State of the Art
Diagnosis and treatment of multiligament knee
1
Oslo University Hospital and
University of Oslo, Oslo, Norway
2
Steadman Philippon Research
Institute, Vail, Colorado, USA
3
OSTRC, The Norwegian School
of Sports Sciences, Oslo, Norway
4
Hospital Britanico de Buenos
Aires, Buenos Aires, Argentina
5 and radiographic examination are required to identify
The Steadman Clinic, Vail,
Colorado, USA
Correspondence to
Dr Robert F LaPrade, The
Steadman Philippon Research
13 Institute, 181 West Meadow
Drive, Suite 1000, Vail, CO
81657, USA; ​drlaprade@​sprivail.​ reconstructions are recommended because repair of
org
Received 9 November 2016
Revised 8 January 2017
Accepted 15 January 2017
Published Online First
7 March 2017
To cite: Moatshe G, Chahla J,
LaPrade RF, et al. J ISAKOS
2017;2:152–161.
152
injury: state of the art
Gilbert Moatshe,1,2,3 Jorge Chahla,2,4 Robert F LaPrade,2,5 Lars Engebretsen1,3
Abstract
Multiligament knee injuries constitute a complex and
challenging entity, not only because of the diagnosis
and reconstruction procedure itself, but also because of
the rehabilitation programme after the index procedure.
A high level of suspicion and a comprehensive clinical
all injured structures. Concomitant meniscal, chondral
and nerve injuries are common in multiligament injuries
necessitating a detailed evaluation. Stress radiographs
are valuable in evaluating patients preoperatively
and postoperatively. The current literature supports
surgical management of multiligament injuries, and
ligaments has higher failure rates. Reconstruction
of all injured ligaments in one stage is advocated (if
possible) in order to achieve early mobilisation and
to avoid joint stiffness. Using biomechanically and
clinically validated anatomic ligament reconstructions
improves outcomes. In the setting of multiligament knee
reconstructions, several technical aspects that require
consideration are vital, such as the graft choice, the
sequence of ligaments reconstruction, tunnel position
and orientation to avoid tunnel interference and graft
tensioning order. This review article discusses the use of
stress radiographs in diagnosing ligament injuries and
evaluating postoperative stability. Tunnel convergence
and tensioning sequence are potential problems, and
guidelines to address these are also discussed. Recovery
after a multiligament reconstruction surgery typically
requires 9 to 12 months of rehabilitation prior to
returning to full activities. The purpose of this article
is to review the specific principles of multiligament
injuries, classification, diagnosis, treatment options and
rehabilitation guidelines for addressing these complex
injuries.
Introduction
The definition of a multiligament knee injury is
commonly recognised as a tear of at least two of the
four major knee ligament structures: the anterior
cruciate ligament (ACL), the posterior cruciate liga-
ment (PCL), the posteromedial corner (PMC) and
the posterolateral corner (PLC).1 2 The terms knee
dislocation and multiligament knee injuries are often
used interchangeably. Knee dislocations often result
in multiligament knee injuries, but some multiliga-
ment knee injuries are not knee dislocations. A knee
dislocation is typically characterised by rupture of
both cruciate ligaments, with or without an asso-
ciated grade III medial or lateral-sided injury.2 3
However, knee dislocations with one of the cruciate
ligaments intact have been reported.4 5 Multiliga-
ment injuries are heterogeneous, and a thorough
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072. Copyright © 2017 ISAKOS
diagnostic workup and treatment plan is mandatory
when dealing with these injuries. The purpose of
this article is to review specific focused principles
of multiligament knee injuries, classification, diag-
nosis, treatment options and rehabilitation guide-
lines for addressing these complex injuries. Key
information and articles on these injuries can be
found in box 1 and box 2 respectively.
Classification
Schenck described the most widely used classifi-
cation system for the dislocated knee in 1994, which
is based on the anatomical patterns of the torn liga-
ments (table 1).3 6 The advantage of this classifica-
tion is that it allows for identification of the torn
ligaments and planning of treatment. In addition, it
makes it possible to compare the different studies in
the literature using the same classification system of
knee dislocations.
Aetiology
Multiligament knee injuries can be caused by
both high-energy trauma,7 such as motor vehicle
accidents and fall from heights, and low-energy
trauma,8 including sporting activities. In a cohort
of 85 patients with knee dislocations, Engebretsen
et al reported that 51% were high-energy injuries,
and 47% were sports-related injuries.9 In a review
of 303 patients with knee dislocations, Moatshe
et al10 reported equivalent rates of high- and
low-energy trauma, with 50.3% and 49.7%, respec-
tively. Miller et al reported on multiligament knee
injuries in obese individuals as a result of ultra-low
velocity trauma.11
Evaluation
Multiligament knee injuries are not uncommon.
