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. 2024 Aug 28;33(4):1281–1298. doi: 10.1002/ksa.12442

Outcomes after multiligament knee injury worsen over time: A systematic review and meta‐analysis

Antonio Klasan 1,2,✉, Anne Maerz 2, Sven E Putnis 3, Justin J Ernat 4, Edouard Ollier 5, Thomas Neri 5,6
PMCID: PMC11948183  PMID: 39194423

Abstract

Purpose

Multiligament knee injuries (MLKIs) are devastating injuries that can have life‐long consequences. A management plan requires the decision to perform surgery or not, timing of surgery, consideration of repair versus reconstruction, reconstruction technique and reconstruction graft choice. The purpose of this study was to analyze development of clinical outcomes of MLKIs over time at a minimum of 2 years of follow‐up.

Methods

Four databases were queried for surgical outcome‐based studies of MLKIs published from 01/2000 through 09/2022 with a minimum 2‐year follow‐up. Technique articles, nonoperative treatment, arthroplasty, pediatric and review articles were excluded. Study characteristics including design, number of patients, age, follow‐up period, anatomical region and posterior‐cruciate ligament (PCL)‐based injury were collected. Primary outcomes were Lysholm, International Knee Documentation Committee (IKDC) outcome scores and Tegner activity score. Random‐effects model analysis was performed.

Results

After the application of inclusion and exclusion criteria, 3571 patients in 79 studies were included in the analysis. The mean age at surgery was 35.6 years. The mean follow‐up was 4.06 years (range 2–12.7). The mean Lysholm score at 2‐year follow‐up was 86.09 [95% confidence interval [CI]: 82.90–89.28], with a yearly decrease of −0.80 [95% CI: −1.47 −0.13], (p = 0.0199). The mean IKDC at 2 years was 81.35 [95% CI: 76.56–86.14], with a yearly decrease of −1.99 [95% CI: −3.14 −0.84] (p < 0.001). Non‐PCL‐based injuries had a higher IKDC 83.69 [75.55–91.82] vs. 75.00 [70.75–79.26] (p = 0.03) and Lysholm score 90.84 [87.10–94.58] versus 84.35 [82.18–86.52] (p < 0.01) than PCL‐based injuries, respectively.

Conclusion

According to the present systematic review and meta‐analysis of MLKIs with minimum 2‐year follow‐ups, the patients who suffered an MLKI can expect to retain around 80‐85% of knee function at 2 years and can expect a yearly deterioration of knee function, depending on the score used. Inferior outcomes can be expected for PCL‐based injuries at 2 years postoperative.

Level of Evidence

Level IV meta‐analysis.

Keywords: knee dislocation, meta‐analysis, multiligament knee injury, outcomes, posterior cruciate ligament based injury

Abbreviations

ACL

anterior cruciate ligament

IKDC

international knee documentation committee

KD

knee dislocation

LCL

lateral collateral ligament

MCL

medial collateral ligament

MLKI

multiligament knee injury

PCL

posterior cruciate ligament

PCLb

posterior cruciate ligament based

INTRODUCTION

Multiligament knee injuries (MLKIs) and knee dislocation (KD) are rare but debilitating events for a patient [14]. The injury is defined as a disruption of at least two out of four major knee ligaments [82]. The incidence ranges between 0.02% and 0.2% of all orthopaedic injuries [70]. The distinction between the KD and MLKI is most commonly defined as a documented versus undocumented knee dislocation, with the former typically being associated with a higher incidence of nerve and vascular injury.

With improvements in MRI diagnosis, surgical approach and rehabilitation, outcomes have improved over the last 30–40 years [72, 84].

These injuries can be potentially life/limb threatening, typically require subspecialized treatment and are prone to postoperative complications [51], with long, often complex surgery and rehabilitation [66]. Due to this long recovery period, the success of the management is not typically determined until after over a year or more postoperatively [13].

