuries [117]. It has been examined in patients with documented tibiofemoral knee dislocations [22]. However, variability exists in the spectrum of reporting on the Schenck KD I classification within the orthopaedic literature [22].

Other Considerations: Traditional classification systems for multiligamentous knee injuries provide limited information regarding the timing of injury (acute, chronic) and the grade of injury (partial, complete) [117]. These systems lack sufficient detail on the specific location of injured anatomic structures, meniscus and articular cartilage injuries, fracture types (avulsion vs non-avulsion), and concomitant injuries [117]. Consequently, current classification systems do not meet all criteria for enhancing communication between providers, facilitating accurate reporting, and guiding management protocols [117]. Consensus for the inclusion of various factors in a knee dislocation classification system was not easily achieved in a global Delphi consensus study [34]. Precise categorization of ligament injuries in knee dislocations and multiple ligament knee injury shows potential for improved awareness of neurovascular injury and patient prognosis [22]. Increased neurovascular morbidity is seen in documented knee dislocation compared to multiligamentous knee injury [22]. Extensor mechanism disruption impacts the treatment of dislocated and multiligament injured knees, with specific treatment and Schenck classification recommendations based on a global Delphi method [22]. A consensus definition of a knee fracture-dislocation (Schenck Knee Dislocation V) was established using a global modified Delphi method [22].

Clinical Presentation

Mechanism and Associated Injuries

Multiligament knee injuries frequently occur within a multisystem injury complex, where additional injuries dictate surgical timing and influence treatment results [10]. Patients with traumatic simultaneous bilateral knee multiligamentous injuries face a high risk of concomitant head, chest, and abdominal injuries compared to those with unilateral injuries from similar mechanisms [13]. High-energy trauma-induced posterior cruciate ligament (PCL) injuries are often associated with severe concurrent knee injuries involving multiple ligaments [122]. Conversely, obese individuals are significantly more likely to sustain multiligamentous knee injuries from low-energy mechanisms [27]. Complication rates for these injuries increase by 9.2% for every 1-unit increase in body mass index [27].

Clinical Examination and Diagnosis

Clinical examination is challenging in multiligament injury, and standard tests assessing peripheral laxity may be unreliable [41]. Evaluation of the anterior cruciate ligament (ACL) and PCL for central pivot injuries can be confounded by a "false Lachman" test, which corresponds to the reduction of the posterior drawer in cases of PCL injury [41]. In the absence of unconsciousness, clinical examination to establish which ligaments are compromised is painful, obliging the surgeon to diagnose injury under specific conditions [44]. Neurovascular complications are commonplace and may require urgent management before any orthopaedic procedure can be considered [41]. Stress radiographs support accurate diagnosis of complex knee injuries and provide an objective measure of knee stability following ligament reconstruction [47].

Associated Soft Tissue and Neurovascular Pathology

Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture [28]. In a series of traumatic knee dislocations, meniscal damage was identified in 53% of cases [36]. Damage to the extensor mechanism, including the patellar and quadriceps tendons, was present in 51% of cases [36]. Vascular compromise was identified in 14.4% of patients with traumatic knee dislocation at initial presentation [36]. This vascular compromise was more prevalent with multitrauma dislocations (17.3%) compared to isolated dislocations (10.5%) [36]. Neurological compromise was identified in 14.4% of patients with traumatic knee dislocation at the time of presentation [36]. Intimal flaps in multiligament knee injuries can lead to limb-threatening ischemia in the context of reconstructive knee surgery and are likely underdiagnosed with ankle-brachial index assessment [40]. Posterolateral corner (PLC) injuries are commonly associated with cruciate injuries, and early recognition is important to achieve successful outcomes [123].

Injury Patterns and Classification

Medial-sided bicruciate injuries were the most common injury pattern in knee dislocations [52]. A classification of multiligament knee injuries into five classes has been presented to aid surgical planning and enhance clinical outcomes research [4]. Consensus for inclusion of various factors in a knee dislocation classification system was not easily achieved [34].

