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. 2024 Jul 19;58(9):1175–1187. doi: 10.1007/s43465-024-01224-1

Effect of Timing of Surgery on the Outcomes and Complications in Multi-ligament Knee Injuries: An Overview of Systematic Reviews and A Meta-analysis

Raju Vaishya 1, Mohit Kumar Patralekh 2,✉, Abhishek Vaish 1, Luke V Tollefson 3, Robert F LaPrade 3
PMCID: PMC11333784  PMID: 39170656

Abstract

Background and Aims

Multi-ligament knee injuries (MLKI) are serious and challenging to manage. This study aimed to elucidate the impact of surgical timing on both early and long-term outcomes following an MLKI.

Methods

A comprehensive search strategy was employed across PubMed, Scopus, Web of Science, and the Cochrane Library. Studies were identified using a combination of relevant keywords encompassing “multi-ligament knee injury,” “knee dislocation,” “reconstruction,” “repair,” “surgery,” and “timing,” and their synonyms, along with appropriate Boolean operators. Selection of articles (systematic reviews and meta-analyses) adhered to predefined inclusion and exclusion criteria. Furthermore, a meta-analysis was conducted utilizing data extracted from primary studies.

Results

Early surgery for MLKI demonstrated a significant advantage over delayed surgery, reflected by significantly higher Lysholm scores (Mean Difference [MD] 3.51; 95% Confidence Interval [CI] 1.79, 5.22), IKDC objective scores (Mantel–Haenszel Odds Ratio [MH-OR] 2.95; 95% CI 1.30, 6.69), Tegner activity scores (MD 0.38; 95% CI 0.08, 0.69), and Mayer’s ratings (MH-OR 5.47; 95% CI 1.27, 23.56). In addition, we found a significantly reduced risk of secondary chondral lesions (MH-OR 0.33; 95% CI 0.23, 0.48), lower instrumented anterior tibial translation in the early surgery group (MD −0.92; 95% CI −1.83, −0.01), but no significant difference was observed in the secondary meniscal tears, between the two groups. However, the early surgery group also exhibited a significantly increased risk of knee stiffness (MH-OR 2.47; 95% CI 1.22, 5.01) and a greater likelihood of requiring manipulation under anaesthesia (MH-OR 3.91; 95% CI 1.10, 13.87).

Conclusion

Early surgery for MLKI improves function, and stability, and reduces further articular cartilage damage, but increases the risk of stiffness.

Level of Evidence

IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01224-1.

Keywords: Knee injuries, Knee dislocation, Anterior cruciate ligament injuries, Multi-ligament injury, Joint stiffness, Cartilage

Introduction

Multi-ligament knee injuries (MLKI), although uncommon, pose a significant challenge due to their potential for limb-threatening complications, particularly in conjunction with an acute knee dislocation. A knee dislocation itself is a rare event, with a reported incidence ranging from 0.02 to 0.072% of all musculoskeletal trauma [1–3]. However, underdiagnosis and spontaneous reductions likely contribute to an underestimation of the true prevalence [1–3]. High-energy trauma is the most frequent cause, often leading to associated fractures and vascular/neural injuries [3–5]. Low-energy mechanisms have also been implicated [6].

The management of an MLKI remains a contentious issue. Following the initial evaluation and treatment of potential vascular and neurological complications, the focus shifts towards long-term sequelae such as instability, stiffness, pain, and difficulty regaining preinjury function [3]. The complex interplay of anatomical injury patterns and potential complications creates a treatment dilemma. Key areas of debate include the choice between a repair and reconstruction, as well as the optimal timing of surgery—early versus delayed intervention. While surgical intervention generally improves functional outcomes, these outcomes may still fall short of those observed in isolated ligamentous knee injuries sustained during sports activities [7].

Historically, open surgical repair and postoperative casting were the mainstay of treatment for MLKI. This approach, however, frequently resulted in stiffness and arthrofibrosis. Consequently, the pendulum swung towards delaying surgery for acute knee injuries to minimize stiffness risk. However, this came at the cost of quadriceps atrophy and an increased risk of secondary meniscal and chondral injuries [3]. Recent advancements in surgical techniques and rehabilitation protocols, along with systematic reviews and meta-analyses, have challenged the association between early surgery and stiffness [8–10].

The purpose of this systematic review and meta-analysis was to assess the impact of surgical timing on both early and long-term outcomes following an MLKI. Our hypothesis was early surgery gives better results for MLKIs with lesser complications. We comprehensively analyzed the existing literature published up to February 2024, incorporating a meta-analysis to gain deeper insights into the optimal timing of surgical intervention for this complex injury.

Methods

This overview of systematic reviews and meta-analyses on the timing of surgery for MLKI was conducted following the guidelines available in the Cochrane Handbook for Systematic Reviews of Interventions (latest edition, available online, https://training.cochrane.org/handbook/current). The protocol was preregistered at PROSPERO and bears registration number #CRD42024502817.

Search Methods

Several databases, including PubMed, Scopus, Web of Science and the Cochrane Library, were searched with appropriate keywords including terms like ‘multi ligament injured knee’, ‘multiligament injured knee’, ‘knee dislocation’, ‘reconstruction’, ‘repair’, ‘treatment’, ‘surgery’, ‘early’, ‘acute’, ‘delayed’, ‘chronic’, ‘timing’ etc., combined with suitable Boolean operators following defined search strategy. (Supplementary file 1) The reference lists of the articles were also screened for any other relevant articles.

Eligibility Criteria

Our inclusion criteria involved all systematic reviews with or without meta-analyses focussing on adult patients (i.e. more than 18 years old) with an MLKI undergoing early surgical treatment (repair/reconstruction) or/and its comparison with delayed surgical treatment in different time frames. The exclusion criteria included simple narrative reviews/opinions, preclinical and pathophysiological articles letters, case reports, reviews, animal study reviews and articles published in languages other than English. Also, reviews with a non-specified timing protocol and revision knee surgery were excluded.

Selection of Articles

All search results from the individual databases were downloaded, and fed into Endnote-web, for deduplication and manual selection. Titles were initially screened by two authors (MKP and AV), followed by the screening of abstracts and full texts according to the above-mentioned inclusion and exclusion criteria. Discrepancies were resolved after arbitration by the senior author (RV).

