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Early surgery of multiligament knee injuries may yield better results than delayed surgery: a systematic review

      Importance

      Multiligament knee injuries are rare, but can lead to significant functional limitations. Surgery has been shown to improve outcomes, however, there remains considerable debate regarding the optimal timing of surgery.

      Objective

      We aimed to determine whether early surgery in the setting of a multiligamentous knee injury was associated with superior functional outcomes when compared with surgery on a delayed basis.

      Evidence review

      A comprehensive literature search of the MEDLINE, EMBASE and PubMed databases was conducted up to March 2018. We identified studies with a sample size greater than 10 that included subjects with an injury to at least two of the four major knee ligaments and compared outcomes between early and delayed surgery. We assessed the methodological quality of each included study using the Newstead-Ottawa Scale.

      Findings

      We identified 11 eligible studies, including a total of 320 patients (195 early and 125 delayed). The mean time to surgery among patients treated early was 11.2 days in comparison to 294.8 days for the delayed group. Early surgery was found to have a statistically significantly higher Lysholm score (p<0.0001) and Meyers rating (p=0.02) when compared with delayed surgery. No statistically significant differences in International Knee Documentation Committee, Tegner Activity Scale, total arc of motion, loss of extension or loss of flexion were demonstrated between early and delayed surgery. Early surgery was noted to have a statistically significantly higher odds of requiring a manipulation under anaesthesia or arthrolysis (p=0.04), however, subsequent subgroup analysis showed no difference between early and delayed surgery when only studies employing an early range of motion protocol were pooled.

      Conclusions and relevance

      Based on the current body of literature, which primarily consists of level IV evidence, early surgery in the setting of multiligament knee injury may provide better functional outcomes without compromising range of motion when using early postoperative mobilisation protocols. Further studies of higher quality are required to corroborate these findings.

      Level of evidence

      Level IV, systematic review.
      What is already known
      • Operative treatment of multiligament knee injuries leads to superior functional outcome scores, greater range of motion, fewer contractures, improved ligamentous stability and higher rates of return to sport and employment.
      • The heterogenous nature of multiligament knee injuries have made them difficult to evaluate with large clinical trials.
      What are the new findings
      • There is a paucity of high-level evidence to provide definitive conclusions and recommendations regarding the optimal timing of surgery for multiligament knee injuries.
      • Quantitative synthesis of low-quality studies suggests that early surgery may provide superior functional outcomes, without compromising range of motion, provided that early postoperative range of motion is initiated.
      • Future studies should use a disease-specific outcome measure, such as the Multiligament Quality of Life questionnaire to assess patient-reported outcomes in multiligament knee injuries.