Prognostic Factors and Outcomes

At intermediate- to long-term follow-up, patients older than 30 years who undergo multiligament knee reconstruction for knee dislocation have inferior IKDC and Lysholm scores compared to those 30 years of age or younger [12]. Functional outcomes after multiligament knee injury are influenced by factors other than the knee, including concomitant injuries and psychosocial factors [18]. The majority of service members who sustain combat-related multi-ligament knee injuries are unable to continue on active duty [35]. Knee function is lower in patients with a knee dislocation caused by high-energy trauma compared to low-energy trauma [43]. Eighty-seven percent of patients with knee dislocation had Kellgren & Lawrence grade 2 or higher for the injured knee at a minimum of 2 years follow-up [43].

Investigations

Plain radiography: Plain radiographs serve as the appropriate initial imaging study for most knee conditions, allowing assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [39]. Stress radiographs support accurate diagnosis of complex knee injuries and provide an objective measure of knee stability following ligament reconstruction [47]. These views are specifically required for the diagnosis of intra-articular fractures of the distal femoral epiphysis, which can mimic ligamentous injuries, particularly posterior cruciate ligament insufficiency [129].

MRI: MRI is a sensitive measure of cruciate and collateral ligament injury in acute knee dislocation [126]. However, it does not reliably diagnose injury to the posterolateral corner or meniscus in this setting [126]. Consequently, a higher index of suspicion is required during arthroscopy to prevent misdiagnosis of posterolateral corner or meniscal injury, which could affect long-term clinical outcome [126]. MRI may identify the degree of articular cartilage injury, including chondrosis and full-thickness cartilage loss, the presence of associated bone marrow edema, and the specific location of pathology (medial condyle, lateral condyle, trochlea, patella; anterior, posterior) [39]. Additionally, MRI may be used to assess the continuity of the quadriceps or patellar tendon [39], assess the margin of resection for a neoplasm, identify vascular malformation, or define the location of nerves or vessels relative to popliteal cysts [39].

CT: Computed tomography provides enhanced bone detail through a three-dimensional study performed with ionizing radiation [39]. Three-dimensional CT reconstructions may help with preoperative planning for complex intra-articular fractures, multiplanar osteotomy for limb malalignment, and reconstitution of bone loss in joint arthroplasty [39].

Other Considerations: Advanced radiographic imaging studies may help assess overall limb alignment and further delineate intra-articular and extra-articular soft tissues, including cartilage, menisci, ligaments, tendons, muscles, and nerve and vascular structures [39]. Dynamic ultrasonographic assessment can accurately quantify the severity of medial knee ligament injury based on medial compartment gapping [127]. A new classification of multiligament knee injuries into five classes has been presented to aid surgical planning and enhance clinical outcomes research [4]. Extensor mechanism disruption impacts treatment of dislocated and multiligament injured knees [22].

Concomitant injury patterns between isolated, multiligament, and revision PCL-R show increased rates of cartilage injuries in the revision setting [19]. These increased rates are specifically localized to the medial femoral condyle, medial tibial plateau, and lateral femoral condyle [19]. The incidence of heterotopic ossification after multiligament knee injury was 35% [128]. This condition is associated with knee-spanning external fixation and central nervous system trauma [128]. Intimal flaps in multiligament knee injuries can lead to limb-threatening ischemia in the context of reconstructive knee surgery [40]. These intimal flaps are likely underdiagnosed with ABI assessment [40].

Treatment

Non-Operative

Nonoperative treatment of knee dislocations is indicated when comorbidity and/or concomitant injury are of sufficient severity to preclude extensive surgery and/or anesthetic [105]. Skeletal immaturity serves as a relative indication for this conservative approach [105]. Conversely, open dislocations, dislocations with associated vascular injury, irreducible dislocations, dislocations with associated compartment syndrome, and dislocations with subsequent multiligament laxity and joint subluxation are relative contraindications for nonoperative management [105]. In patients with substantial comorbidities or polytrauma, the risk of operative intervention likely outweighs the benefit [105]. Life-threatening polytrauma is associated with high-energy mechanism knee dislocations in approximately 27% of cases [105]. Multiligament knee injury can occur with minimal trauma in obese individuals, many of whom have concomitant medical conditions that preclude a general anesthetic [105]. In patients with significant open wounds, the implantation of allograft tissue for reconstruction of torn knee ligaments may be too dangerous given the risk of contamination and potential infection [105]. The role of surgical reconstruction in skeletally immature and elderly patients with knee dislocations is unknown [105]. In the elderly, there is obvious risk imposed by comorbidity, poor bone quality, and the unpredictability of surgical reconstruction of ligamentous injury in those with any degree of preexisting arthritis [105]. Complex constructs described for reconstruction of multiligament injuries significantly increase the chance for growth disturbance in children with open growth plates [105].