Data Extraction, Synthesis, and Quality Assessment

Data extraction and synthesis, besides an assessment of study quality as per AMSTAR 2 criteria were performed as per the prespecified format by the two authors (initials blinded for review) and any disagreement was resolved after discussion with the senior author (initials blinded for review) [11]. All relevant data including knee stiffness after surgery, knee range of motion (ROM), flexion deficit, extension deficit/extensor lag, Lysholm score, Tegner activity level, Mayer’s ratings, meniscal injuries, and chondral lesions at follow-up were extracted from individual studies in duplicate. AMSTAR 2 is a tool used for the evaluation of study quality/risk of bias in systematic reviews and meta-analysis and has 16 domains aimed at assessing different aspects of risk of bias in a systematic review individually. The responses are graded as yes, partial yes or no, and it does not generate an overall score.

After going through the meta-analysis in the included reviews, a fresh meta-analysis (including the assessment of an exploration of reasons for heterogeneity) for several variables was performed as necessary. Knee stiffness after surgery, knee ROM, flexion deficit, extension deficit/extensor lag, Lysholm score, Tegner activity level, meniscal injuries and chondral lesions at follow-up were the main outcome variables to be considered for a meta-analysis, as reported in individual studies/reviews (Data from individual primary studies was explored and included in the revised meta-analysis as necessary). The standard deviation (SD) was calculated from the available data, if not directly available from individual studies (e.g., Sundararajan et al.2018) using RevMan Calculator and as per recommendations of Chapter 7 of the Cochrane Handbook, and for ROM data, flexion deficit and extension deficit for studies by Liow et al., Billières et al. and Shelbourne et al.; imputation was used as per prognostic method Ma et al. by calculating the average of the observed variances and used for studies with missing variance information. MCID values of relevant variables were also considered while interpreting results of meta-analysis [12–15].

A mean difference (MD)/standardised mean difference (SMD) was used for continuous variables, whereas for categorical variables, reported figures were considered for revised meta-analysis using the Mantel–Haenszel Odds Ratio (OR) method. We pooled the results using a random-effects meta-analysis (e.g., the DerSimonian and Laird method) or a fixed-effect meta-analysis, as appropriate (heterogeneity between the studies was assessed using the χ2 and I2 statistics and a fixed-effect model was used if I2 < 40%, and a random-effects model was considered if I2 ≥ 40%). Suitable forest plots and funnel plots (to depict possible publication bias) were also generated and tests for funnel plot asymmetry, including Begg and Mazumdar rank correlation, Egger’s regression test and Rosenthal fail-safe N were used to explore for any significant publication bias for suitable variable(s) if more than ten studies were available.

Subgroup analyses were planned for studies comparing surgery within 3 weeks vs. more than 3 weeks, those comparing surgery within 6 weeks vs. more than 6 weeks and those comparing surgery within 3 months vs. more than 3 months. The reasons for discordance in the results of the published meta-analysis, including the role of confounding factor(s) if any, were explored. Libre Office for Mac version 7.3.7.2 was used for data management and all meta-analysis was conducted using Revman for Mac, version 5.4.1(Nordic Cochrane Center), and JASP for Mac, Version 0.16.4 for intel (University of Amsterdam, Netherlands). A two-sided P value <0.05 was regarded as statistically significant.

Results

Literature Search

The search revealed 281 documents on PubMed, 360 Documents on Scopus (all fields search) and 484 results on the Web of Science (WoS). The search was then restricted and it left 94 results from PubMed (filters applied-reviews/systematic reviews/meta-analysis), 77 documents on Scopus (reviews) and 46 results on the WoS (review article). Thus, we had 217 papers and 182 papers were left after deduplication. After going through the titles, 68 papers related to MLKI were isolated, 15 papers were isolated after the abstract and full-text screening, and 9 were systematic reviews. Two more systematic reviews were found after reference screening and finally, 11 systematic reviews (and 5 for a meta-analysis) were considered for the present overview.

Characteristics of the Studies

Systematic reviews [8–10, 16–21], primary papers reporting accurate data on the timing of surgery (early vs. delayed) [22–43] and other important primary papers for discussion purposes [44–46] were considered for the present review. Characteristics of the included systematic reviews are presented in Table 1.

Table 1.