      Introduction

      Multiligament knee injuries (MLKI) are rare, however, they can result in significant morbidity.
      • Brautigan B
      • Johnson DL
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      • Hoover NW
      Injuries of the popliteal artery associated with fractures and dislocations.
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      The substantial force required to cause these injuries is often associated with a knee dislocation or substantial subluxation of the knee resulting in an injury to two or more ligaments.
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      Surgical treatment of multiligament knee injuries.
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      Surgical treatment of combined PCL-ACL medial and lateral side injuries (global laxity): surgical technique and 2- to 18-year results.
      Its low incidence and heterogeneous injury profile have it made it inherently difficult to evaluate with large clinical trials, resulting in a lack of consensus regarding the most effective management of these complex injuries.
      • Cook S
      • Ridley TJ
      • McCarthy MA
      • et al.
      Surgical treatment of multiligament knee injuries.
      ,
      • Levy BA
      • Dajani KA
      • Whelan DB
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      Decision making in the multiligament-injured knee: an evidence-based systematic review.
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      • Levy BA
      • Fanelli GC
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      Knee Dislocation Study Group
      Controversies in the treatment of knee dislocations and multiligament reconstruction.
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      • Richter M
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      • et al.
      Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations.
      While it is well established that operative treatment leads to superior functional outcome scores, greater range of motion, fewer contractures, improved ligamentous stability and higher rates of return to sport and employment, there is still no consensus on the optimal timing of surgery for this challenging injury.
      • Levy BA
      • Dajani KA
      • Whelan DB
      • et al.
      Decision making in the multiligament-injured knee: an evidence-based systematic review.
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      • Acharya KKV
      • Pandey V
      • Rao PS
      Knee dislocation with multi-ligament injury: evaluation, treatment and results.
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      • Bin SI
      • Nam TS
      Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation.
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      • Dedmond BT
      • Almekinders LC
      Operative versus nonoperative treatment of knee dislocations: a meta-analysis.
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      • Gauffin H
      • Rockborn P
      Knee dislocations: is reconstruction of the posterior cruciate ligament crucial?.
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      • Ibrahim SA
      • Ahmad FH
      • Salah M
      • et al.
      Surgical management of traumatic knee dislocation.
      ,
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Ohkoshi Y
      • Nagasaki S
      • Shibata N
      • et al.
      Two-stage reconstruction with autografts for knee dislocations.
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      • Ríos A
      • Villa A
      • Fahandezh H
      • et al.
      Results after treatment of traumatic knee dislocations: a report of 26 cases.
      ,
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      Many surgeons have advocated for early surgical treatment to achieve the best result.
      • Levy BA
      • Dajani KA
      • Whelan DB
      • et al.
      Decision making in the multiligament-injured knee: an evidence-based systematic review.
      ,
      • Gauffin H
      • Rockborn P
      Knee dislocations: is reconstruction of the posterior cruciate ligament crucial?.
      ,
      • Ibrahim SA
      • Ahmad FH
      • Salah M
      • et al.
      Surgical management of traumatic knee dislocation.
      ,
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Ohkoshi Y
      • Nagasaki S
      • Shibata N
      • et al.
      Two-stage reconstruction with autografts for knee dislocations.
      ,
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Ibrahim SA
      • Ghafar S
      • Salah M
      • et al.
      Surgical management of traumatic knee dislocation with posterolateral corner injury.
      Proponents of early repair or reconstruction suggest that the first 3 weeks after injury represent a critical time to re-establish anatomic relationships and offer the best chance to restore the central axis of knee motion.
      • Gwathmey FW
      • Shafique DA
      • Miller MD
      Our Approach to the Management of the Multiple-Ligament Knee Injury.
      On the other hand, those who advocate delaying surgery believe that it offers the advantage of obtaining improved preoperative range of motion and provides extra-articular structures the opportunity to heal on their own.
      • Levy BA
      • Dajani KA
      • Whelan DB
      • et al.
      Decision making in the multiligament-injured knee: an evidence-based systematic review.
      ,
      • Levy BA
      • Fanelli GC
      • Whelan DB
      • et al.
      Knee Dislocation Study Group
      Controversies in the treatment of knee dislocations and multiligament reconstruction.
      ,
      • Fanelli GC
      • Edson CJ
      Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up.
      ,
      • Fanelli GC
      • Edson CJ
      Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up.
      ,
      • Fanelli GC
      • Giannotti BF
      • Edson CJ
      Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction.
      ,
      • Karataglis D
      • Bisbinas I
      • Green MA
      • et al.
      Functional outcome following reconstruction in chronic multiple ligament deficient knees.
      Others have reported superior outcomes with staged intervention, with repair of the extra-articular injuries acutely, followed by reconstruction of the cruciate ligaments at a later date once knee range of motion improves.
      • Acharya KKV
      • Pandey V
      • Rao PS
      Knee dislocation with multi-ligament injury: evaluation, treatment and results.
      ,
      • Bin SI
      • Nam TS
      Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation.
      ,
      • Ohkoshi Y
      • Nagasaki S
      • Shibata N
      • et al.
      Two-stage reconstruction with autografts for knee dislocations.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Jiang W
      • Yao J
      • He Y
      • et al.
      The timing of surgical treatment of knee dislocations: a systematic review.
      In 2009, Mook et al
      • Mook WR
      • Miller MD
      • Diduch DR
      • et al.
      Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation.
      attempted to clarify this conflicting evidence with a systematic review, which examined over 60 years of published data on the optimal timing of surgery for MLKIs. The authors concluded that while early and delayed surgical intervention may yield equivalent stability outcomes, those who underwent early repair or reconstruction were more likely to require additional interventions for range of motion deficits, even when combined with an early range of motion protocol. However, the results of the systematic review were limited by a paucity of high-level evidence and were less generalisable as only studies with the most severe knee injuries were included. Notably, another systematic review published in the same year concluded that early operative treatment of MLKIs resulted in improved functional and clinical outcomes, which further highlights the heterogeneous nature of the available literature.
      • Levy BA
      • Dajani KA
      • Whelan DB
      • et al.
      Decision making in the multiligament-injured knee: an evidence-based systematic review.
      Considering this lack of consensus, the purpose of this study was to provide an update on the optimal timing of surgery for MLKIs by performing a systematic review of the orthopaedic literature to determine whether early surgery results in superior functional outcomes without adversely affecting range of motion.