Functional outcomes for patients treated nonoperatively for combined complete tears of the ACL and MCL indicate that 68% of the patients had returned to their previous activity level [111]. Specifically, 74% of contact athletes and 67% of noncontact athletes returned to their previous activity level [111]. The ability to return to previous activity was lower in recreational athletes (50%) treated nonoperatively for combined complete tears of the ACL and MCL [111]. By use of the Hospital for Special Surgery knee assessment, 71% of patients treated nonoperatively for combined complete tears of the ACL and MCL attained good to excellent outcomes [111]. Older patients were less successful with their return to activity when treated nonoperatively for combined complete tears of the ACL and MCL [111]. A consensus of ACL reconstruction and nonsurgical treatment of the MCL injury is accepted for complete ACL tears associated with grade I and II MCL injuries [111]. There is no consensus in the literature regarding the optimal treatment regimen for combined complete tears of both the ACL and MCL [111].

Operative

Indications: Operated patients with Schenck KDII / III / IV lesions have better outcomes than those treated without surgery in terms of stability, work return, and quality of life [44]. In patients with multiligament knee injuries associated with high-energy lower limb fractures, poor functional outcomes are reported [6].

Surgical Approach / Technique: A treatment protocol has been described to help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries [55]. Successful surgical management of a multiligamentous knee injury in a skeletally immature athlete has been detailed in a case report [21]. Ten of 14 patients (71%) with multiligament knee injuries required a second-stage ligament reconstruction [33]. This study presents mid-term outcomes of one of the largest series of consecutive multi-ligament knee injuries reported to date [11]. Concomitant injury patterns between isolated, multiligament, and revision PCL-R show increased rates of cartilage injuries in the revision setting, specifically localized to the medial femoral condyle, medial tibial plateau, and lateral femoral condyle [19].

Graft Selection: Most surgeons are hesitant to add further morbidity by harvesting autograft tissue from the injured knee due to the extreme insult to the joint and its soft tissue envelope at the time of dislocation [42]. The integrity of autograft tissue may be compromised in the recently traumatized state [42]. Concerns among surgeons who favor autograft harvest include the mechanical integrity of allograft, its sterility, and its ability to integrate into a foreign host [42]. The debate over the optimal preparation of allograft tissue continues with maintenance of structural integrity being weighed against the complete eradication of potential pathogens [42]. Allograft is unavailable in many countries and centers, and in other places, the cost of procuring the grafts may be prohibitive [42]. For surgeons who employ allograft in the treatment of multiple ligament knee injuries, a specific conversation with the patient outlining its necessity and potential risks is essential [42]. The issue of autograft versus allograft is likely another question that will only be effectively answered by a multicentered study [42]. Allograft reconstruction for a multiligament knee injury in patients aged 40 years and older may have clinical utility, demonstrating high levels of satisfaction and adequate patient-reported outcomes [16].

Other Considerations: There is a paucity of literature focused on the management of combined ACL and PLC injuries [124]. Both fibular-based and tibiofibular-based constructs for posterolateral corner reconstruction had comparable clinical outcomes and were equally effective in restoring varus and rotational stability [48].

Rehabilitation

A small, randomized pilot study suggests a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies [23]. A systematic review suggested that immobilizing knees after acute surgery for knee dislocation led to increased posterior instability versus a protocol of early mobilization [101]. A systematic review found that immobilization after acute surgical treatment of knee dislocations increased the incidence of both flexion loss >10 degrees and extension loss >5 degrees [101]. Patients were significantly more likely to have severely abnormal or poor outcomes and were significantly less likely to return to work with prolonged immobilization after acute surgical treatment of knee dislocations [101]. Statistically significant improvements were seen in the Lysholm and Tegner scores, but not the IKDC scores, in patients treated with functional rehabilitation compared to 6 weeks of immobilization [101]. Early results suggest reduced instability and reduced surgical failure rates with the use of a hinged external fixator compared to a hinged knee brace in a prospective randomized study of knee dislocations [101].

