Acute Management of the Multiligament Injured Knee

Multiligament knee injuries and knee dislocation are rare and complex injuries that are challenging to evaluate and treat. In most cases, they occur following a low-energy trauma or a high-energy trauma that can result in knee dislocation or significant morbidity due to concomitant severe soft tissue injuries, which might be limb-threatening. The initial management of acute multiligament knee injuries should be started with Advanced Trauma and Life Support (ATLS) protocols since it is likely that the patient has contaminant multisystem traumatic injuries and to exclude life or limb-threatening conditions. Then, a detailed assessment and evaluation of the knee is key to understanding the situation and ensuring that no associated serious neurovascular injuries, joint malposition, compartment syndrome, or open dislocations have occurred. Imaging studies, i.e., X-ray, CT scan, and MRI, must be interpreted correctly to correlate with examination findings but cannot replace a thorough physical examination, which will be discussed in more detail in another chapter. Definitive surgical management of MLKI is controversial, but most agree on initial assessment and management principles. Surgery for multiligament injuries can occur in three basic windows according to the condition, whether urgently (within hours), acutely (within days or weeks), or chronically (within months). If there are no urgent or emergent indications for surgery, the procedure can be delayed to allow the patient and surgeon to monitor vascular status, reduce swelling, obtain advanced imaging, plan surgical procedures, procure the necessary equipment and grafts, and assemble an experienced team. Despite improved outcomes with operative treatment in certain patients, nonoperative treatment remains an option. Moreover, long-term prognosis is improved if all injuries are identified early and allows all treatment options to be considered.