      Methods

      We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
      • Moher D
      • Liberati A
      • Tetzlaff J
      • PRISMA Group
      • et al.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

      Search strategy

      Two investigators (US and JS) independently performed a systematic literature search of the electronic databases MEDLINE, EMBASE and PubMed from their inception to March 2018. A keyword search including a combination of the following medical subject headings (MeSH) was performed: knee dislocation, multiligament, reconstructive surgical procedure and repair. Additional articles were detected by searching through the reference lists of eligible studies. The complete search strategy used for EMBASE is presented in online supplementary appendix 1.

      Eligibility criteria

      Studies were eligible for inclusion if they met the following criteria: (1) knee injury to at least two of the four primary knee ligaments; (2) functional outcome data reported for both the ‘early’ and ‘delayed’ surgery cohorts; and (3) total sample size >10 patients. Early surgery was defined as operative treatment within 4 weeks of injury. There were no age or language restrictions. All review articles, conference abstracts and case reports were excluded.

      Study selection

      The titles, abstracts and full text of all retrieved articles were screened independently by two reviewers (US and JS). If any uncertainty was encountered during the screening process, the study was included until full-text review could be performed. Any disagreements at the full-text stage were resolved through discussion with the senior author until consensus was reached.

      Data extraction

      Two reviewers (US and JS), working independently and in duplicate, extracted all relevant data from eligible studies into a standardised collection form using spreadsheet software. Data collected included: (1) general study information (author, year of publication, level of evidence); (2) study population data (sample size, mean age, gender); (3) injury data (mechanism, type of MLKI based on the Schenck classification
      • Schenck RC
      The dislocated knee.
      and mean time of surgery); (4) follow-up data (mean and range); and (5) outcomes reported.

      Assessment of risk of bias in included studies

      A modified version of the Newstead-Ottawa Scale was used to assess the methodological quality of all included studies.
      • Marsh J
      • Somerville L
      • Giffin JR
      • et al.
      Multiligament knee injury: should surgical reconstruction be acute or delayed?.
      ,
      • Peskun CJ
      • Whelan DB
      Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review.
      This rating scale evaluates non-randomised studies on the selection of the study groups, the comparability of the groups and the ascertainment of the outcome of interest. A maximum score of 8 points represents a high-quality study.
      • Marsh J
      • Somerville L
      • Giffin JR
      • et al.
      Multiligament knee injury: should surgical reconstruction be acute or delayed?.
      Two independent reviewers assessed the quality of all included studies (US and JS).

      Statistical analysis

      Descriptive statistics were calculated with continuous data reported as weighted means with their associated SD and categorical data reported as frequencies with percentages. Pooled analyses were performed using RevMan (Review Manager V.5.3, The Cochrane Collaboration, Oxford, England). Continuous outcomes were reported as weighted mean differences (MD), while dichotomous outcomes were reported as ORs. Pooled summary statistics were calculated using a fixed effects model. Heterogeneity was quantified by the I2 statistic (ie, <25% being low and >75% being high), while the Cochrane X2 test of homogeneity (ie, Q test, p<0.10) was used to test for the presence of heterogeneity.
      • Higgins JP
      • Thompson SG
      Quantifying heterogeneity in a meta-analysis.
      For studies that did not report the mean and SD directly, these values were imputed from the median and IQR using well-established statistical techniques.
      • Hozo SP
      • Djulbegovic B
      • Hozo I
      Estimating the mean and variance from the median, range, and the size of a sample.
      An a priori subgroup analysis was performed to assess the effect of early postoperative range of motion on the need for subsequent manipulation under anaesthesia or operative arthrolysis. All tests of significance (two tailed) were performed with an alpha value of 0.05.