Characteristics of included systematic reviews

S. No Author Year Journal Study details/outcome Key findings
1 Mook WR et al 2009 J Bone Joint Surg Am Three hundred ninety-six knees, surgical treatment of MLKI. Acute treatment led to more residual anterior knee instability than chronic treatment (OR 2.58; 95% CI 1.2–5.8, more flexion deficits OR 5.18; 95% CI 1.5–17.5 Delayed reconstructions of severe MLKI might lead to similar outcomes in terms of stability when compared with acute surgery. However, in acutely managed patients, early mobilisation leads to better outcomes than immobilisation. Early surgery is significantly associated with ROM. Staged procedures may lead to better subjective outcomes and lesser ROM deficits despite the need for additional treatment for joint stiffness
2 Levy BA et al 2009 Arthroscopy Five studies compared early surgery (3 weeks) with delayed surgery. Early treatment led to higher mean Lysholm scores (90 vs. 82) and excellent/good IKDC scores of 47 vs. 31%, as well as higher sports activity scores (89 vs. 69) on the Knee Outcome Survey
3 Jiang W et al 2015 Knee Surg Sports Traumatol Arthrosc No statistically significant difference was found in the percentage of excellent or good results between the acute and chronic surgery groups (n.s.) or between the KD-IIIM and KD-IIIL groups (n.s.)
4 Hohmann E et al 2017 Knee In two hundred sixty cases of MLIK, 149 were treated early with a mean of 10.6 (range 3–21) days, whereas 111 patients were treated late with a mean of 294 (range 21–1890) days. 31% of all patients undergoing early surgery intervention had a normal or near normal knee, compared to only 15% with delayed reconstruction. Lysholm score, IKDC categorical score and ROM were meta-analysed, but Meyers and Tegner scores were not included in the analysis. Significantly more excellent Lysholm score (SMD 0.669, 95% CI 0.379–0.959, p = 0.0001, I2 = 0%). ROM was not significantly different (SMD 0.113, 95% CI −0.271 to 0.498, p = 0.564) Early surgical intervention in MLKI leads to a significantly better clinical outcome than late reconstruction. A trend of better ROM was also Observed but it was very small and unlikely to be clinically relevant
5 Seth U et al 2018 Journal of ISAKOS Eleven studies, with 320 patients (195 early and 125 delayed). Early surgery led to a significantly higher Lysholm score (p < 0.0001) and Meyer’s rating (p = 0.02) when compared to delayed surgery. There were no statistically significant differences in IKDC, Tegner Activity level, ROM, extension loss or flexion loss. Early surgery had significantly higher odds of need for MUA or arthrolysis (p = 0.04), but subgroup analysis showed no difference between early vs. delayed surgery when only studies employing an early ROM protocol were considered Early surgery in the setting of MLKI may provide better functional outcomes without compromising the range of motion when using an early postoperative mobilisation protocols
6 Vicenti G et al 2019 Injury Two studies compared surgical treatment with conservative treatment. There was a higher Lysholm score (85 vs. 67) in operated cases, besides higher excellent/good IKDC scores (69 vs. 64%) and return to sport (41 vs. 18%). 4 studies compared repair with the reconstruction, with similar mean Lysholm score (84 vs. 84) and excellent/good IKDC scores (63 vs. 63%). Repair of the PLC had a higher failure rate (39 vs. 8%) and a lower return to sports activities (25 vs. 51%). Similarly, repair of the cruciate achieved decreased stability and ROM. Six studies compared early surgery (within three weeks) with late surgery. Early surgery led to a greater mean Lysholm score (89 vs. 82) and excellent/good IKDC scores (57 vs. 41%), as well as greater mean ROM (129 vs. 124)
7 Marder RS et al 2021 Orthop J Sports Med Thirty-one studies were designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n =20). These studies reported on 2594 MLKI sustained by 2585 patients Could not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes
8 Fahlbusch H et al 2022 Arch Orthop Trauma Surg Twenty-five studies with a total of 709 patients Injuries treated after an initial non-operative rehabilitation (>3 weeks) tended to develop lower rates of AF, with 9.5% compared to injuries treated surgically in the acute phase with 12.7%. However, the highest prevalence of AF was found after staged treatment algorithms with 18.0%
9 Kim SH et al 2022 Knee Surg Relat Res 16 studies on isolated ACL injury and 14 studies on MLKI were included in the analysis, which showed significant decreases in Lysholm score (NMD −5.3 [95% CI −7.37 to −3.23]) and Tegner activity level (NMD −0.25 [95% CI −0.45 to −0.05]) and increases in the risk of meniscus tear (OR 1.73 [95% CI 1.1–2.73], p = 0.01) and chondral injury (OR 2.48, 95% CI 1.46–4.2), p = 0.0007 in the late surgery group regardless of a single ACL injury or MLKI Late ACL surgery resulted in a greater risk of meniscal tear and chondral injury, besides reduced Lysholm scores and Tegner activity levels when compared with early ACL surgery
10 Vermeijden HD et al 2023 Am J Sports Med Fourteen studies with 1172 patients. Low evidence was observed: patients treated early had significantly fewer meniscal injuries (RR, 0.7; P = .04) and chondral injuries (RR, 0.5; P = .001), while no differences were found in reoperation rates, complications, stiffness, ROM deficits, muscle strength, instrumented laxity, and functional outcomes between the groups. Other than higher Lysholm scores in the early group for the 3-week analysis (mean difference, 6.8; P = .01), there were no differences between cutoff analyses For MLKI injuries, there were also no differences in surgical outcomes between early and delayed surgery
11 Özbek EA et al 2023 Knee Surg Sports Traumatol Arthrosc Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07–0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥3 ligaments injured (OR = 0.45, 95% CI (0.26–0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (<3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥3 weeks) (OR = 2.18; 95% CI 1.11–4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.) Performing surgery within the first three weeks following MLKI, or concomitant injury of ≥3 ligaments, is significantly associated with a higher risk of postoperative stiffness
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MLKI Multiligament knee injury, OR Odds ratio, CI Confidence Interval, KD-IIM Knee Dislocation type 3 medial (ACL, PCL, MCL), KD-IIIL Knee Dislocation type 3 lateral (ACL, PCL, PLC, LCL), IKDC International Knee Documentation Committee, ROM Range Of Motion, SMD Standardised Mean Difference, ACL Anterior Cruciate Ligament, PCL Posterior Cruciate Ligament, MCL Medial Collateral Ligament, LCL Lateral Collateral Ligament, NMD Normalised Mean Difference, RR Relative Risk, AF Arthrofibrosis, n.s. Not significant 

Meta-analysis of Studies on MLKI Operated at Various Timeframes

A summary of the meta-analysis of the studies on MLKI operated at various timeframes is presented in Table 2.

Table 2.

The details of meta-analysis of the studies on MLKI operated at various timeframes

S. No Variable MH-OR/MD 95% CI Chi-square/Tau square, df, I square Z value, P value, significance Significant/not significant
1 Stiffness after Surgery OR 2.47 1.22, 5.01 4.56, 4, p = 0.42, I2 = 12% 2.50, p = 0.01 Significant
2 ROM MD 2.02; −0.91, 4.95 1.69, 3, p = 0.64, I2 = 0% 1.35, p = 0.18 Not significant
3 Flexion Deficit MD 1.17 −2.13, 4.47 1.97, 2, p = 0.58, I2 = 0% 0.69, p = 0.49 Not significant
4 Extension Deficit MD 1.11 95% CI −0.39, 2.61 Tau square = 1.24, Chi-square = 6.91, 3, p = 0.03, I2 = 71% 1.45, p = 0.15 Not significant
5 Need for MUA OR 3.91; 1.10, 13.87 1.33, 5, p = 0.93, I2 = 0% 2.11, p = 0.04 Significant
6 Chondral lesions OR 0.33 0.23, 0.48 2.41, 2, p = 0.30, I2 = 17% 5.69, p < 0.0001 Significant
7 Meniscal Tear OR 0.70 0.31, 1.60 1.9, 3, p = 0.59, I2 = 0% 0.84, p = 0.40 Not significant
8 Lysholm score MD 3.51 1.79, 5.22 20.10, 14, p < 0.13, I2 = 30% 4.01, p < 0.001 Significant
9 Tegner activity level MD 0.38; 0.08, 0.69 4.12, 6, p = 0.66, I2 = 0% 2.48, p = 0.01 Significant
10 IKDC Subjective Scores MD 5.81 −1.32, 12.93 Tau square = 25.3 Chi-square = 5.88, 3, p = 0.12, I2 = 49% 1.60, p = 0.11 Not significant
11 IKDC Objective Scores 2.95 1.30, 6.69 3.59, 4, p = 0.46, I2 = 0% 2.59, p = 0.010 Significant
12 Mayer’s Ratings 5.47 1.27, 23.56 0.71, 1, p = 0.40, I2 = 0% 2.28, p = 0.02 Significant
13 Instrumented Knee Laxity −0.92 −1.83, −0.01 1.09, 1, p = 0.30, I2 = 8% 1.97, p = 0.05 Significant
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Stiffness After Surgery