In a KDIIIM reconstruction protocol, patients are kept nonweightbearing for a total of 6 weeks to allow all soft tissues to heal [120]. In a KDIIIM reconstruction protocol, patients are initially protected in a postoperative brace locked in extension for the first 2 weeks [120]. In a KDIIIM reconstruction protocol, ROM from full extension up to 70° of flexion is allowed from Weeks 2 through 6 [120]. In a KDIIIM reconstruction protocol, full active and passive ROM is allowed after Week 6 [120]. In a KDIIIM reconstruction protocol, jogging is not allowed for a minimum of 3 months postoperatively [120]. Complex multiligament reconstructions more often take 9 to 12 months of recovery, although some patients may be able to return to heavy labor or sports at 6 months from surgery [120].

Patient Factors and Complications

Compared to unilateral MLIs with similar mechanisms, patients with traumatic simultaneous bilateral knee multiligamentous knee injuries are at high risk of concomitant head, chest and abdominal injuries [13]. Complication rates increase by 9.2% for every 1-unit increase in BMI in patients with multiligamentous knee injuries [27]. Neurovascular complications are commonplace in multiligament injury and sometimes require urgent management before any orthopaedic procedure can be considered [41].

Complications

Perioperative and Surgical Complications

Surgical management of multi-ligament knee injuries carries a significantly increased risk of 30-day post-operative minor or severe adverse events compared to arthroscopic ACL reconstruction [15]. A 15-year single academic institution experience reports a low intraoperative complication rate but a high early postoperative complication rate associated with multiligamentous knee surgery [51]. The surgical treatment of open traumatic knee dislocations is extensive and challenging due to the complexity of the injuries [53].

Risk Factors: Obese individuals experience a 9.2% increase in complication rates for every 1-unit increase in BMI [27].

Associated Injuries and Multisystem Trauma

Patients with ligamentous knee injuries often present with multi-system injuries, resulting in longer hospital stays compared to those without ligamentous knee injuries [3]. Functional outcomes are influenced by factors other than the knee, including concomitant injuries and psychosocial factors [18].

Intraarticular and Structural Complications

Concomitant injury patterns in the revision setting for PCL-based multiligament knee injuries show increased rates of cartilage injuries specifically localized to the medial femoral condyle, medial tibial plateau, and lateral femoral condyle [19].

Long-term Outcomes and Functional Limitations

At intermediate- to long-term follow-up, patients >30 years of age undergoing multiligament knee reconstruction for knee dislocation have inferior IKDC and Lysholm scores compared to those ≤30 years of age [12]. Patients with a previous history of knee ligament surgery had a significantly worse quality of life relative to those with no history of knee ligament surgery [56].

Recovery

Functional Outcomes and Return to Activity: Functional outcomes following multiligament knee injury are satisfactory but remain less favorable than those reported after surgical reconstruction of isolated cruciate ligament tears [131].

Patient-Reported Outcomes and Satisfaction: High levels of satisfaction and adequate patient-reported outcomes are observed after operative reconstruction of multiligament knee injury with allograft among patients aged 40 years and older [16].

Rehabilitation and Surgical Technique Impact: A single-stage anatomic reconstruction technique provides a reproducible strategy to address multiligament knee injuries, restoring stability across all planes and supporting functional recovery [2]. An anatomic posterolateral corner reconstruction with autografts, concomitant to other surgical procedures, improves subjective outcomes and objective stability in patients with a chronic posterolateral corner knee injury [31]. Patients who underwent a staged cruciate reconstruction had higher subjective outcome scores than those who had cruciate injuries left untreated [130].

Complications and Risk Factors: A 15-year single-institution experience reveals a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery [51].