      Results

      Literature search

      The results of our electronic database search and the number of studies excluded at each stage of study selection are depicted in the PRISMA flow diagram (figure 1). The baseline characteristics of all included studies are reported in table 1.
      Figure thumbnail gr1
      Figure 1Flow diagram summarising the literature search, screening and review of eligible articles.
      Table 1Baseline characteristics of included studies
      Author (year)Level of evidenceKnee injuries included

      (Schenck)
      Sample sizeTime to surgerySex

      (% male)
      Mean age (years, range)Mean follow-up (months, range)Outcome measuresNewstead-Ottawa Scale score
      Early (n)Delayed (n)Early

      (days, range)
      Delayed

      (days, range)
      Noyes and Barber-Westin
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      (1997)
      IVIII–IV7414 (7–28)660 (390–930)9127 (17–42)57 (30–108)Complications2
      Wascher et al
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      (1999)
      IVIII9411 (7–18)337 (45–517)NR27.5 (14–51)38.4 (24–54)ROM, Complications, Lysholm, IKDC, Meyers4
      Martinek et al
      • Martinek V
      • Steinbacher G
      • Friederich NF
      • et al.
      Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?.
      (2000)
      IVIII226<30>30NR30 (12–55)65 (12–168)IKDC2
      Liow et al
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      (2003)
      IVI–III81410.4 (3–14)860 (180–1890)7627.7 (15–46)32 (11–77)Complications, Lysholm, IKDC, Tegner4
      Harner et al
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      (2004)
      IVIII–IV191212 (5–21)195 (35–630)NR28.4 (16–51)44.2 (24–67)ROM, Complications, Lysholm, IKDC, Meyers4
      Tzurbakis et al
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      (2006)
      IVI, III–IV38107.5±5.8
      SD. No range provided in study.
      204.7±138.1
      SD. No range provided in study.
      8528.6 (16–40)51.3 (24–96)ROM, Complications, Lysholm, IKDC, Tegner4
      Shelbourne et al
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      (2007)
      IVIII17412.6 (4.2–23.1)35 (30.1–41.3)9521.4 (17–32)67.2 (24–175)IKDC, Complications4
      Subbiah et al
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      (2011)
      IVI–III1185.4 (1–14)128.5 (30–575)10036 (24–55)22 (14–33)Lysholm, IKDC1
      Li and Liu
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      (2013)
      IVII–III6910.5±6.9
      SD. No range provided in study.
      186.5±140.1
      SD. No range provided in study.
      6730.5 (25–43)90 (72–144)ROM, Lysholm, IKDC, Tegner4
      Zhang et al
      • Zhang Y
      • Zhang X
      • Hao Y
      • et al.
      Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports.
      (2013)
      IVI–V48117.3 (1–13)116 (30–274)8543.7 (21–63)30 (21–45)Lysholm2
      Wajsfisz et al
      • Wajsfisz A
      • Bajard X
      • Plaweski S
      • French Arthroscopy Society (SFA)
      • et al.
      Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?.
      (2014)
      IVI1043<21225 (87–5597)8729.8 (15–49)49 (12–146)Lysholm2
      Study quality.
      IKDC, International Knee Documentation Committee; n, sample size; NR, not reported; ROM, range of motion.
      * SD. No range provided in study.

      General study characteristics

      A total of 320 patients were enrolled in the 11 included studies.
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Martinek V
      • Steinbacher G
      • Friederich NF
      • et al.
      Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?.
      ,
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      ,
      • Wajsfisz A
      • Bajard X
      • Plaweski S
      • French Arthroscopy Society (SFA)
      • et al.
      Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?.
      ,
      • Zhang Y
      • Zhang X
      • Hao Y
      • et al.
      Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports.
      Of note, all the included studies were retrospective cohorts or case series. The mean age of participants across all studies was 31.6 years. The majority of patients were male (86%) and had an injury to at least three of the major knee ligaments (62%). The most common mechanism of injury was a motor vehicle accident (40%) followed by participation in sports (38%). The mean time to surgery among patients treated early was 11.2 days in comparison to 294.8 days for the delayed group. All patients in the early intervention group underwent surgery within 30 days of MLKI. The mean follow-up time across studies was 47 months. The Lysholm
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      ,
      • Wajsfisz A
      • Bajard X
      • Plaweski S
      • French Arthroscopy Society (SFA)
      • et al.
      Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?.
      ,
      • Zhang Y
      • Zhang X
      • Hao Y
      • et al.
      Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports.
      and overall International Knee Documentation Committee (IKDC) score
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Martinek V
      • Steinbacher G
      • Friederich NF
      • et al.
      Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      were the most commonly reported functional outcome measures. Range of motion (eg, total arc of motion, loss of extension and loss of flexion)
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      and rates of manipulation under anaesthesia or arthrolysis
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      were also frequently reported.
      The details of the methodological quality assessment using the modified Newstead-Ottawa Scale are outlined in online supplementar y appendix 2. The mean score for all included studies was 3.0 (range 1–4), which suggests an overall low-quality rating. Although the majority of studies examined representative cohorts and reported excellent long-term follow-up, the methodological issues inherent to a retrospective study design limited the overall rigour (ie, lack of blinded assessment and adjusting for confounders) of these studies.