A meta-analysis of 5 studies reporting on postoperative knee stiffness found 38 cases of knee stiffness out of 248 undergoing early surgery and 12 cases of knee stiffness out of 139 cases undergoing delayed surgery. We observed a significantly higher risk of knee stiffness in the early surgery group as compared to the delayed surgery group. (Supplementary Fig. 1A).

Range of Motion (ROM)

A meta-analysis of available data from four studies found no significant difference in ROM in the early surgery group, as compared to the delayed surgery group (Supplementary Fig. 1B).

Flexion Deficit

A meta-analysis of available data from four studies found no significant difference in flexion deficit in the early surgery group, as compared to the delayed surgery group. No significant difference could be detected in the within 3 weeks vs. the after 3 weeks subgroup and also in the within 6 weeks vs. after 6 weeks subgroup (Supplementary Fig. 1C).

Extension Deficit

We did not find any significant difference (from the three studies’ data) in an extension deficit seen in the early versus delayed surgery group (Supplementary Fig. 1D).

Need for Manipulation Under Anaesthesia (MUA)

A significantly higher need for an MUA was observed in the early surgery group, as compared to the delayed surgery group (MH-OR 3.91; 95% CI 1.10, 13.87), from the data of six studies (Supplementary Fig. 1E).

Chondral Lesions and Meniscal Tear(s)

We found, from the data of three studies, significantly fewer chondral lesions in the early surgery group. A total of 57 cases with chondral lesions were seen out of 278 cases undergoing early surgery vs. 112 cases with chondral lesions out of 253 cases undergoing delayed surgery. On further subgroup analysis, we found significantly fewer chondral lesions in the early (before 3 weeks) as compared to the delayed (after 3 weeks) surgery group (Supplementary Fig. 2A).

A total of 20 cases with meniscal tears were reported out of 60 cases undergoing early surgery versus other group totals of 17 cases with meniscal tear(s) out of 42 cases undergoing delayed surgery, without any significant difference. (Supplementary Fig. 2B).

Lysholm Score

A meta-analysis of available data from 15 studies found a significantly higher Lysholm score in the early surgery group, as compared to the delayed surgery group. It was noted that the significant difference persisted in both the subgroups (within 3 weeks vs. after 3 weeks and 6 weeks vs. after 6 weeks). Moreover, this difference (even the upper limit of the CI) was lower than the MCID for the Lysholm score (8.9), so the clinical effect of such difference may be debatable [12] (Supplementary Fig. 3A).

Tegner Activity Level

A meta-analysis of available data from 15 studies found a significantly higher Tegner activity level in the early surgery group, as compared to the delayed surgery group. On subgroup analysis, it was found that the significant difference persisted in the within 3 weeks vs. after 3 weeks subgroup. This difference was lower than the MCID for Tegner score (1), so the clinical effect of such a small difference may be debatable [12] (Supplementary Fig. 3B).

IKDC Subjective Scores

A meta-analysis of available data from four studies found no significant difference in IKDC subjective scores in the early surgery group, as compared to the delayed surgery group. On subgroup analysis, it was found that a significant difference was detected in the within 3 weeks vs. after 3 weeks subgroup. But this finding did not persist in the within 6 weeks vs. after 6 weeks subgroup (Supplementary Fig. 3C).

IKDC Objective Scores

A meta-analysis of available data from five studies found a significantly higher IKDC objective score in the early surgery group, as compared to the delayed surgery group. On subgroup analysis, a significant difference was detected within 3 weeks vs. after 3 weeks subgroup (Supplementary Fig. 3D).

Mayer’s Ratings

A meta-analysis of available data from two studies found significantly higher Mayer’s ratings in the early surgery group, as compared to the delayed surgery group (Supplementary Fig. 3E).

Instrumented Knee Laxity

A meta-analysis of available data on objective Instrumented Knee Laxity (ΔATT i.e. difference in anterior knee translation (ATT) for the contralateral knee, as measured with arthrometers such as KT-1000 (Tzurbakis et al.) or KT-2000 (Shelbourne et al.) available from two studies found lesser laxity in the early surgery group, as compared to the delayed surgery group (Supplementary Fig. 3F). The test for subgroup differences was not significant in any case (Fig. 1).

Fig. 1.

Fig. 1

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PRISMA flowchart of the study

Risk of Bias

Six systematic reviews were found to have several problems and were labelled as Critical, four had moderate and one had a low risk of bias as per AMSTAR 2 ratings (Fig. 2).

Fig. 2.

Fig. 2

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Risk of Bias in systematic reviews by AMSTAR2 tool

Publication Bias

Visual inspection of the funnel plot for Lysholm scores (with 15 studies) did not reveal any obvious asymmetry (Fig. 3). Neither the Begg and Mazumdar rank correlation nor the Egger’s regression test indicated any funnel plot asymmetry (p = 0.2816 and p = 0.3086, respectively), and Rosenthal fail-safe N was 66 (P < 0.001), indicating a lack of any publication bias.

Fig. 3.

Fig. 3

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Funnel plot for Lysholm scores showing no publication bias

Discussion

The most important finding of this study was that our meta-analysis revealed significantly higher functional scores (Lysholm, IKDC Objective , Tegner, Mayer’s) and demonstrably lower risk of secondary chondral lesions and anterior tibial translation in the early surgery group, which likely explains the improved functional outcomes. Nevertheless, this approach was accompanied by a higher incidence of knee stiffness and an increased need for a MUA.

