Multiple-Ligament Knee Injuries: A Systematic Review of the Timing of Operative Intervention and Postoperative Rehabilitation

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 % confidenc