      Functional outcomes

      Lysholm score

      The mean Lysholm scores for those who underwent early and delayed surgery were 87.7 and 80.1, respectively. Pooled analyses from eight studies
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      ,
      • Wajsfisz A
      • Bajard X
      • Plaweski S
      • French Arthroscopy Society (SFA)
      • et al.
      Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?.
      ,
      • Zhang Y
      • Zhang X
      • Hao Y
      • et al.
      Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports.
      demonstrated a statistically significant difference in Lysholm scores between the early and delayed surgery groups favouring early surgery (MD 6.80 (95% CI 4.06 to 9.55); p<0.0001) (figure 2A).
      Figure thumbnail gr2
      Figure 2Pooled analysis of functional outcomes including the (A) Lysholm score, (B) International Knee Documentation Committee (IKDC) score, (C) Tegner Activity Scale and (D) Meyers rating.

      Overall IKDC score

      Approximately 69% (88/127) of the early group and 48% (32/66) of the delayed group were found to have a ‘normal’ (IKDC A) or ‘nearly normal’ (IKDC B) knee. A quantitative synthesis of eight studies
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Martinek V
      • Steinbacher G
      • Friederich NF
      • et al.
      Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      found no statistically significant difference between the early and delayed surgery groups (OR 1.97 (95% CI 1.00 to 3.88); p=0.05) (figure 2B). When pooling studies with severe injuries (ie, KD III and IV) only, no statistically significant difference in the proportion of overall IKDC scores was noted between the early and delayed surgery groups (4 studies; OR 1.81 (95% CI 0.68 to 4.85); p=0.24).
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Martinek V
      • Steinbacher G
      • Friederich NF
      • et al.
      Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?.

      Tegner Activity Scale

      Pooled estimates from three studies reporting on activity level using the Tegner Activity Scale
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      showed no statistically significant difference in scores between early and delayed surgery (MD 0.42 (95% CI 0.01 to 0.83); p=0.05) (figure 2C).

      Meyers Rating Scale

      The overall rate of an ‘excellent’ or ‘good’ rating was 89% (25/28) and 56% (9/16) for patients who underwent early and delayed surgery, respectively. The odds of having an ‘excellent’ or ‘good’ rating were approximately 5.5 times higher with early surgery compared with delayed surgery after pooling the results from two studies
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      reporting the Meyers rating (OR 5.47 (95% CI 1.27 to 23.56); p=0.02) (figure 2D).

      Range of motion

      Total arc of motion, loss of extension and loss of flexion

      There was no statistically significant difference in the total arc of motion (p=0.22), loss of extension (p=0.36) or loss of flexion (p=0.54) between the early (n=72) and delayed (n=35) surgery groups after pooling the estimates from four studies.
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.

      Manipulation under anaesthesia or arthrolysis

      The pooled rate of manipulation under anaesthesia or arthrolysis after early and delayed surgery was 17% (17/98) and 2% (1/48), respectively. There was a statistically significant difference in the odds of requiring a manipulation under anaesthesia or arthrolysis between groups, with the odds being 3.9 times higher with early surgery (6 studies; OR 3.91 (95% CI 1.10 to 13.87); p=0.04)
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      (figure 3). However, subgroup analysis demonstrated that when only those studies utilising an early postoperative range of motion protocol were pooled, there was no statistically significant difference in the odds of requiring a manipulation under anaesthesia or arthrolysis (4 studies; OR 3.50 (95% CI 0.72 to 16.95); p=0.12).
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      Similarly, no difference in the odds of undergoing subsequent manipulation under anaesthesia or arthrolysis was noted when pooling studies reporting on severe injuries (ie, KD III and IV) alone (4 studies; OR 4.01 (95% CI 0.87 to 18.43); p=0.07).
      • Shelbourne KD
      • Haro MS
      • Gray T
      Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Noyes FR
      • Barber-Westin SD
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis.
      Figure thumbnail gr3
      Figure 3Pooled results showing the overall odds of manipulation under anaesthesia or arthrolysis after early and delayed surgery.