The heterogeneity of the injury patterns, combined with the surgical timing options (acute, semi‐acute, delayed; single vs. multiple stages), surgical approach (repair and reconstruct), graft choice (autograft, allograft or synthetics) and fixation, creates a major issue in trying to perform a controlled study for better understanding of each of these factors. Additionally, posterior cruciate‐based (PCL‐based) injuries have worse clinical outcomes than non‐PCL‐based injuries [24, 27, 61, 76]. Finally, there is the issue of the potential of neurovascular injury, which can be a major risk factor for significantly worse outcomes [24, 27].

Previous systematic reviews have assessed timing of surgery [34, 64, 75, 92], outcomes depending on the mechanism of injury [8], return to work and sports [13] and compared repair and reconstruction [18, 92]. Presently, no meta‐analysis has tried to provide an answer to the question of long‐term functional outcomes after MLKIs and their development.

The primary purpose of the present systematic review and meta‐analysis was to analyze long‐term clinical and functional outcomes after MLKIs and their development over time, starting at minimum 2 years. The secondary purpose was to determine a potential difference between PCL‐based and non‐PCL based injuries. We hypothesized worsening of outcomes over time and worse outcomes for PCL‐based injuries.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension statement for reporting of systematic reviews was followed. The PRISMA checklist is presented in Supporting Information: Appendix. This systematic review was registered with PROSPERO, the international prospective register of systematic reviews of the National Institute for Health Research, in April 2022 (registration number CRD42022364292).

Search strategy

An independent review of citations in Medline, Embase, Web of Science and Cochrane Library after 1 January 2000 to 30 September 2022 was conducted independently by three authors (A.K., A.M. and S.P.). The search terms were as follows: ((multiligament) AND (knee)) AND (injury); (knee) AND (dislocation); (anterior cruciate ligament) AND (posterior cruciate ligament); (anterior cruciate ligament) AND (medial collateral ligament); (anterior cruciate ligament) AND (lateral collateral ligament); (anterior cruciate ligament) AND (posterolateral corner); (anterior cruciate ligament) AND (posteromedial corner); (posterior cruciate ligament) AND (posteromedial corner); (posterior cruciate ligament) AND (posterolateral corner); (posterior cruciate ligament) AND (medial collateral ligament); (posterior cruciate ligament) AND (lateral collateral ligament).

Study selection

After exclusion of duplicates using Zotero® (Corporation for Digital Scholarship), all abstracts were screened by the three authors. Any disagreements among the authors about a study's potential inclusion were resolved by two other authors (J.E. and T.N.). References of included studies were additionally screened for further studies. We included clinical evidence level 4 and above and studies in skeletally mature adults, with minimum 2‐year clinical outcomes reported using either Lysholm [62] or IKDC [39] questionnaires. We excluded studies with concomitant osteotomies, partial or total knee replacements, fracture dislocations and studies with knee dislocations in a setting of congenital disorders. Excluded were non‐English studies, review articles, meta‐analyses, abstracts, case reports, biomechanical studies, cadaveric and animal studies and surgical techniques.

Data extraction

Data extraction was performed by the same three authors and included study design, number of patients per group and patient characteristics. Mean follow‐up per group was used for the analysis. The data, however, are presented with the age and follow‐up averaged out across the cohort. Clinical outcomes extracted included Lysholm, IKDC and Tegner scores at the reported follow‐up. If the mean for any of the continuous variables was not reported in the study, it was calculated from the median, minimum and maximum using the estimate method described by Wan et al. [94]. Due to the heterogeneity of involved ligaments involved across studies and a current lack of a ligament‐oriented classification which predicts clinical outcomes, a subanalysis of outcomes was performed using the differentiation of studies explicitly including PCL‐based (PCLb) only, non‐PCL‐based (nPCLb) only or mixed (all ligament combinations, ALL) cohorts [6, 24, 27, 61, 76], where both PCL and non‐PCL‐based injuries in any possible combination of two or more ligaments were included.

Risk‐of‐bias assessment

The methodological quality of each study was assessed independently by 4 review authors (A.K., A.M., S.P. and T.N.) according to the Newcastle–Ottawa scale [95] and reported in Table 1.