Only 28% of PLC injuries occur in isolation.12 The
clinician should have a high level of suspicion, and
a detailed knee examination should be performed
including assessment of the limb’s neurovascular
status. PLC injuries are associated with both common
peroneal nerve injuries and vascular injuries
(Moatshe et al10). When both cruciate ligaments are
torn, the risk of vascular and neurological injuries is
very high and vascular assessment is often needed.2
Magnetic resonance imaging (MRI) is performed
to evaluate all the injured structures (figure 1). For
both acute and chronic injuries, stress radiographs
are essential, but can be difficult to carry out in the
acute phase (tables 2 and 3, figures 2 and 3).13–15
Acute multiligament knee injuries
For high-energy injuries, Advanced Trauma Life
Support principles apply. Foot pulses and skin colour

Box 1 Key information
►► Multiligament injuries are complex and challenging.
►► Detailed evaluation with physical examination, MRI, stress
radiographs and angiography if ankle–brachial index <0.9
►► Concomitant injuries including meniscal, chondral, nerve and
vascular injuries are common.
►► Surgical treatment of all injured structures in the same
setting is recommended.
►► A well-crafted rehabilitation protocol is important to ensure
good functional outcomes.
►► Good functional outcomes can be achieved with surgical
treatment.
should be monitored and compared with the uninjured side.
An ankle–brachial index (ABI) <0.9 warrants an angiography
(figure 4).16 17 Knee dislocations are associated with injuries to the
popliteal artery (23%–32%).7 18 Injury to the common peroneal
nerve occurs in 14%–40% of knee dislocations.19 20 Ultra-low
velocity knee dislocations in the obese patients are associated both
Box 2 Key articles
1. 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.
2. Levy BA, Fanelli GC, Whelan DB, et al. Controversies in
the treatment of knee dislocations and multiligament
reconstruction. J Am Acad Orthop Surg 2009;17:197–206.
3. James EW, Williams BT, LaPrade RF. Stress radiography for
the diagnosis of knee ligament injuries: a systematic review.
Clin Orthop Relat Res 2014;472:2644–2657.
4. 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;30:718–727.
5. Medina O, Arom GA, Yeranosian MG, Petrigliano FA,
McAllister DR. Vascular and nerve injury after knee
dislocation: a systematic review. Clin Orthop Relat Res
2014;472:2621–2629.
6. Schenck R. Classification of knee dislocations. Oper Tech
Sports Med 2003;11:193–198.
7. Peskun CJ, Whelan DB. Outcomes of operative and
nonoperative treatment of multiligament knee injuries:
an evidence-based review. Sports Med Arthrosc
2011;19:167–173.
8. Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC,
Johansen S. Outcome after knee dislocations: a 2–9 years
follow-up of 85 consecutive patients. Knee Surg Sports
Traumatol Arthrosc 2009;17:1013–1026.
9. Dedmond BT, Almekinders LC. Operative versus nonoperative
treatment of knee dislocations: a meta-analysis. Am J Knee
Surg 2001;14:33–38.
10. Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and
combined grade-III posterior cruciate ligament tears
treated with double-bundle reconstruction with use of
endoscopically placed femoral tunnels and grafts: operative
technique and clinical outcomes. J Bone Joint Surg Am
2011;93:1773–1780.
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072
State of the Art
Table 1 Explaining Schenck’s knee dislocation classification
KD I Injury to single cruciate + collaterals
KD II Injury to ACL and PCL with intact
collaterals
KD III M Injury to ACL, PCL, MCL
KD III L Injury to ACL, PCL, FCL
KD IV Injury to ACL, PCL, MCL, FCL
KD V Dislocation + fracture
Additional caps of “C” and “N” are utilized for associated injuries. “C” indicates an
arterial injury. “N” indicates a neural injury, such as the tibial or, more commonly,
the peroneal nerve. ACL, anterior cruciate ligament; FCL, fibular collateral ligament;
KD, Knee Dislocation Classification I–V; MCL, media collateral ligament.
with nerve and vascular injuries, and also with higher complication
rates after surgical treatment.11 21
ABI is useful as an adjunct to physical examination to assess
for vascular injuries. Physical examination with the presence of
a normal vascular examination (normal and symmetrical pulses,
capillary refill, normal neurological examination) is reported to
be reliable to screen patients with knee dislocations for ‘selec-
tive’ arteriography.22 Some protocols recommend an ABI cut-off
of <0.8,23 and others recommend <0.9 to perform arteriog-
raphy.22 24 Stannard et al developed a protocol for monitoring
vascular injuries in knee dislocations.25 Patients with vascular
injuries are treated with acute revascularisation, and the knee is
protected in an external fixator to protect the revascularisation
graft and to maintain knee reduction.23 26 The external fixator is
usually removed at 2–6 weeks and the knee is placed in a hinged
brace to avoid pin infections and joint stiffness.