Key Evidence

• [L4] Future research, particularly large prospective studies evaluating surgical approaches and timing, will be critical in advancing the treatment of multiligament knee injuries. [1] (10.1007/s11999-014-3653-3)
• [L5] This technique provides a reproducible single-stage strategy to address multiligament knee injuries, restoring stability across all planes and supporting functional recovery. [2] (10.1002/atn2.70079)
• [L3] Patients with ligamentous knee injuries often had multi-system injuries with resulting longer hospital stay when compared to those without ligamentous knee injuries. [3] (10.1186/s12891-020-03397-w)
• [L4] The authors present a new classification of multiligament knee injuries into five classes to aid surgical planning and enhance clinical outcomes research. [4] (10.1177/2325967120s00493)
• [L2] 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. [5] (10.1016/j.arthro.2009.01.008)
• [L4] Poor functional outcomes are reported in patients with multiligament knee injuries associated with high-energy lower limb fractures. [6] (10.1177/2325967117s00029)
• [L4] Most young athletes who sustained multiligament knee injury were able to return to play at some level, but a minority returned to their preinjury level. [7] (10.1177/23259671231179109)
• [L3] Further work is needed to elucidate patient and surgical factors that may influence subjective outcomes after multiligament knee injuries. [8] (10.1177/2325967117694818)
• [L5] The optimal treatment of multiligamentous knee injuries continues to evolve with controversy surrounding the role of repair versus reconstruction. [9] (10.5435/00124635-200903000-00004)
• [L5] Multiple ligament injured knees are often part of a multisystem injury complex where additional injuries affect surgical timing and treatment results. [10] (10.1016/j.csm.2018.11.004)
• [L4] This study presents mid-term outcomes of one of the largest series of consecutive multi-ligament knee injuries reported to date. [11] (10.1016/j.arthro.2013.07.137)
• [L4] At intermediate- to long-term follow-up, patients >30 years of age that undergo multiligament knee reconstruction for knee dislocation have inferior IKDC and Lysholm scores compared to those ≤30 years of age. [12] (10.1007/s00167-015-3750-1)
• [L3] Compared to unilateral MLIs with similar mechanisms, patients with traumatic simultaneous bilateral knee multiligamentous knee injuries are at high risk of concomitant head, chest and abdominal injuries. [13] (10.1007/s00167-015-3720-7)
• [L3] Despite the type of injury, there were only minor differences in knee laxity and subjective outcome scores between the isolated PCL group and the multiligament group. [14] (10.1177/2325967117700077)
• [L4] The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse events over arthroscopic ACL reconstruction. [15] (10.1007/s00167-020-06252-6)
• [L4] This demonstrates that allograft reconstruction for a multiligament knee injury in older patients may have clinical utility. [16] (10.1016/j.asmr.2022.09.012)
• [L5] The current literature supports surgical management of multiligament injuries, with reconstructions recommended over repairs due to higher failure rates of repairs. [17] (10.1136/jisakos-2016-000072)
• [L3] Functional outcomes are influenced by factors other than the knee, including concomitant injuries and psychosocial factors. [18] (10.1007/s00167-017-4784-3)
• [L3] Concomitant injury patterns between isolated, multiligament, and revision PCL-R show increased rates of cartilage injuries in the revision setting, specifically localized to the medial femoral condyle, medial tibial plateau, and lateral femoral condyle. [19] (10.1016/j.jisako.2023.03.229)
• [L5] This case report details the successful surgical management of a multiligamentous knee injury in a skeletally immature athlete. [21] (10.5435/jaaosglobal-d-25-00266)
• [L5] [22] (10.1016/j.arthro.2025.05.011)
• [L2] The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. [23] (10.1097/corr.0000000000001729)
• [L3] Obese individuals are significantly more likely to have a multiligamentous knee injury caused by low-energy mechanisms, and complication rates increase by 9.2% for every 1-unit increase in BMI. [27] (10.1016/j.arthro.2014.05.035)
• [L4] Meniscal root tears occur more frequently in multi-ligament knee injury than previously reported with isolated anterior cruciate rupture. [28] (10.1007/s00167-018-5009-0)
• [L4] Reconstruction with a combination tibial-inlay and two-femoral-tunnel technique provides good results after multiligament knee injuries. [29] (10.1177/03635465030310020701)