Table 1.

Included studies, by study design, quality, patients per group, age and follow‐up.

Author, year Study design Newcastle–Ottawa Patients per group Mean age Mean follow‐up, years
Ishibashi 2020 [40] Cohort study Good 12 19 48.0 4.9
Khakha 2016 [44] Case series Poor 36 36.5 10.1
Tapasvi 2022 [89] Case series Poor 34 30.6 4.2
Jakobsen 2010 [41] Case Series Poor 27 31.5 3.8
Kim 2012 [47] Cohort study Poor 20 25 n.r. 2
Van der Wal 2016 [93] Cohort study Poor 16 35.5 5
Fanelli 2002 [14] Case series Poor 35 n.r. 6
Hua 2016 [36] Case series Poor 18 38.8 4.8
Kim 2011 [48] Cohort study Good 21 25 35.5 2
Kim 2013 [49] Cohort study Good 22 24 39.7 2.9
Helito 2021 [32] Cohort study Good 18 24 24 27.0 5.2
Strobel 2006 [87] Case series Poor 17 30.7 3.4
Denti 2015 [10] Cohort study Good 10 10 34.5 10.2
Zorzi 2013 [107] Case series Poor 19 29.0 3.2
Fanelli 2004 [15] Case series Poor 41 n.r. 3.2
Lee 2011 [55] Case series Poor 70 31.2 3.3
Lutz 2021 [61] Cohort study Good 11 21 32.0 4.8
Lee 2010 [56] Cohort study Good 28 16 31.8 4.1
Khanduja 2006 [46] Case series Poor 19 29.6 5.6
Bonadio 2017 [5] Case series Poor 13 32.0 3.7
Helito 2022 [31] Cohort study Poor 37 41 30.4 3.4
Levy 2015 [57] Cohort study Poor 61 64 33.8 5
Gauffin 2013 [21] Case series Poor 4 n.r. 8
Zaffagnini 2011 [102] Cohort study Good 32 19 36.0 3.3
LaPrade 2018 [54] Cohort study Good 31 69 33.5 2.9
Millett 2004 [67] Case series Poor 19 35.7 3.8
Ranger 2011 [78] Case series Poor 71 38.5 4.5
Dekker 2021 [9] Cohort study Poor 50 19 38 3.6
Helito 2014 [30] Case series Poor 9 29.9 2.3
Moatshe 2017 [68] Case series Poor 65 36.0 12.7
Shelbourne 2007 [83] Case series Poor 21 21.4 4.6
Fanelli 2014 [17] Cohort study Poor 9 22 13 31.0 10.0
Djebara 2022 [11] Case series Poor 29 30.2 7.5
Plancher 2008 [77] Cohort study Good 31 19 26.0 8.3
Hirschmann 2010 [33] Cohort study Good 31 20 23 30.3 12.0
Zhang 2022 [105] Cohort study Poor 11 9 30.9 13.1
Li 2019 [59] Case series Poor 49 32.0 2.6
Godin 2017 [23] Case series Poor 20 17.7 3.1
Billières 2020[3] Case series Poor 20 28.3 2.5
Westermann 2019 [97] Cohort study Good 19 15 27.2 6
Freychet 2020 [20] Cohort study Good 20 20 29.5 4.8
Zhang 2021 [104] Cohort study Good 57 31 32.4 3.8
Hongwu 2018 [35] Case series Poor 13 37.8 2.7
Engebretsen 2009 [12] Case series Poor 85 31.0 6
Görmeli 2015 [25] Cohort study Poor 9 12 31.1 3.4
Mygind‐Klavsen 2017 [71] Cohort study Poor 77 119 34 5.9
Hanley 2017 [28] Cohort study Poor 25 9 25.7 6
Woodmass 2018 [98] Cohort study Poor 31 31 33.5 5.6
Jung 2008 [43] Cohort study Good 19 20 33.5 2.9
Van Gennip 2020 [22] Case series Poor 11 30.5 2
Woodmass 2018 [100] Case series Poor 20 30.7 4.4
Yang 2013 [101] Case series Poor 60 37.8 3
Burton 2020 [7] Cohort study Good 23 11 37.2 6.5
Li 2021 [58] Cohort study Poor 61 34 42.8 2
Woodmass 2017 [99] Case series Poor 23 26.7 7.5
Sanders 2018 [81] Case series Poor 61 32.0 3.8
Barrett 2018 [2] Case series Poor 32 30.0 3.3
Mardani‐Kivi 2019 [63] Case series Poor 28 30.9 3.0
Lo 2009 [60] Case series Poor 11 33.0 4.6
Zhao 2006 [106] Case series Poor 12 27.0 2.7
Zhang 2014 [103] Case series Poor 21 39.6 3.3
Osti 2010 [74] Case series Poor 22 28.8 3.0
LaPrade 2019 [53] Cohort study Good 153 41 34.5 3.5
Khan 2022 [45] Cohort study Good 14 13 35.8 2
Harner 2004 [29] Cohort study Poor 19 12 28.4 3.6
Angelini 2015 [1] Case series Poor 14 29.3 4.1
Ibrahim 2008 [37] i Case series Poor 26 27.3 4.4
Ibrahim 2013 [38] Case series Poor 20 26.4 3.6
Bin 2007 [4] Case series Poor 15 30.4 7.4
King 2016 [50] Cohort study Good 24 32 34 6.4
Fanelli 2012 [16] Case series Poor 35 n.r. 3 (2‐10)
Tzurbakis 2006 [90] Cohort study Poor 12 11 25 28.6 4.3
Shirakura 2000 [85] Cohort study Good 14 11 32.2 5.9
Stannard 2005 [86] Cohort study Poor 35 22 33 2.8
Jokela 2021 [42] Cohort study Good 18 7 43.1 6.9
Sundararajan 2018 [88] Cohort study Poor 31 14 39 3
Werner 2013 [96] Cohort study Good 192 23 33.8 5.8
Mariani 2001 [65] Case series Poor 14 25.1 3
Richter 2002 [79] Cohort study Poor 49 14 26 33.5 8.2
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Data analysis