Chronic multiligament knee injuries
Some multiligament knee injuries are missed in the acute phase,
or concurrent ligament injuries are not acknowledged, in a multi-
trauma patient. A thorough patient history, clinical examination
supplemented with stress radiography and MRI are mandatory
to identify all injured structures. Concomitant cartilage and
meniscal injuries should be diagnosed and treated concurrently.
In addition, long axis radiographs of the lower extremity should
be obtained to assess alignment, especially for chronic multi-
ligament knee injuries. Varus malalignment is defined as being
present when a line from the centre of the femoral head to the
centre of the ankle joint (the mechanical axis) falls medial to
the apex of the medial tibial eminence on a long-leg alignment
radiograph (figure 5). When varus mal-alignment is present in a
patient with a chronic PLC injury, a corrective osteotomy should
be considered prior to reconstruction. Reconstruction grafts
in the PLC do not tolerate varus mal-alignment, and this will
Figure 1 MRI showing a PCL tear on the sagittal plane (A) and a sMCL
injury seen in the coronal plane (B). A detailed evaluation of the patient;
and the images are mandatory to diagnose all the injured structures. PCL,
posterior cruciate ligament; sMCL, superficial medial collateral ligament.
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 State of the Art
Table 2 Evaluation of posterior knee instabilityClinical test findings
and the corresponding stress radiograph values in evaluating posterior
knee instability
Clinical finding with posterior
Grade drawer test Kneeling stress radiographs
I 0–5 mm PTT 0–7 mm PTT → normal or partial tear
II 5–10 mm PTT 8–11 mm PTT → Complete PCL tear
III >10 mm PTTposterior sag ≥12 mm PTT → Combined ligament
injury
PCL, posterior cruciate ligament; PTT, posterior tibial translation.
potentially lead to graft stretching and reconstruction failure.
Arthur et al reported on 21 patients with chronic combined
PLC injuries, 38% had sufficient improvement after proximal
tibia osteotomy that subsequent PLC reconstruction was not
­necessary.27
Concomitant injuries
High incidences of meniscal and focal cartilage injuries are
reported in multiligament knee injuries. In a review of 303
patients at a level I trauma centre (Moatshe et al),10 reported
meniscal injuries were found in 37.3% of the patients and carti-
lage injuries in 28.3%. Richter et al reported lower incidence
(15%) of meniscal injuries in association with knee dislocations28
however, Krych et al reported higher rates of meniscal and chon-
dral lesions associated with knee dislocation in 121 patients (122
knees) with 76% of overall patients having a meniscal or chondral
injury; 55% presented with meniscal tears while 48% presented
with a chondral injury.29 Common peroneal nerve injuries are
frequently associated with lateral-sided injuries. Moatshe et al10
reported common peroneal nerve injuries and vascular inju-
ries in 19% and 5% of the 303 patients with knee dislocations,
respectively. Medina et al19 reported a frequency of 25% and
18% for nerve and vascular injuries in knee dislocations, respec-
tively, in a recent systematic review. Becker et al reported pero-
neal nerve injury in 25% of knees and arterial injury in 21% in
a series of 106 patients.30 Moatshe et al10 reported that the odds
of having a peroneal nerve injury were 42 times higher among
patients with injury than those without, while the odds of having
a popliteal artery injury were 9.2 times higher in patients with a
posterolateral corner injury (figure 6).
Medial-sided injuries are usually the most common injuries
in multiligament knee injury patterns. Moatshe et al 10 reported
that medial-sided injuries constituted 52% of the injuries in
303 patients with multiligament knee injuries. In their series,
lateral-sided injuries constituted 28% and bicruciate injuries
constituted only 5%. In a review by Robertson et al,31 medi-
al-sided and lateral-sided injuries were reported in 41% and
Table 3 Evaluation of varus and valgus instability using stress
radiographs Side-to-side differences between the injured and the
noninjured knee using stress radiograph to evaluate varus and valgus
knee instability
Varus stress test Valgus stress test
<2.7 mm → Normal or partial tear <3.2 mm → Normal or partial tear
2.7 mm → Isolated FCL tear 3.2 mm → Complete sMCL tear
≥4 mm: → Complete PLC injury ≥9.8 mm → Complete tear of all medial
structures
FCL, fibular collateral ligament; PLC, posterolateral corner; sMCL, superficial medial
collateral ligament.