This study reported significantly higher functional scores including Lysholm, IKDC, Tegner, and Mayer’s scores for patients in the early surgery group versus the delayed surgery group. Previous studies have reported similar findings with patients in the early surgery group having a higher Lysholm score than patients in the delayed surgery group [17, 20, 37, 52]. A systematic review and meta-analysis by Hohman et al. reported significantly improved Lysholm scores for patients with early surgery (average 10.6 days) versus delayed surgery (average 294 days) [20]. This study adds to previous literature by reporting on IKDC, Tegner, and Mayer outcome scores in addition to Lysholm scores. The findings reinforce the current trends in treating MLKIs, emphasizing that reconstructions should be the early phase (<3 weeks) for optimal patient-reported outcomes [53]. The optimal timing for MLKI surgery is a multifaceted decision influenced by several factors. Injury severity, presence of concomitant injuries, and patient-specific characteristics like age, health status, and activity level all play a role. Furthermore, the choice between performing a single-stage or multi-stage surgery is another consideration. The primary surgical objective is ligament reconstruction to restore knee stability and minimize further joint damage [50, 51–56].

Another important finding from this study was that there was significantly decreased chondral lesions and anterior tibial translation in the early reconstruction group. These findings highlight the importance of early treatment for the overall restoration of knee stability. The increased incidence of chondral lesions in the delayed treatment group could be due to prolonged knee instability before treatment [17]. A systematic review by Vermeijden et al. reported on increased chondral and meniscal lesions at the time of surgery for patients in the delayed reconstruction group compared to the early reconstruction group [17]. Secondary meniscal damage can further exacerbate instability. Although there is limited data on postoperative knee laxity and timing of surgery, a previous study by Grassi et al. reported that at a 20-year follow-up for ACLR, delayed surgery was a risk factor for osteoarthritis, likely due to chondral, meniscal, or residual laxity from the delayed reconstruction [57].

In this study, there was no significant difference in arthrofibrosis and range of motion postoperatively for patients in the early versus delayed reconstruction groups. This finding is important due to the heterogeneity of previous literature on this topic. Various studies have reported findings both ways, with some reporting increased arthrofibrosis in the early reconstruction group, and some reporting decreased arthrofibrosis in the early reconstruction groups [15, 16]. Historically, concerns about stiffness and arthrofibrosis dominated the discourse around early surgery for MLKI [47–49]. There was no difference in Flexion deficit, but higher rate of stiffness overall in the early surgery group. This may be due to different set of studies reporting on rate of knee stiffness [29, 34, 37, 39, 40] and flexion deficit [26, 34, 39, 42]. Recent literature supports the findings that there is no significant difference in arthrofibrosis and range of motion between early and delayed MLKI reconstructions [17, 20]. This is likely due to improved accelerated rehabilitation techniques focused on early range of motion. Other newer techniques like early anatomic repair with ligament bracing are also coming on the horizon, with good results [58].

Our review acknowledges several limitations that affect the generalizability and strength of the conclusions. First, the timing of surgery across studies varied considerably [30, 38]. While we performed subgroup analyses to account for these variations, some studies lacked clear definitions of “early” versus “delayed” surgery, relying solely on continuous timeframes. Additionally, the primary studies exhibited significant heterogeneity in terms of injury mechanisms, specific knee ligament involvement, and the presence of additional injuries (neurovascular involvement, bone fractures). This heterogeneity makes data interpretation more challenging. Finally, the outcome scores, including the Lysholm and IKDC scores, while commonly used, have not been specifically validated for MLKI patients. Similarly, the absence of a standardized, MLKI-specific patient-reported outcome measure necessitates the use of multiple scales [19]. The validity and clinical relevance of these scores in the context of MLKI require further investigation, potentially limiting the generalizability of our findings on functional outcomes [15]. Future research should focus on standardized definitions of surgical timing, rigorous study designs (e.g., prospective cohorts), and the development and validation of MLKI-specific patient-reported outcome measures.

Conclusion

The optimal timing for surgical intervention in MLKI remains an area of active investigation. While our study provides further evidence for the potential benefits of early surgery, concerns about stiffness and the increased need for a MUA require careful consideration.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 900 KB) (899.6KB, docx)

Author’s Contributions

RV, MKP: Conceptualization, Data curation and analysis, literature search, manuscript writing, editing and final approval. LVT, RFL, AV: Literature search, data collection and analysis, manuscript writing, references, editing, supervision, and final approval.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

No primary data was involved in this study. Details of meta-analysis have been provided.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Statement of Ethics

None, since it is not a clinical article.

Statement of Patient Consent

Not applicable.

Use of AI Technology

During the preparation of this manuscript, the authors used Google Bard to improve the readability and language. After using this tool, the authors reviewed and edited the content and take full responsibility for the content of the publication.