The summary statistics for Lysholm, IKDC and Tegner, both overall and in prespecified subgroups, were generated using a random‐effect model with the corresponding 95% confidence intervals (95% CIs). For each meta‐analysis, statistical heterogeneity among studies was explored using the I 2 statistic. The influence of heterogeneity on the variability of summary statistics was illustrated by computing the 95% prediction intervals (95% PIs) both overall and in prespecified subgroups. The correlation between follow‐up duration and clinical scores was investigated by performing a linear meta‐regression. A P‐value for the association <0.05 was considered statistically significant. Statistical analysis was performed using R 4.3.2 (R Foundation).

RESULTS

Study inclusion and characteristics

After application of inclusion and exclusion criteria (Figure 1), 79 studies were included in the meta‐analysis, Table 1. All studies were either case series or cohort studies. A total of 3571 patients with MLKIs and KD were included in the meta‐analysis. The mean patient age was not reported in five studies [14, 15, 16, 21, 47], with the mean age at surgery across the studies of 35.6 years (range: 17.7–48.0 years). The mean follow‐up was 4.06 years (range: 2–12.7 years).

Figure 1.

Figure 1

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Flow chart of study inclusion.

Studies were further divided into PCLb, nPCLb and ALL, Table 2. Management included non‐operative, primary surgical repair and surgical reconstruction with autograft, allograft, synthetic graft or a combination thereof, Table 2. The majority of studies included all injury patterns, Table 2.

Table 2.

Included studies by PCL presence of PCL injury, surgical technique and anatomical region.