154
Figure 2 Kneeling stress radiographs for evaluation posterior laxity
are an important part of the evaluation. In this patient, there was a
10 mm increase in posterior tibial translation on the left compared with
the right knee. To compare the posterior tibial translation, a point is
identified along the posterior tibial cortex 15 cm distal to the joint line. A
line is then drawn from this point parallel to the posterior cortex, through
the femoral condyles. The most posterior point of Blumensaat’s line is
marked. A perpendicular line is drawn from the most posterior point of
the Blumensaat´s line to intersect the first line drawn parallel to the tibial
cortex. This distance is compared with the contralateral side to give a
side-to-side difference. A posterior translation side-to-side difference of
0 to 6 mm are usually due to partial PCL tear or in patients who are too
sore to put sufficient weight on the knee; an 8 mm to 11 mm side-to-side
difference is associated with a complete isolated PCL tear; ≥12 mm is
usually observed in patients with complete PCL tear with another ligament
injury, usually the PLC or PMC, but can also be seen in patients with
decreased sagittal plane tibial slope. PCL, posterior cruciate ligament; PLC,
posterolateral corner; PMC, posteromedial corner.
28%, respectively. In contrast, Becker et al reported that later-
al-sided injuries were the most common (43%) in a series of 106
patients.30
Surgical versus nonsurgical management
Surgical treatment of the torn ligaments in multiligament injured
knees improves patient-reported outcomes.28 32 33 In a meta-anal-
ysis including 132 knees treated surgically and 74 treated nonsur-
gically, Dedmond et al reported improved motion and Lysholm
scores in the surgical treatment group.32 The surgical group had
significantly better range of motion (123° in the surgical group
vs 108° in the nonsurgical group) and Lysholm scores (85.2 in
the surgical group vs 66.5 in the nonsurgical group). Richter
Figure 3 Valgus stress radiographs to evaluate the medial and
posteromedial side of the knee are important and should be incorporated
in the evaluation, especially in chronic cases. In this case there is a 3.4 mm
increase in medial compartment gapping on the right (A) compared with
the left (B) knee, indication a complete sMCL tear. Overall, a 3.2 mm side to
side difference of gapping represents a complete sMCL tear, and a 9.8 mm
difference represents injury to all medial structures. sMCL, superficial
medial collateral ligament.
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072

Figure 4 A photograph demonstrating measurement of systolic blood
pressure on the injured limb (ankle) using a Doppler probe (A) and systolic
blood pressure on the uninjured upper limb (brachial) (B). The ankle
brachial index (ABI) is calculated by taking the ratio of the Doppler systolic
blood pressure in the injured limb (ankle) to the systolic arterial blood
pressure in the uninjured upper limb (brachial). ABI = Doppler systolic
blood pressure in the injured limb/systolic blood pressure in the uninjured
upper limb.
Figure 5 In chronic cases, long-leg radiographs are recommended
to evaluate alignment. Patients with chronic PLC injuries and varus
malalignment should be treated with an osteotomy to correct mal-
alignment prior to PLC reconstruction. Untreated mal-alignment will likely
cause the grafts to stretch over time and fail. PLC: posterolateral corner.
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072
State of the Art
Figure 6 Image showing a left knee with multiligament knee injury
involving the posterolateral corner. There is increased risk of common
peroneal nerve injury with posterolateral corner injuries. CPN, common
peroneal nerve.
et al28 reported on 89 patients with traumatic knee dislocations
with a mean follow-up of 8.2 years. Sixty-three patients were
treated with surgical repair or reconstruction, while 26 patients
were treated nonsurgically. The authors reported significantly
improved outcomes in the surgical group compared with the
nonsurgical group. Functional rehabilitation after surgery was
reported to be the most important positive prognostic factor. In
addition, patients who were 40 years of age or younger and who
had low velocity sports injuries had better scores.28 In a liter-
ature review by Peskun and Whelan,33 evaluating outcomes in
855 patients from 31 studies treated surgically, and 61 patients
from four studies treated nonsurgically, functional outcomes,
contracture, instability, and return to activity favoured surgical
treatment. In summary, the literature supports surgical treat-
ment, and postoperative functional rehabilitation of multiliga-
ment knee injuries. It is in rare occasions such as advanced age,
immobility and comorbidities that nonsurgical treatment can be
considered.
Repair versus reconstruction
Earlier studies have reported poor outcomes after repair of
isolated ACL injuries.34–36 Mariani et al evaluated outcomes
in a cohort of patients with multiligament injuries; 52 patients
treated with repair of the ligaments versus 28 treated with
reconstructions.37 All patients had bicruciate ligament injuries,
and they were divided into three groups; direct ACL/PCL repair
(group 1), ACL reconstruction and PCL repair (group 2) and
ACL and PCL reconstruction (group 3). Patients with repair of
cruciate ligaments had higher rates of flexion deficit >6°, higher
rates of posterior instability and lower rates of return to prein-
jury activity levels. High reoperation rates have been reported
in patients with posterolateral injuries treated with repair.38 39
Anatomic reconstruction of the injured structures using biome-
chanically validated techniques has been reported to yield
improved outcomes (figure 7).40–42 In the setting of multilig-
ament injuries, reconstruction of the torn ligaments is recom-
mended. Repair of the collaterals is usually reserved for bony
avulsion injuries.43
Timing of surgery
Timing of surgery during multiligament injuries is a topic of
debate. In addition, there is still no consensus on the point of
demarcation between acute and chronic. Some authors have used
3 weeks as the critical time to better identify and treat the struc-
tures before scarring and tissue necrosis affect outcomes.9 37 44 45
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 State of the Art
Figure 7 An intraoperative arthroscopy image showing double-bundle
PCL reconstruction. Anatomic reconstruction of all the torn ligaments using
biomechanically and clinically validated techniques is recommended. ALB,
anterolateral bundle; PMB, posteromedial bundle; MFC, medial femoral
condyle.