• [L3] In this series of bicruciate multiligamentous knee reconstructions at midterm follow-up, no differences in graft failures, complications, reoperations, revisions, or PRO scores based on PTS were identified. [30] (10.1177/23259671241249473)
• [L4] The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls. [31] (10.1016/j.arthro.2019.01.016)
• [L2] [33] (10.1177/0363546507304717)
• [L4] Consensus for inclusion of various factors in a knee dislocation classification system was not easily achieved. [34] (10.1016/j.jisako.2022.02.003)
• [L4] The majority of service members who sustain combat-related multi-ligament knee injuries are unable to continue on active duty. [35] (10.1016/j.injury.2017.02.019)
• [L3] [36] (10.1016/j.injury.2018.02.016)
• [Case_report] Intimal flaps in multiligament knee injuries can lead to limb-threatening ischemia in the context of reconstructive knee surgery and are likely underdiagnosed with ABI assessment. [40] (10.1016/j.jisako.2024.100313)
• [L5] [41] (10.1002/ksa.70082)
• [L3] [43] (10.1007/s00167-009-0869-y)
• [L5] [44] (10.1186/s40634-020-00260-8)
• [L5] Stress radiographs support accurate diagnosis of complex knee injuries and provide an objective measure of knee stability following ligament reconstruction. [47] (10.1016/j.arthro.2020.11.001)
• [L4] Both constructs had comparable clinical outcomes and were equally effective in restoring varus and rotational stability for PLC knee injuries. [48] (10.1177/03635465221138548)
• [L4] Our 15-year data reveal there is a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery. [51] (10.1016/j.arthro.2021.05.027)
• [L3] Medial-sided bicruciate injuries were the most common injury pattern in knee dislocations. [52] (10.1177/2325967117706521)
• [L4] Due to the complexity of the injuries in open traumatic knee dislocations, the surgical treatment is extensive and challenging. [53] (10.1007/s00167-009-0721-4)
• [L4] This treatment protocol can help determine the surgical management of grade 3 medial knee injuries combined with cruciate ligament injuries. [55] (10.1007/s00167-011-1541-x)
• [L4] Patients with a previous history of knee ligament surgery had a significantly worse quality of life relative to those with no history of knee ligament surgery. [56] (10.1177/2325967115s00073)
• [L5] The study suggests progressive damage to translational and rotational knee soft-tissue restraints with increasing knee hyperextension. [96] (10.1177/0363546507308189)
• [L3] Patients with MLKR display abnormalities in knee kinematics during gait at an average of 4.5 years after surgery. [97] (10.1007/s00167-016-4104-3)
• [L4] [111] (10.1016/j.arthro.2011.08.293)
• [Paper] [117] (10.1016/j.csm.2018.11.006)
• [L4] [120] (10.1007/s11999-014-3557-2)
• [L4] [121] (10.1007/s00167-009-1011-x)
• [L3] High-energy trauma-induced PCL injuries are often associated with severe concurrent knee injuries with multiple ligament involvement. [122] (10.1186/s13018-024-04927-1)
• [L5] PLC injuries are commonly associated with cruciate injuries, and early recognition is important to achieve successful outcomes. [123] (10.5435/jaaos-d-23-00278)
• [L4] There is a paucity of literature focused on the management of combined ACL and PLC injuries. [124] (10.1177/0363546513507555)
• [Paper] [125] (10.1016/j.csm.2018.11.010)
• [L2] MRI is a sensitive measure of cruciate and collateral ligament injury in acute knee dislocation; however, it does not reliably diagnose injury to the posterolateral corner or meniscus, and therefore, a higher index of suspicion is required during arthroscopy to prevent misdiagnosis which could affect long-term clinical outcome. [126] (10.1007/s00167-015-3857-4)
• [L5] Dynamic ultrasonographic assessment can accurately quantify the severity of medial knee ligament injury based on medial compartment gapping. [127] (10.1016/j.asmr.2022.07.003)
• [L3] The incidence of heterotopic ossification (HO) after multiligament knee injury (MLKI) was 35%. [128] (10.1177/23259671261416523)
• [Case_report] Intra-articular fractures of the distal femoral epiphysis can mimic ligamentous injuries, particularly posterior cruciate ligament insufficiency, and require stress radiographs for diagnosis. [129] (10.2106/00004623-198870030-00024)
• [L4] Patients who underwent a staged cruciate reconstruction(s) had higher subjective outcome scores than those who had cruciate injuries left untreated. [130] (10.1177/23259671221131817)
• [L3] Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. [131] (10.1016/j.otsr.2014.09.010)

See Also

• ACL reconstruction

References

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