Author, year PCL‐based Surgical technique per group (repair vs. reconstruction vs. combination) Anatomical region per group
Ishibashi 2020 [40] Yes Repair Combined Combined Combined
Khakha 2016 [44] Yes Combined Combined
Tapasvi 2022 [89] No Reconstruction autograft Combined
Jakobsen 2010 [41] Combined Reconstruction autograft LCL or PLC
Kim 2012 [47] Yes Reconstruction allograft Reconstruction allograft Combined Combined
Van der Wal 2016 [93] Combined Reconstruction allograft Combined
Fanelli 2002 [14] Yes Combined Combined
Hua 2016 [36] Yes Repair Combined
Kim 2011 [48] Yes Combined Combined ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Kim 2013 [49] Yes Reconstruction allograft Reconstruction allograft ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Helito 2021 [32] Combined Reconstruction autograft Reconstruction autograft ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Strobel 2006 [87] Yes Reconstruction autograft ACL + PCL + LCL/PLC
Denti 2015 [10] Yes Reconstruction allograft Reconstruction autograft Combined Combined
Zorzi 2013 [107] Yes Reconstruction allograft ACL + PCL + LCL/PLC
Fanelli 2004 [15] Yes Combined ACL + PCL + LCL/PLC
Lee 2011 [55] Yes Combined Combined
Lutz 2021 [61] Combined Reconstruction autograft Reconstruction autograft ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Lee 2010 [56] No Reconstruction autograft Reconstruction autograft ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Khanduja 2006 [46] Yes Combined ACL + PCL + LCL/PLC
Bonadio 2017 [5] Yes Reconstruction allograft ACL + PCL + MCL
Helito 2022 [31] Combined Combined Combined Combined Combined
Levy 2015 [57] Combined Combined Combined Combined Combined
Gauffin 2013 [21] Yes Combined ACL + PCL + LCL/PLC
Zaffagnini 2011 [102] No Reconstruction autograft Reconstruction autograft only ACL ACL + PCL + MCL
LaPrade 2018 [54] Yes Reconstruction allograft Reconstruction allograft only PCL Combined
Millett 2004 [67] No Combined ACL + PCL + MCL
Ranger 2011 [78] Combined Combined Combined
Dekker 2021 [9] No Reconstruction autograft Reconstruction allograft ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Helito 2014 [30] No Combined ACL + PCL + LCL/PLC
Moatshe 2017 [68] Combined Combined Combined
Shelbourne 2007 [83] Combined Combined Combined
Fanelli 2014 [17] Yes Combined Combined Combined Combined Combined Combined
Djebara 2022 [11] Combined Reconstruction autograft Combined
Plancher 2008 [77] Combined Combined Non‐operative Combined Combined
Hirschmann 2010 [33] Yes Combined Combined Combined ACL + PCL + MCL ACL + PCL + LCL/PLC Combined
Zhang 2022 [105] Combined Combined Non‐operative Combined Combined
Li 2019 [59] Yes Reconstruction allograft ACL + PCL + LCL/PLC
Godin 2017 [23] Combined Reconstruction allo‐ or autograft Combined
Billières 2020[3] Combined Reconstruction allograft Combined
Westermann 2019 [97] No Combined Repair ACL + PCL ACL + PCL
Freychet 2020 [20] Combined Combined Combined Combined Combined
Zhang 2021 [104] Yes Combined Combined Combined Combined
Hongwu 2018 [35] Yes Combined Combined
Engebretsen 2009 [12] Yes Combined Combined
Görmeli 2015 [25] Combined Reconstruction allograft Combined PLC Combined
Mygind‐Klavsen 2017 [71] Yes Combined Combined only PCL Combined
Hanley 2017 [28] Combined Repair Reconstruction allograft Combined Combined
Woodmass 2018 [98] Combined Combined Combined Combined Combined
Jung 2008 [43] Yes Combined Combined ACL + PCL + LCL/PLC ACL + PCL + LCL/PLC
Van Gennip 2020 [22] Combined Reconstruction allograft Combined
Woodmass 2018 [100] Combined Combined Combined
Yang 2013 [101] Combined Reconstruction allograft Combined
Burton 2020 [7] Combined Repair Reconstruction autograft Combined Combined
Li 2021 [58] Combined Combined Combined Combined Combined
Woodmass 2017 [99] Combined Combined Combined
Sanders 2018 [81] Combined Combined Combined
Barrett 2018 [2] Combined Reconstruction allograft Combined
Mardani‐Kivi 2019 [63] Yes Reconstruction allograft ACL + PCL + MCL + LCL
Lo 2009 [60] Yes Reconstruction autograft Combined
Zhao 2006 [106] Yes Reconstruction autograft Combined
Zhang 2014 [103] No Reconstruction allograft ACL + PCL + MCL
Osti 2010 [74] No Combined ACL + PCL + MCL
LaPrade 2019 [53] Combined Combined Combined Combined Combined
Khan 2022 [45] Combined Combined Combined Combined Combined
Harner 2004 [29] Yes Combined Combined Combined Combined
Angelini 2015 [1] Yes Reconstruction allograft Combined
Ibrahim 2008 [37] i Yes Combined Combined
Ibrahim 2013 [38] Yes Reconstruction autograft ACL + PCL + LCL/PLC
Bin 2007 [4] Yes Combined Combined
King 2016 [50] Yes Combined Combined ACL + PCL + MCL ACL + PCL + LCL/PLC
Fanelli 2012 [16] Yes Combined Combined
Tzurbakis 2006 [90] Combined Combined Combined ACL ACL + PCL + LCL/PLC ACL + PCL + MCL or ACL + PCL + LCL/PLC
Shirakura 2000 [85] No Repair Non‐operative ACL + PCL + MCL ACL + PCL + MCL
Stannard 2005 [86] Combined Repair Reconstruction allograft Combined Combined
Jokela 2021 [42] Yes Combined Combined ACL + PCL + MCL prox ACL + PCL + MCL dist
Sundararajan 2018 [88] Yes Combined Combined ACL + PCL + MCL ACL + PCL + LCL/PLC
Werner 2013 [96] Combined Combined Combined Combined Combined
Mariani 2001 [65] Yes Reconstruction autograft Combined
Richter 2002 [79] Yes Repair Reconstruction allo‐ or autograft Non‐operative Combined Combined Combined
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Abbreviations: ACL, anterior cruciate ligament; LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.