This is also particularly important in the case of bony avulsion
injuries. However, some authors have used 6 weeks to demarcate
between acute and chronic.40 Better outcomes are reported in
acute compared with chronic treatment in studies that directly
compared timing of treatment. Levy et al reported no difference
in range of motion after acute and chronic surgery in a system-
atic review of literature that included five studies46 Moatshe
et al. (unpublished data, 2016) reported on 303 patients with
knee dislocations, and the percentage of patients developing
arthrofibrosis was 15.2% and 3.8% in the acutely treated and
the chronic injuries, respectively. The authors preferred acute
treatment of the injured structures to facilitate early rehabili-
tation.40 In addition, staging the reconstruction can potentially
alter joint kinematics, and increase the risk of graft failure.47–49
In high energy trauma, surgery may be delayed because of inju-
ries to the soft tissue about the knee and concomitant injuries to
other vital organs. However, stiffness in these patients may be
easier to treat than recurrent instability.
Surgical principles
Avoiding tunnel convergence
Reconstructing several reconstruction tunnels in the distal femur
and proximal tibia pose a risk of tunnel convergence because of
limited bone mass in these areas. Tunnel convergence increases
the risk of reconstruction graft failure because of the potential
damage to reconstruction grafts, fixation devices and not having
sufficient bone stock between the grafts for fixation and graft
incorporation. Few studies have evaluated the risk of tunnel
convergence and optimal angulation of the tunnels. Moatshe
et al reported a 66.7% tunnel convergence rate between the
posterior oblique ligament (POL) tunnel and the PCL tunnel in
the tibia when the POL tunnel was aimed at Gerdy’s tubercle.
They recommended that the POL tunnels be aimed to a point
15 mm medial to Gerdy’s tubercle to reduce risk of convergence
156
with the PCL, and that the superficial medial collateral ligament
(sMCL) tunnel be aimed 30° distally to avoid convergence with
the PCL.50
On the lateral femoral side, Moatshe et al (in press, 2016)
performed a 3D imaging study varying the angles of the FCL and
popliteus tunnels. A 35°–40° angulation in the axial plane and 0°
in the coronal plane were safe and avoided tunnel convergence.
On the medial side, aiming the sMCL tunnel 40° in the axial and
coronal planes and the POL tunnel 20° in the axial and coronal
planes was safe to avoid convergence with the double-bundle
PCL tunnels (figure 8). In a laboratory study, Carmada et al
reported a high risk of tunnel convergence between the ACL and
the FCL (69%–75% depending on the length of the tunnel) and
recommended aiming the FCL tunnel 0° in the coronal plane
and 20°–40° in the axial plane.51 Gelber et al evaluated tunnel
convergence and optimal angulation of the tunnels on the medial
femur condyle. They found that angulations of 30° in the axial
plane and coronal plane reduced the risk of convergence with
the PCL tunnels.52 However, the diameter of their PCL tunnels
were smaller than those used by Moatshe et al.
Tensioning sequence
The tensioning sequence in multiligament injuries is a topic of
debate. Different tensioning sequences have been reported in the
literature. Some authors advocate for starting with the PCL to
restore the central pivot and tibial step-off, followed by the ACL
in extension to ensure the knee can be fully extended, postero-
lateral corner and the posteromedial corner last.53 54 A biome-
chanical study by Wentorf et al reported that in a posterolateral
corner deficient knee, tension during fixation of the ACL graft
increased external tibial rotation of the tibia.49 Therefore, there
are authors that advocate for fixing the posterolateral corner
prior to the ACL to avoid external tibial rotation. Markolf et al
reported in a biomechanical study that the PCL should be fixed
prior to the ACL to best restore graft forces.55 Kim et al retro-
spectively reviewed 25 patients with multiligament injuries, 14
with the PCL tensioned first and 11 with simultaneous tension
and fixing the ACL first. Posterior stress radiographs, Lysholm
score, International Knee Documentation Committee (IKDC)
Figure 8 Reconstruction of the sMCL on a right knee. The AT is an
important landmark to locate the adductor tubercle which is just distal to
the adductor tendon insertion. The attachment site of the MCL is 12 mm
distal and 8 mm anterior to the adductor tubercle. To avoid convergence
with the PCL tunnels, the sMCL and popliteus tunnels should be aimed
anteriorly and proximally. AT, adductor tendon; PCL, posterior cruciate
ligament; sMCL, superficial medial collateral ligament.