      Discussion

      The results of the current systematic review suggest that early repair or reconstruction of an MLKI may lead to superior functional outcomes, specifically higher Lysholm scores and Meyers ratings. In addition, a non-significant trend in IKDC scores favouring early surgery was observed, with the majority of patients in the early group (69%) classified as having a ‘normal’ or ‘nearly normal’ knee, compared with less than half of patients (48%) who had delayed surgery. Notably, no difference was observed in the overall range of motion, loss of extension and loss of flexion between the two groups. A statistically significantly higher odds of requiring a manipulation under anaesthesia or operative arthrolysis was noted among patients who underwent early surgery, however, no difference was found between early and delayed surgery when only studies that reported employing an early postoperative range of motion protocol were included.
      Our findings seem to diverge from those of Mook et al,
      • Mook WR
      • Miller MD
      • Diduch DR
      • et al.
      Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation.
      who found that early surgery yielded significantly more range of motion deficits and additional treatments for joint stiffness (ie, manipulation under anaesthesia or arthrolysis) despite the use of early postoperative mobilisation protocols. In addition, contrary to our findings, Mook et al
      • Mook WR
      • Miller MD
      • Diduch DR
      • et al.
      Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation.
      reported no difference in Lysholm scores when comparing those treated early and on a delayed basis. The fact that Mook and colleagues restricted their systematic review to the study of severe MLKIs (KD III and higher) may account for the differences seen between our results. Another possible explanation may be that our inclusion of more recent studies, utilising contemporary postoperative rehabilitation protocols with an emphasis on early mobilisation, may have led to a true improvement in overall function and range of motion. Interestingly, Levy and colleagues published a systematic review on the management of MLKIs in the same year as Mook et al, and reported findings similar to the current study, with higher mean Lysholm score and higher percentage of excellent and good IKDC scores in patients undergoing early versus delayed surgery.
      In 2015, Jiang et al
      • Jiang W
      • Yao J
      • He Y
      • et al.
      The timing of surgical treatment of knee dislocations: a systematic review.
      published the results of a systematic review evaluating the ideal time to surgery in patients with KD III (medial or lateral) injuries. They concluded that staged treatment yielded the best clinical results, while no difference was found between the early and delayed surgical groups.
      • Jiang W
      • Yao J
      • He Y
      • et al.
      The timing of surgical treatment of knee dislocations: a systematic review.
      However, these results were based solely on the proportion of ‘excellent’, ‘good’, ‘fair’ and ‘poor’ IKDC or Lysholm scores. Furthermore, they did not examine the impact of surgical timing on range of motion and the need for additional treatments due to arthrofibrosis. Similar to the findings of the current review, Hohmann et al
      • Hohmann E
      • Glatt V
      • Tetsworth K
      Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis.
      reported significantly higher Lysholm scores among patients who underwent early surgery, while demonstrating no difference in range of motion between groups. However, Hohmann and colleagues
      • Hohmann E
      • Glatt V
      • Tetsworth K
      Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis.
      did not evaluate the effect of timing of surgery on the development of arthrofibrosis and the need for additional treatments. Finally, Barfield and colleagues
      • Barfield WR
      • Holmes RE
      • Slone H
      • et al.
      Acute versus staged surgical intervention in multiligamentous knee injuries: a review of the literature since 2009.
      conducted a systematic review of the literature after 2009 and noted that although there had been a significant increase in the number of publications reporting outcomes after MLKI, there remained a paucity of high-level evidence to provide any conclusive recommendations regarding the timing of surgery.
      • Barfield WR
      • Holmes RE
      • Slone H
      • et al.
      Acute versus staged surgical intervention in multiligamentous knee injuries: a review of the literature since 2009.
      This systematic review attempted to provide a quantitative synthesis of all studies comparing early and delayed surgery in patients with an MLKI. However, our results must be interpreted with caution, as they are based on level IV evidence. A lack of high-quality evidence continues to plague the study of MLKIs. The need for large, well-designed, prospective, multicentre randomised trials has been well established,
      • Levy BA
      • Dajani KA
      • Whelan DB
      • et al.
      Decision making in the multiligament-injured knee: an evidence-based systematic review.
      ,
      • Barfield WR
      • Holmes RE
      • Slone H
      • et al.