Clinical outcomes

Mean Lysholm score at 2 years follow‐up is 86.09 [95% CI: 82.90–89.28], as a starting point for patient‐reported outcomes in the present meta‐analysis, Figure 2a. The yearly decrease of Lysholm score was −0.80 [95% CI −1.47 −0.13], (p = 0.0199), Figure 2b. Some long‐term follow‐up outliers existed, but the overall trend toward worsening of outcomes over time is visible.

Figure 2.

Figure 2

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(a) Forest plot of outcomes according to the Lysholm score. Reported are authors, number of patients, mean Lysholm score, forrest plot and weight. (b) Graph demonstrating the development of Lysholm score over time. Each dot represents a study, the size of the dot represents the size of the cohort (weight), x‐axis is the follow‐up and y‐axis is the Lysholm score. The orange line represents the development of the mean score over time. CI, confidence interval.

In studies where IKDC was used for evaluation, at 2 years, the mean score was 81.35 [95% CI 76.56–86.14], a lower starting point than when Lysholm was used. There was a higher yearly decrease of −1.99 [95% CI −3.14 −0.84] (p < 0.001) (Figure 3a,b).

Figure (3).

Figure (3)

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(a) Forest plot of outcomes according to the IKDC score. Reported are authors, number of patients, mean IKDC score, forest plot and weight. (b) Graph demonstrating the development of IKDC score over time. Each dot represents a study, the size of the dot represents the size of the cohort (weight), x‐axis is the follow‐up and y‐axis is the IKDC score. The orange line represents the development of the mean score over time. CI, confidence interval; IKDC, International Knee Documentation Committee.