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072

Box 3 Key issues of patient selection
►► Injury to>1 major knee ligament (ACL, PCL, MCL, FCL or PCL)
►► Active patients without major comorbidities
►► Detailed assessment of all injuries
►► Aim for surgical treatment of all injured structures in the
acute setting
►► Obese patients have higher complication rates
►► Delay ligament surgery in patients with vascular injuries
scores favoured fixing the ACL first.56 The optimal tensioning
sequence can be best evaluated with well-designed biome-
chanical studies.57 The authors preferred tensioning sequence
which fixes the anterolateral bundle of the PCL at 90° to restore
the normal tibial step-off, the posteromedial bundle of the PCL
in extension, the FCL at 20°−30° of knee flexion and a slight
valgus force, followed by the rest of the PLC structures at 60°
of flexion and neutral rotation, the ACL near full extension and
finally the posteromedial corner.
Surgical technique
A thorough preoperative assessment to aid patient selection
and planning of treatment is important (box 3). The surgical
technique uses both allografts and autografts depending on the
ligaments injured. Anatomic ligament reconstructions that are
biomechanically and clinically validated are performed. An open
surgical approach is performed prior to arthroscopy to allow for
improved soft tissue visualisation and to limit fluid extravasa-
tion into the surgical site. On the medial side, a skin incision
is performed proximally between the adductor tubercle and
the patella and extended 8 cm distally from the joint line to the
medial part of the tibia. The semitendinosus and gracilis tendons
are harvested and fixed at the superficial MCL attachment site,
6 cm distal to the joint line with two suture anchors.58 A femoral
reconstruction tunnel is reamed at the anatomic attachment of
the MCL, and the grafts are passed under the sartorius fascia
and the graft ends are whipstitched so that 30 mm will fit into
the femoral tunnel (figure 9).59 On the posterolateral side,
a technique described by LaPrade et al60 is performed using a
split Achilles graft (figure 10). The fibular, tibial and femoral
Figure 9 A diagram of a left knee illustrating the superficial medial
collateral: ligament (sMCL) and posterior oblique ligament (POL)
reconstruction grafts. ME: medial epicondyle. Reprinted with permission of
SAGE Publications, Inc, from Coobs BR, et al.73
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072
State of the Art
Figure 10 An illustration of the right knee demonstrating the
posterolateral knee reconstruction procedure. A, posterior view; B,
lateral view. PLT, popliteus tendon; FCL, fibular collateral ligament; PFL,
popliteofibular ligament. Reprinted with permission of SAGE Publications,
Inc, from LaPrade RF, et al.60
tunnels are reamed and passing sutures are placed. After drilling
the tunnels for the collateral ligament reconstruction grafts,
attention is turned to the intra-articular injuries. An anatomic
double-bundle PCL41 61 and single-bundle ACL reconstruc-
tions are performed. The concomitant meniscal and chondral
lesions are addressed prior to graft fixation and tensioning. Graft
tensioning is performed as described above. Tips and tricks, and
some potential pitfalls when performing this type of surgery can
be found in box 4 and box 5 respectively.
Rehabilitation
Multiligament knee injuries are complex and challenging pathol-
ogies to rehabilitate due to the extensive soft tissue damage and
the different injury patterns that can occur. An appropriate diag-
nosis and treatment of all the damaged structures is vital for a
successful outcome. Reconstruction of all injured ligaments and
repair of soft tissue structures such as the meniscus or cartilage
are recommended to aid in early mobilisation and to avoid joint
stiffness or graft failure. Postoperative recovery after a multilig-
ament reconstruction procedure typically requires 9–12 months
of rehabilitation prior to returning to full activities. This allows
proper time for the grafts to incorporate and to heal in order
to prevent reconstruction graft failure. A well-crafted rehabil-
itation plan after a multiligament reconstruction should focus
on graft protection and functional outcomes including regaining
motion, strength and function. A dynamic PCL brace (Ossur
PCL Rebound brace, Foothill Ranch, CA, USA) or a Jack PCL
brace (Albrecht GmbH, DE, USA) is used in the rehabilitation
period (9–12 months) to protect the reconstruction. It is also
recommended to use a brace on the first year of returning to
activities. Full range of motion is especially vital to long-term
outcomes, and patients should aim to obtain 0–90° of knee
flexion within the first 2 weeks after surgery. Once a muscular
strength foundation with good dynamic neuromuscular control
has been established, patients can progress to their functional
sport specific exercises.