Footnotes

Publisher's Note

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References

  • 1.Dedmond, B. T., & Almekindujers, L. C. (2001). Operative versus nonoperative treatment of knee dislocations: A meta-analysis. American Journal of Knee Surgery,14, 33–38. [PubMed] [Google Scholar]
  • 2.Frosch, K., Preiss, A., Heider, S., Stengel, D., Wohlmuth, P., Hoffmann, M., et al. (2013). Primaryligament sutures as a treatment option of knee dislocations: A meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy,21, 1502–1509. 10.1007/s00167-012-2154-8 10.1007/s00167-012-2154-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.AromGA, Y. M. G., Petrigliano, F. A., Terrell, R. D., & McAllister, D. R. (2014). The changing demographics of knee dislocation: A retrospective database review. Clinical Orthopaedics and Related Research,472(9), 2609–2614. 10.1007/s11999-013-3373-0 10.1007/s11999-013-3373-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Medina, O., Arom, G. A., Yeranosian, M. G., Petrigliano, F. A., & McAllister, D. R. (2014). Vascularand nerve injury after knee dislocation: A systematic review. Clinical Orthopaedics and Related Research,472, 2621–2629. 10.1007/s11999-014-3511-3 10.1007/s11999-014-3511-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Natsuhara, K. M., Yeranosian, M. G., Cohen, J. R., Wang, J. C., McAllister, D. R., & Petrigliano, F. A. (2014). What is the frequency of vascular injury after knee dislocation? Clinical Orthopaedics and Related Research,472, 2615–2620. 10.1007/s11999-014-3566-1 10.1007/s11999-014-3566-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Solarino, G., Notarnicola, A., Maccagnano, G., Piazzolla, A., & Moretti, B. (2015). Irreducibleposterolateral dislocation of the knee: A case report. Joints,3, 91–96. 10.11138/jts/2015.3.2.091 10.11138/jts/2015.3.2.091 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Jenkins, P. J., Clifton, R., Gillespie, G. N., Will, E. M., & Keating, J. F. (2011). Strength and function recovery after multiple-ligament reconstruction of the knee. Injury,42, 1426–1429. 10.1016/j.injury.2011.03.026 10.1016/j.injury.2011.03.026 [DOI] [PubMed] [Google Scholar]
  • 8.Fahlbusch, H., Krivec, L., Müller, S., Reiter, A., Frosch, K. H., & Krause, M. (2023). Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: A systematic review. Archives of Orthopaedic and Trauma Surgery,143(8), 5117–5132. 10.1007/s00402-022-04730-9 10.1007/s00402-022-04730-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Kim, S. H., Han, S. J., Park, Y. B., Kim, D. H., Lee, H. J., & Pujol, N. (2021). A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries. Knee Surgery & Related Research,33(1), 1. 10.1186/s43019-020-00086-9 10.1186/s43019-020-00086-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Marder, R. S., Poonawala, H., Pincay, J. I., Nguyen, F., Cleary, P. F., Persaud, C. S., Naziri, Q., & Zikria, B. A. (2021). Acute versus delayed surgical intervention in multiligament knee injuries: A systematic review. Orthopaedic Journal of Sports Medicine,9(10), 23259671211027856. 10.1177/23259671211027855 10.1177/23259671211027855 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., Moher, D., Tugwell, P., Welch, V., Kristjansson, E., & Henry, D. A. (2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ,358, j4008. 10.1136/bmj.j4008 10.1136/bmj.j4008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Higgins, J., & Deeks, J. (2011). Obtaining standard deviations from standard errors and confidence intervals for group means. Cochrane handbook for systematic reviews of interventions. 5. https://handbook-5-1.cochrane.org/chapter_7/7_7_3_3_obtaining_standard_deviations_from_standard_errors.htm#:~:text=Standard%20deviations%20can%20be%20obtained,value%20or%20the%20P%20value. Assessed February 18, 2024.
  • 13.Wan, X., Wang, W., Liu, J., & Tong, T. (2014). Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology,14, 135. 10.1186/1471-2288-14-135 10.1186/1471-2288-14-135 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Ma, J., Liu, W., Hunter, A., & Zhang, W. (2008). Performing meta-analysis with incomplete statistical information in clinical trials. BMC Medical Research Methodology,8, 56. 10.1186/1471-2288-8-56 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Harris, J. D., Brand, J. C., Cote, M. P., Faucett, S. C., & Dhawan, A. (2017). Research pearls: the significance of statistics and perils of pooling. Part 1: Clinical versus statistical significance. Arthroscopy,33(6), 1102–1112. 10.1016/j.arthro.2017.01.053 10.1016/j.arthro.2017.01.053 [DOI] [PubMed] [Google Scholar]
  • 16.Özbek, E. A., Dadoo, S., Grandberg, C., Runer, A., Cong, T., Hughes, J. D., Irrgang, J. J., & Musahl, V. (2023). Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: A systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy,31(10), 4448–4457. 10.1007/s00167-023-07514-9 10.1007/s00167-023-07514-9 [DOI] [PubMed] [Google Scholar]
  • 17.Vermeijden, H. D., Yang, X. A., Rademakers, M. V., Kerkhoffs, G. M. M. J., van der List, J. P., & DiFelice, G. S. (2023). Early and delayed surgery for isolated ACL and multiligamentous knee injuries have equivalent results: A systematic review and meta-analysis. American Journal of Sports Medicine,51(4), 1106–1116. 10.1177/03635465211069356 10.1177/03635465211069356 [DOI] [PubMed] [Google Scholar]
  • 18.Vicenti, G., Solarino, G., Carrozzo, M., De Giorgi, S., Moretti, L., De Crescenzo, A., & Moretti, B. (2019). Major concern in the multiligament-injured knee treatment: A systematic review. Injury,50(Suppl 2), S89–S94. 10.1016/j.injury.2019.01.052 10.1016/j.injury.2019.01.052 [DOI] [PubMed] [Google Scholar]
  • 19.Mook, W. R., Miller, M. D., Diduch, D. R., Hertel, J., Boachie-Adjei, Y., & Hart, J. M. (2009). Multiple-ligament knee injuries: A systematic review of the timing of operative intervention and postoperative rehabilitation. Journal of Bone and Joint Surgery. American Volume,91(12), 2946–2957. 10.2106/JBJS.H.01328 10.2106/JBJS.H.01328 [DOI] [PubMed] [Google Scholar]
  • 20.Hohmann, E., Glatt, V., & Tetsworth, K. (2017). Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis. The Knee,24(5), 909–916. 10.1016/j.knee.2017.06.011 10.1016/j.knee.2017.06.011 [DOI] [PubMed] [Google Scholar]