      Acute versus staged surgical intervention in multiligamentous knee injuries: a review of the literature since 2009.
      however, the relative rarity of MLKIs, unique characteristics of each injury pattern and variety of surgical techniques available present significant challenges to organising a randomised study. Moving forward, a prospective multicentre cohort study may be a more plausible study design to adequately evaluate outcomes following MLKIs. The Multicenter Orthopaedic Outcomes Network group have successfully employed this study design to examine outcomes following anterior cruciate ligament reconstruction
      • Kaeding CC
      • Pedroza AD
      • Reinke EK
      • et al.
      Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort.
      and rotator cuff tears.
      • Dunn WR
      • Kuhn JE
      • Sanders R
      • et al.
      Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear.
      The standard use of Lysholm and IKDC scores has become commonplace in the study of MLKIs despite their lack of validation in the setting of these complex injuries.
      • Li X
      • Liu T
      Surgical management of multiple knee ligament injuries.
      ,
      • Subbiah M
      • Pandey V
      • Rao SK
      • et al.
      Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee.
      ,
      • Wascher DC
      • Becker JR
      • Dexter JG
      • et al.
      Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.
      ,
      • Harner CD
      • Waltrip RL
      • Bennett CH
      • et al.
      Surgical management of knee dislocations.
      ,
      • Liow RY
      • McNicholas MJ
      • Keating JF
      • et al.
      Ligament repair and reconstruction in traumatic dislocation of the knee.
      ,
      • Tzurbakis M
      • Diamantopoulos A
      • Xenakis T
      • et al.
      Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.
      ,
      • Wajsfisz A
      • Bajard X
      • Plaweski S
      • French Arthroscopy Society (SFA)
      • et al.
      Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?.
      ,
      • Zhang Y
      • Zhang X
      • Hao Y
      • et al.
      Surgical management of the multiple-ligament injured knee: a case series from Chongqing, China and review of published reports.
      As such, the interpretation of their results, specifically the Lysholm score, can be difficult. For instance, in the current study, the MD in Lysholm scores between the early and delayed surgery groups was 6.8 points, which was found to be statistically significant. However, due to the lack of studies evaluating the validity, reliability and responsiveness of the Lysholm score as an instrument in this population, the minimal clinically important difference remains unknown. As a result, it is difficult to determine whether our results are clinically significant. Therefore, future studies should use a disease-specific patient-reported outcome, such as the Multiligament Quality of Life questionnaire, which is a novel outcome measure that has previously demonstrated excellent validity and reliability in the MLKI population.
      • Chahal J
      • Whelan DB
      • Jaglal SB
      • et al.
      The multiligament quality of life questionnaire: development and evaluation of test-retest reliability and validity in patients with multiligament knee injuries.
      Despite the shortcomings of the existing MLKI literature, this study represents a methodologically rigorous critical appraisal of the current evidence. This systematic review has a number of strengths including the pooling of data across common outcomes from all available studies comparing early and delayed surgery, its generalisability across all levels of severity and minimisation of bias by performing study selection, data extraction and quality assessments in duplicate.

      Limitations

      The present systematic review has several limitations. First, the level of evidence and methodological quality of included studies were generally poor as demonstrated by the Newstead-Ottawa Scale score. As such, the results of the current review must be interpreted with caution. Second, the presence of within (eg, cohort sizes, sex) and between (eg, surgical technique, postoperative protocol) study heterogeneity may limit the external validity of our results. Third, the current review did not examine the effect of staged surgery on functional outcomes, as a result, definitive conclusions regarding optimal timing of surgery cannot be made. Lastly, the early and delayed surgery groups may be inherently different from one another (eg, associated injuries, transfer, definition of delayed surgery), thereby introducing potential selection and attrition bias.

      Conclusions

      Evidence from the current body of literature, although of low quality, suggests that in patients with MLKIs, early surgery may lead to superior functional outcomes with no difference in range of motion when compared with delayed surgery. Although early surgery was associated with a higher odds of requiring a manipulation under anaesthesia or arthrolysis for knee stiffness, subgroup analysis revealed no difference in the need for additional treatments when examining only those studies employing an early postoperative range of motion protocol.

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