Initial management should focus on supportive measures such
as pain control, inflammation/effusion control (cryotherapy,
elevation and compression of the affected limb), range of motion
re-establishment, patellar mobilisation, restoring appropriate
157
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Box 4 Tips and tricks
►► Patient positioning: The patient should be positioned to
allow full flexion and extension of the knee.
►► Graft preparation: Ensure availability of grafts and correct
graft length. Tightly spacing the whipstitch sutures
protects the grafts from laceration when securing with an
interference screw.
►► Steps during surgery: Start with the collateral ligament
injuries. Fluid extravasation from arthroscopy can impair
visualisation and identification of structures.
►► Tunnel positioning: All the tunnels should be placed at the
anatomic footprint of the ligaments being reconstructed. All
the tunnels’ positions and orientations should be planned
in detail to avoid tunnel convergence. Aiming the femoral
FCL and popliteus tunnels anteriorly reduces the risk of
convergence with the ACL tunnel and the risk of violating
the intercondylar notch. The centre of the popliteus tunnel is
18.5 mm anterior to the centre of the FCL tunnel, and there
is an 8–9 mm bone bridge between the tunnels. The femoral
tunnels for the posteromedial corner should be aimed
anteriorly and proximally to avoid convergence with the PCL
tunnels. The femoral PCL tunnels should be divergent.
►► Acorn reamers: These reamers allow the surgeon to add
fine adjustments to the tibial tunnel paths. The edges of the
tunnels should be smooth to prevent the bone edges from
damaging the grafts.
►► Fixation: The sequence of graft fixation affects the
tibiofemoral orientation and the graft forces. The PCL is
tensioned first, followed by the PLC, then the ACL and finally
the PMC.
►► Postoperative rehabilitation: Early protected range of motion
is important. Periodisation, progressive weight bearing,
quadriceps activation and patella mobility. Rehabilitation
takes 9–12 months. Use brace during activities the first year
of returning to activities.
muscle activation patterns and progressive gait training. Soft
tissue healing involves a predictable series of phases (inflam-
mation, proliferative and remodelling phases) that should be
addressed at a proper time to promote physiological healing
responses, minimise negative changes and facilitate the prolif-
eration and alignment of collagen fibres.62 Patellar mobilisation
should be a primary initial focus of the rehabilitation, as hypo-
mobility of the proximal pole of the patella can interfere with
the extensor mechanism leading to loss of range of motion and a
quadricep lag.62 Conversely, flexion can be affected by a dimin-
ished patellar inferior glide. With regards to weight bearing, to
date there is no randomised clinical trial assessing the effective-
ness of early weight bearing after a multiligament reconstruc-
tion, and therefore protected weight bearing is carried out for
the first 6 weeks after which partial weight bearing is allowed.
Periodisation is the division of a training or rehabilitation
programme into smaller phases (periods) as a means of creating
more manageable segments. In a multiligament knee reconstruc-
tion rehabilitation programme, the phases are constituted by
muscular endurance, strength and power and can be developed
based on the patient’s expectations and return to activity time-
line. The length of each phase depends on the time frame of
the rehabilitation programme, but it should be no shorter than
6 weeks. With range of motion (ROM) restored, the treatment
emphasis shifts to the development of a muscular endurance
158
Box 5 Major pitfalls
►► Patient positioning: Incorrect positioning of the patient may
limit knee motion and the space available for the surgeon to
work effectively.
►► Graft preparation: Oversizing the grafts can complicate
the passage of grafts in the tunnels. Care must be taken to
ensure availability of graft for all torn ligaments.
►► Tunnel convergence: With many tunnels being created in
both the femur and tibia, the risk of tunnel convergence
is high. Tunnel convergence will potentially damage the
grafts, fixation devices, create too short tunnels or leave not
enough bone stock for graft fixation and integration. The
PCL femoral tunnels should be divergent.
►► Meniscal root injuries: Malposition of the PCL tibial tunnel
can potentially injure the posterior root of the medial
meniscus. Malposition of the ACL tibial tunnels can
potentially injure the anterior horn of the lateral meniscus.
►► Neurovascular complications: There is increased risk of
neurovascular injuries when creating tibial femoral tunnels.
The guide pin should be visualised and advancement of the
guide pin should be prevented during reaming.
►► Fixation: The sequence of graft fixation can theoretically
alter tibiofemoral orientation and thus knee kinematics,
increasing the risk of graft failure and osteoarthritis.