  • 21.Sheth, U., Sniderman, J., & Whelan, D. B. (2019). Early surgery of multiligament knee injuries may yield better results than delayed surgery: A systematic review. Journal of ISAKOS,4(1), 26–32. 10.1136/jisakos-2015-000021 [DOI] [Google Scholar]
  • 22.Zhang, Z., Zhang, K. B., Mao, B. N., Lai, S. K., Li, J., & Fu, W. L. (2020). The effect of irreducible dislocation on functional outcomes in knees with multiligament injuries: A matched-cohort analysis. Orthopaedic Journal of Sports Medicine,8(8), 2325967120940203. 10.1177/2325967120940203 10.1177/2325967120940203 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Zhang, Y., Zhang, X., Hao, Y., Zhang, Y. M., Wang, M., & Zhou, Y. (2013). Surgical management of the multiple-ligament injured knee: A case series from Chongqing, China and review of published reports. Orthopaedic Surgery,5(4), 239–249. 10.1111/os.12077 10.1111/os.12077 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Wascher, D. C., Becker, J. R., Dexter, J. G., & Blevins, F. T. (1999). Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts. The American Journal of Sports Medicine,27(2), 189–196. 10.1177/03635465990270021301 10.1177/03635465990270021301 [DOI] [PubMed] [Google Scholar]
  • 25.Wajsfisz, A., Bajard, X., Plaweski, S., Djian, P., Demey, G., Limozin, R., Bousquet, V., Rocheconcar, G., Louis, M. L., Arndt, J., Azar, M., Sonnery-Cottet, B., Boisrenoult, P.; French Arthroscopy Society. (2014). Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: For what functional results? Orthopaedics & Traumatology, Surgery & Research,100(8 Suppl), S379–S383. 10.1016/j.otsr.2014.10.003 10.1016/j.otsr.2014.10.003 [DOI] [PubMed] [Google Scholar]
  • 26.Tzurbakis, M., Diamantopoulos, A., Xenakis, T., & Georgoulis, A. (2006). Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results. Knee Surgery, Sports Traumatology, Arthroscopy,14(8), 739–749. 10.1007/s00167-006-0039-4 10.1007/s00167-006-0039-4 [DOI] [PubMed] [Google Scholar]
  • 27.Tardy, N., Boisrenoult, P., Teissier, P., Steltzlen, C., Beaufils, P., & Pujol, N. (2017). Clinical outcomes after multiligament injured knees: Medial versus lateral reconstructions. Knee Surgery, Sports Traumatology, Arthroscopy,25(2), 524–531. 10.1007/s00167-016-4067-4 10.1007/s00167-016-4067-4 [DOI] [PubMed] [Google Scholar]
  • 28.Sundararajan, S. R., Sambandam, B., Rajagopalakrishnan, R., & Rajasekaran, S. (2018). Comparison of KD3-M and KD3-L multiligamentous knee injuries and analysis of predictive factors that influence the outcomes of single-stage reconstruction in KD3 injuries. Orthopaedic Journal of Sports Medicine,6(9), 2325967118794367. 10.1177/2325967118794367 10.1177/2325967118794367 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Subbiah, M., Pandey, V., Rao, S. K., & Rao, S. (2011). Staged arthroscopic reconstructive surgery for multiple ligament injuries of the knee. Journal of Orthopaedic Surgery,19(3), 297–302. 10.1177/230949901101900307 10.1177/230949901101900307 [DOI] [PubMed] [Google Scholar]
  • 30.Shelbourne, K. D., Haro, M. S., & Gray, T. (2007). Knee dislocation with lateral side injury: Results of an en masse surgical repair technique of the lateral side. American Journal of Sports Medicine,35(7), 1105–1116. 10.1177/0363546507299444 10.1177/0363546507299444 [DOI] [PubMed] [Google Scholar]
  • 31.Shamrock, A. G., Hall, J. R., Hajewski, C. J., An, Q., & Duchman, K. R. (2022). Cartilage and meniscus injuries are more common in patients undergoing delayed multiligament reconstruction. The Journal of Knee Surgery,35(05), 560–565. 10.1055/s-0040-1716378 [DOI] [PubMed] [Google Scholar]
  • 32.Noyes, F. R., & Barber-Westin, S. D. (1997). Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis. The American Journal of Sports Medicine,25(6), 769–778. 10.1177/036354659702500608 10.1177/036354659702500608 [DOI] [PubMed] [Google Scholar]
  • 33.Moatshe, G., Dornan, G. J., Løken, S., Ludvigsen, T. C., LaPrade, R. F., & Engebretsen, L. (2017). Demographics and injuries associated with knee dislocation: A prospective review of 303 patients. Orthopaedic Journal of Sports Medicine,5(5), 2325967117706521. 10.1177/2325967117706521 10.1177/2325967117706521 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Liow, R. Y., McNicholas, M. J., Keating, J. F., & Nutton, R. W. (2003). Ligament repair and reconstruction in traumatic dislocation of the knee. Journal of Bone and Joint Surgery. British Volume,85(6), 845–851. [PubMed] [Google Scholar]
  • 35.Li, X., & Liu, T. (2013). Surgical management of multiple knee ligament injuries. European Journal of Orthopaedic Surgery & Traumatology,23(6), 691–697. 10.1007/s00590-012-1043-7 10.1007/s00590-012-1043-7 [DOI] [PubMed] [Google Scholar]
  • 36.Lau, B. C., Varsheya, K., Morriss, N., Wickman, J., Kirkendall, D., & Abrams, G. (2022). Single-stage surgical treatment of multi-ligament knee injuries results in lower cost and fewer complications and unplanned reoperations compared with staged treatment. Arthroscopy, Sports Medicine, and Rehabilitation,4(5), e1659–e1666. 10.1016/j.asmr.2022.06.012 10.1016/j.asmr.2022.06.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.LaPrade, R. F., Chahla, J., DePhillipo, N. N., Cram, T., Kennedy, M. I., Cinque, M., Dornan, G. J., O’Brien, L. T., Engebretsen, L., & Moatshe, G. (2019). Single-stage multiple-ligament knee reconstructions for sports-related injuries: Outcomes in 194 patients. American Journal of Sports Medicine,47(11), 2563–2571. 10.1177/0363546519864539 10.1177/0363546519864539 [DOI] [PubMed] [Google Scholar]
  • 38.Krych, A. J., Sousa, P. L., King, A. H., Engasser, W. M., Stuart, M. J., & Levy, B. A. (2015). Meniscal tears and articular cartilage damage in the dislocated knee. Knee Surgery, Sports Traumatology, Arthroscopy,23(10), 3019–3025. 10.1007/s00167-015-3540-9 10.1007/s00167-015-3540-9 [DOI] [PubMed] [Google Scholar]
  • 39.Harner, C. D., Waltrip, R. L., Bennett, C. H., Francis, K. A., Cole, B., & Irrgang, J. J. (2004). Surgical management of knee dislocations. Journal of Bone and Joint Surgery. American Volume,86(2), 262–273. 10.2106/00004623-200402000-00008 10.2106/00004623-200402000-00008 [DOI] [PubMed] [Google Scholar]