The mean Tegner activity scale at 2 years was 5.0527 [95% CI 4.5312–5.5742]. Per year, there was a decrease of −0.0840 [95% CI −0.1796; 0.0116] (p = 0.085).

Although the majority of studies investigated a mixed cohort, for both Lysholm and IKDC, there was a difference of mean values between PCL‐based and non‐PCL‐based injuries, Figure 4a,b, for the same mean follow‐up time. Lysholm score at 2 years uncontrolled for PCL‐based injuries was 86.09, compared to 90.84 without a PCL injury and 84.35 with PCL‐based injury. Similarily, IKDC score for non PCL‐based injuries was 83.69 compared with 75.00 for PCL‐based injuries.

Figure 4.

Figure 4

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(a) Forest plot of outcomes based on the presence of a PCL injury according to the Lysholm score. (b) Forest plot of outcomes based on the presence of a PCL injury according to the IKDC score. CI, confidence interval; IKDC, International Knee Documentation Committee; PCL, posterior cruciate ligament.

DISCUSSION

The most important finding of the present systematic review and meta‐analysis is the worsening of the clinical outcomes over time, when measured with Lysholm, IKDC and Tegner scores. Furthermore, long‐term results of PCLb injuries are significantly worse than those in nPCLb injuries at minimum 2‐year follow‐ups and with progression over time.

In the present systematic review, 6 studies investigated ≥10 year follow‐up [10, 17, 33, 44, 68, 105]. On average, the present meta‐analysis estimates the Lysholm score at 10 years to around 78, providing a good overall estimate and overlapping with the results of these long‐term studies, but this is very dependent on the type of injury. If this is compared to results at 2 years, the difference is clear. In the lack of similar studies on multiligament injuries, a comparison to ACL reconstruction and long‐term outcomes can be performed. After 20 years, the results of ACL reconstruction are considered satisfactory but with 10% of patients having residual laxity [26]. Osteoarthritis prevalence is high, especially in patients with concomitant injuries to the cartilage, meniscus [52] and extensor mechanism [69], as well as delayed surgery [26]. The heterogeneity of the possible injured‐ligament combinations renders any systematic review complex: surgery or no surgery, repair or reconstruct, what to use for reconstruction, which technique to use and, finally, when to do the surgery. Several systematic reviews on the subject of MLKIs have been published in the literature, addressing various aspects. None have provided an answer to long‐term recovery and progression of functional outcomes over time. It can be hypothesized that the injury pattern of MLKIs, including neurovascular damage, causes significantly faster deterioration of knee function at long‐term follow‐ups.

Previous systematic reviews in MLKIs mostly investigated differences in acute versus delayed surgical treatment. Marder et al. investigated acute versus delayed intervention in MLKI in 31 studies; however, they did not elucidate whether acute or delayed intervention produced superior outcomes [64]. Hohmann et al. [34] on the other hand, investigated eight studies and found early surgery to have better outcomes than delayed surgery. Interestingly, Özbek et al. [75] investigated 36 studies and found that early surgery in a setting of more than three ligaments increases the odds of stiffness (OR = 0.45). Vermeijden et al. [91] investigated both isolated ACL (16 studies) and MLKI (14 studies) and found no differences in early versus delayed surgery for both ACL and MLKI injuries. In the present study, with a larger number of included studies, this sub‐analysis has not been performed due to the heterogeneity of timelines between the studies. Given that there is conflicting literature reporting on the benefits/risk of early versus delayed surgery, we elected to study these outcomes collectively, with a larger goal focussed on projected outcomes. Although, admittedly, we understand that failure to control for staging/timing is a limitation of this meta‐analysis.

Dean et al. [8] performed a meta‐analysis comparing high‐ and low‐energy MLKI in 15 studies. The authors found improved Tegner scores for low‐energy injuries but no differences in Lysholm or IKDC score at 5.3 years postoperatively. The clinical outcomes reported in the study by Dean et al. are lower than the scores found in the present study, using the 2‐year follow‐up average score and the yearly loss of score, which might be due to the majority of studies including injuries of all four major ligaments. Everhart et al. [13] investigated return to work or sport after MLKI in 21 studies, finding a return to sport rate at 60% and most patients going back to work. However, most patients returned to work with frequent workplace or job duty modifications.