base. A transition in training emphasis to the development of
muscular strength can then be made before muscular power is
developed. Three to four sessions a week are appropriate while
still providing adequate recovery between sessions.63
Given the numerous variables (age, BMI, sport, concurrent
injuries, etc) that can interact in the decision to allow a patient
to return to sport, the rehabilitation process and return to sport
timeline should be tailored to each patient. A systematic review of
264 studies by Barber-Westin and Noyes reported that the return
to play decision was based on subjective nonspecific criteria such
as ‘regained full functional stability’, ‘normal knee function on
clinical examination’, ‘satisfactory stability’ or ‘nearly full ROM
and muscle strength’.64 Few studies described objective criteria
such as time from surgery, muscle strength, ROM and effusion,
which were the most frequently used.64
Subjective and objective outcomes
Poor outcomes are reported for nonsurgical management of
multiligament knee injuries, therefore this section will focus on
outcomes after surgical management. Preoperative and post-
operative stability and functional scores are usually compared
to evaluate patient outcomes (box 6). Unfortunately, most
studies on multiligament knee injuries have small cohorts and
the follow-up is generally short. Good functional outcomes
are reported in short to medium follow-up after surgical treat-
ment of multiligament injuries.9 46 In a follow-up of 85 patients
Box 6 Validated outcome measures and classifications
►► Stress radiographs to evaluate knee stability
►► Tegner Activity Score
►► Lysholm Score
►► International Knee Documentation Committee (IKDC)
►► Use Schenck´s Knee Dislocation Classification (KD I-V)
(table 1)
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072

Figure 11 Stress radiographs are an important method to evaluate joint
stability both preoperatively (A and B) and postoperatively (C and D).
with knee dislocations at 2–9 years, Engebretsen et al reported
improved patient reported outcomes with a mean Lysholm of
83, median Tegner Activity score of 5 and mean IKDC 2000
subjective score of 64. However, 87% of the patients in the
cohort had radiological osteoarthritis in the injured knee based
on Kellgren-Lawrence classification.9 Moatshe et al (unpub-
lished data, 2016) reported a mean Lysholm score of 84,
Tegner score of 4 and subjective IKDC 73 in a follow-up of
65 patients with multiligament knee injuries at a minimum
follow-up of 10 years. Forty-two per cent of the cohort had
radiological osteoarthritis in the injured knee compared with
only 6% in the uninjured knee. Geeslin et al40 reported on 29
patients (30 knees), 8 knees had isolated posterolateral corner
injuries and 22 knees had combined ligament injuries involving
the posterolateral corner. At a mean follow-up of 2.4 years,
Cincinnati and IKDC subjective outcome scores improved from
21.9 to 81.4 and 29.1 to 81.5, respectively. Side-to-side varus
gapping on stress radiographs improved from 6.2 mm preoper-
atively to 0.1 mm postoperatively.40 Postoperative stress radio-
graphs are an important objective method of evaluating stability
(figure 11).
Good functional outcomes have also been reported by other
authors.40 41 65–68 Despite good functional scores, several studies
report relatively high prevalence of radiographic osteoarthritis
ranging from 23% to 87%.9 65 68 Certain factors have been
reported to correlate with poor outcomes including high-energy
trauma,9 repair of medial side injury,69 age >30 years70 (Moatshe
et al71), concomitant cartilage injury,72 combined medial and
lateral meniscal tears.72
Conclusions and future perspectives
Multiligament knee injuries are complex and a high level of
suspicion is required when treating these patients. Some of
the concurrent ligament and meniscal injuries may be missed
initially, and this necessitates a detailed history and clinical
Moatshe G, et al. J ISAKOS 2017;2:152–161. doi:10.1136/jisakos-2016-000072
State of the Art
Box 7 Future perspectives
►► The effect of tensioning force during multiligament
reconstructions
►► The optimal tensioning sequence during multiligament
reconstructions
►► Long-term follow-up outcomes after multiligament knee
injuries
►► Optimal treatment protocol for ultra-low velocity
multiligament injuries in obese patients
►► Multiligament injuries: optimal treatment and outcomes in
the adolescent population
examination, supplemented with MRI and stress radiographs.
Failure to treat all injured structures can lead to changes in knee
kinematics and hence poorer outcomes and an increased risk of
graft failure. Treating all the injured structures in the acute phase
is recommended in order to facilitate early rehabilitation and
better restoration of knee function. Good functional outcomes
can be achieved after surgical treatment of these injuries, but
post-traumatic osteoarthritis is common.
There is still no consensus on the optimal tensioning sequence
of the grafts during multiligament knee injury surgery. Biome-
chanical studies are necessary to evaluate the effects of the
different tensioning orders to the knee kinematics. This will
potentially pave the way for multicentre clinical studies to eval-
uate this in clinical settings. In addition, several reconstruction
grafts are often needed during this type of surgery, posing a
problem in areas where allografts are not available. Optimal
reconstruction in the setting where allografts are not available is
an area that needs further research (box 7).
Contributors All the authors (GM, JC, RFL, LE) have contributed fully at all phases
of this manuscript. All the the authors have read and approved the final version of
the manuscript being submitted.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
© International Society of Arthroscopy, Knee Surgery and Orthopaedic
Sports Medicine (unless otherwise stated in the text of the article) 2017.
All rights reserved. No commercial use is permitted unless otherwise expressly
granted.
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