  • 40.Hanley, J., Westermann, R., Cook, S., Glass, N., Amendola, N., Wolf, B. R., & Bollier, M. (2017). Factors associated with knee stiffness following surgical management of multiligament knee injuries. The Journal of Knee Surgery,30(6), 549–554. 10.1055/s-0036-1593624 10.1055/s-0036-1593624 [DOI] [PubMed] [Google Scholar]
  • 41.Fanelli, G. C., Giannotti, B. F., & Edson, C. J. (1996). Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy,12(5), 521–530. 10.1016/s0749-8063(96)90189-9 10.1016/s0749-8063(96)90189-9 [DOI] [PubMed] [Google Scholar]
  • 42.Billières, J., Labruyère, C., Steltzlen, C., Gonzalez, A., Boisrenoult, P., Beaufils, P., & Pujol, N. (2020). Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes. Orthopaedics & Traumatology, Surgery & Research,106(5), 937–944. 10.1016/j.otsr.2019.08.001 10.1016/j.otsr.2019.08.001 [DOI] [PubMed] [Google Scholar]
  • 43.Bi, A. S., Mojica, E. S., Markus, D. H., Blaeser, A. M., Kahan, J., Moran, J., Jazrawi, L. M., Medvecky, M. J., & Alaia, M. J. (2022). Risk of postoperative stiffness following multiligamentous knee injury surgery is not affected by obesity: A multicenter study. Arthroscopy,38(12), 3175–3181. 10.1016/j.arthro.2022.06.017 10.1016/j.arthro.2022.06.017 [DOI] [PubMed] [Google Scholar]
  • 44.Patel, N. K., Lian, J., Nickoli, M., Vaswani, R., Irrgang, J. J., Lesniak, B. P., & Musahl, V. (2021). Risk factors associated with complications after operative treatment of multiligament knee injury. Orthopaedic Journal of Sports Medicine,9(3), 2325967121994203. 10.1177/2325967121994203 10.1177/2325967121994203 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Axibal, D. P., Yeatts, N. C., Hysong, A. A., Hong, I. S., Trofa, D. P., Moorman, C. T., 3rd., Piasecki, D. P., Fleischli, J. E., & Saltzman, B. M. (2022). Intraoperative and early (90-day) postoperative complications and associated variables with multiligamentous knee reconstruction: 15-year experience from a single academic institution. Arthroscopy,38(2), 427–438. 10.1016/j.arthro.2021.05.027 10.1016/j.arthro.2021.05.027 [DOI] [PubMed] [Google Scholar]
  • 46.Fanelli, G. C. (2020). Timing of repair or reconstruction after knee dislocation. The Journal of Knee Surgery,33(4), 335–338. 10.1055/s-0039-1700573 10.1055/s-0039-1700573 [DOI] [PubMed] [Google Scholar]
  • 47.Berbig, R., & Rillmann, P. (2000). Timing of the surgery of rupture of the anterior cruciate ligaments. Effects of acute or delayed surgery on arthrofibrosis rate and work disability. Der Unfallchirurg,103(9), 726–730. 10.1007/s001130050611 [DOI] [PubMed] [Google Scholar]
  • 48.Shelbourne, K. D., & Patel, D. V. (1995). Timing of surgery in anterior cruciate ligament-injured knees. Knee Surgery, Sports Traumatology, Arthroscopy,3, 148–156. 10.1007/BF01565474 [DOI] [PubMed] [Google Scholar]
  • 49.Mohtadi, N. G., Webster-Bogaert, S., & Fowler, P. (1991). Limitation of motion following anterior cruciate ligament reconstruction. A case-control study. American Journal of Sports Medicine,19, 620–624. 10.1177/036354659101900612 [DOI] [PubMed] [Google Scholar]
  • 50.Schenck, R. C., Richter, D. L, & Wascher, D. C. (2014). Knee dislocations. Lessons learned from 20-year follow-up. Orthopaedic Journal of Sports Medicine, 2(5). 10.1177/2325967114534387 [DOI] [PMC free article] [PubMed]
  • 51.Barfield, W. R., Holmes, R. E., Slone, H., et al. (2009). Acute versus staged surgical intervention in multiligamentous knee injuries: A review of the literature since 2009. Current Orthopaedic Practice,26, 530–535. 10.1097/BCO.0000000000000268 [DOI] [Google Scholar]
  • 52.Levy, B. A., Dajani, K. A., Whelan, D. B., Stannard, J. P., Fanelli, G. C., Stuart, M. J., Boyd, J. L., MacDonald, P. A., & Marx, R. G. (2009). Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy,25(4), 430–438. 10.1016/j.arthro.2009.01.008 10.1016/j.arthro.2009.01.008 [DOI] [PubMed] [Google Scholar]
  • 53.Braaten, J. A., et al. (2022). Modern treatment principles for multiligament knee injuries. The Archives of Bone and Joint Surgery,10(11), 937–950. 10.22038/ABJS.2021.60188.2971 10.22038/ABJS.2021.60188.2971 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Jiang, W., Yao, J., He, Y., Sun, W., Huang, Y., & Kong, D. (2015). The timing of surgical treatment of knee dislocations: A systematic review. Knee Surgery, Sports Traumatology, Arthroscopy,23(10), 3108–3113. 10.1007/s00167-014-3435-1 10.1007/s00167-014-3435-1 [DOI] [PubMed] [Google Scholar]
  • 55.Fine, R., Curtis, W., Stevens, K., Imada, A. O., Stein, E. R., Treme, G., Schenck, R. C., & Richter, D. L. (2023). Return to sport after multiligament knee injury in young athletes. Orthopaedic Journal of Sports Medicine,11(6), 23259671231179108. 10.1177/23259671231179109 10.1177/23259671231179109 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Vaishya, R., Gupta, B. M., Mamdaur, G. M. N. M., & Vaish, A. (2024). Multiligamentous knee injury: A scientometric assessment of global publications during 2008–2023. Indian Journal of Orthopaedics. 10.1007/s43465-024-01149-9
  • 57.Grassi, A., Pizza, N., Al-Zu’bi, B. B. H., Fabbro, G. D., Lucidi, G. A., & Zaffagnini, S. (2022). Clinical outcomes and osteoarthritis at very long-term follow-up after ACL reconstruction: A systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine,10(1), 23259671211062240. 10.1177/23259671211062238 10.1177/23259671211062238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Heitmann, M., Akoto, R., Krause, M., Hepp, P., Schöpp, C., Gensior, T. J., Bartl, C., Lill, H., & Frosch, K. H. (2019). Management of acute knee dislocations: Anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surgery, Sports Traumatology, Arthroscopy,27(8), 2710–2718. 10.1007/s00167-018-5317-4 10.1007/s00167-018-5317-4 [DOI] [PubMed] [Google Scholar]

Associated Data

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Supplementary Materials

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Data Availability Statement

No primary data was involved in this study. Details of meta-analysis have been provided.

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