Evidence-Based Orthopaedics   |    
Multiple-Ligament Knee Injuries: A Systematic Review of the Timing of Operative Intervention and Postoperative Rehabilitation
William R. Mook, MD1; Mark D. Miller, MD1; David R. Diduch, MD1; Jay Hertel, PhD, ATC2; Yaw Boachie-Adjei, MD1; Joseph M. Hart, PhD, ATC1
1 Department of Orthopaedic Surgery, University of Virginia Health System, P.O. Box 801016, Charlottesville, VA 22908
2 Department of Human Services, Curry School of Education, University of Virginia, P.O. Box 400407, Charlottesville, VA 22904
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Investigation performed at the Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Dec 01;91(12):2946-2957. doi: 10.2106/JBJS.H.01328
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Background: Traumatic knee dislocations that result in multiple-ligament knee injuries are unusual and are poorly studied. We are not aware of any prospective data regarding their treatment. Both the optimum timing of surgery for repair or reconstruction and the aggressiveness of rehabilitation are debated. The purpose of this systematic review was to compare the outcomes of early, delayed, and staged procedures as well as the subsequent rehabilitation protocols.

Methods: We surveyed the literature and retrieved twenty-four retrospective studies, involving 396 knees, dealing with the surgical treatment of the most severe multiple-ligament knee injuries (those involving both cruciate ligaments and either or both collateral ligaments). Data were extracted, and surgical timing was categorized as acute, chronic, or staged. Early postoperative mobility and immobilization were also compared.

Results: We found that acute treatment was associated with residual anterior knee instability when compared with chronic treatment (odds ratio, 2.58; 95% confidence interval, 1.2 to 5.8; p = 0.018). Significantly more patients who were managed acutely were found to have more flexion deficits when compared with those who were managed chronically (odds ratio, 5.18; 95% confidence interval, 1.5 to 17.5; p = 0.004). Staged treatments yielded the highest percentage of excellent and good subjective outcomes (79%; 95% confidence interval, 62.2% to 89.3%). Additional treatment for joint stiffness was significantly more likely in association with acute treatment (17%; 95% confidence interval, 13.0% to 22.4%; p < 0.001) and staged treatment (15%; 95% confidence interval, 7.6% to 28.2%; p = 0.001) when each was compared with chronic treatment (0% [zero of seventy-one]; 95% confidence interval, 0.0% to 5.1%). Early mobility was not associated with increased joint instability in acutely managed patients. Early mobility yielded fewer range-of-motion deficits but did not reduce the rate of follow-up manipulation or arthrolysis.

Conclusions: This review of the available literature suggests that delayed reconstructions of severe multiple-ligament knee injuries could potentially yield equivalent outcomes in terms of stability when compared with acute surgery. However, in the acutely managed patient, early mobility is associated with better outcomes in comparison with immobilization. Acute surgery is highly associated with range-of-motion deficits. Staged procedures may produce better subjective outcomes and a lower number of range-of-motion deficits but are still likely to require additional treatment for joint stiffness. More aggressive rehabilitation may prevent this from occurring in multiple-ligament knee injuries that are treated acutely.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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