Fortier et al. [18] investigated injuries of the posterolateral corner only and found significantly higher success rate of reconstruction versus repair. The authors also conclude that the heterogeneity in the literature is present even if only one anatomical region/ligament is investigated. Vicenti et al. [92] tried to answer three questions in a systematic review: surgical repair or non‐operative treatment, repair versus reconstruction and early versus late surgery. The authors concluded that there is no discernable “best” treatment but that reconstruction seems to work better and that surgery should be done within 3 weeks when possible [92].

Instead, a distinction PCL versus non‐PCL based (PCLb versus nPCLb) injuries was performed, due to the previously reported significantly worse outcomes of PCLb injuries in some studies [61, 76]. Currently, no classification or clear distinction between PCL‐based and non‐PCL‐based injuries is reported in the literature. Instead, there are individual studies investigating this issue [57, 70]. This was added to the present study mainly to increase awareness of the vast difference in outcomes between these two, which will hopefully drive a distinction in reporting in the literature. Overall, the present study found worse outcomes for PCLb injuries. The observed difference in IKDC is clinically detectable [19], and the difference in Lysholm is somewhat below the minimally clinically important difference [73], although this also depends on the procedure performed [80]. The principal difference is the fact that a PCLb injury more often signifies a knee dislocation, either with or without radiologic evidence of dislocation, which is a more severe MLKI [24]. The underlying issue with classifying these injuries is the fact that KD classification is used for MLKIs, where not every MLKI is a KD [27].

LIMITATIONS

The limitation of the present study is the heterogeneity of the severity of injury, management, surgical techniques, follow‐up periods and preoperative data. Early versus late, repair versus reconstruction, allograft versus autograft and PCL‐based versus non‐PCL based are all parameters that add a significant number of permutations, virtually impossible to control for. Despite that, by applying wide search criteria and including 79 MLKI studies with minimum 2‐year follow‐ups, a decrease in the skewness of the data of potential outliers in terms of results can be expected. Even PCL‐based injuries have not been completely reported in the includes studies, but the observed difference reported in some smaller clinical studies and in this meta‐analysis open an important aspect to further investigate and discuss. Six studies that did not utilize Lysholm or IKDC were excluded, representing less than 10% of the overall studies. It is unlikely that these studies would alter the results significantly. Finally, neurovascular complications were not assessed in the study, both due to the heterogeneity of the injuries and lack of reporting.

CONCLUSION

According to the present systematic review and metanalysis of MLKI with minimum 2‐year follow‐ups, the patients who suffered a MLKI can expect to retain around 80‐85% of knee function at 2 years and can expect a yearly deterioration of knee function, depending on the score used. Inferior outcomes can be expected for PCL‐based injuries at 2 years postoperative.

AUTHOR CONTRIBUTIONS

All the authors devised the study. Antonio Klasan, Anne Maerz and Sven Edward Putnis did the screening, data extraction and the review. Justin J. Ernat resolved discrepancies. Antonio Klasan wrote the first draft; Thomas Neri and Justin J. Ernat revised it. All authors have read and approved the manuscript.

CONFLICT OF INTEREST STATEMENT

A.K. is an associate editor for the Journal of Knee Surgery and Editorial Board Member of Archives of Orthopaedic and Trauma Surgery and Knee Surgery, Sports Traumatology, Arthroscopy. He has been paid for presentations by Arthrex, Implantcast and FH Ortho. S.E.P. and T.N. are consultants for FH Ortho. J.J.E. is a consultant for DePuy Synthes.

ETHICS STATEMENT

PROSPERO Registration number CRD42022364292. Systematic review requires no consent.

Supporting information

Supplementary Information

KSA-33-1281-s001.docx (31.6KB, docx)

ACKNOWLEDGMENTS

The authors have no funding to report.

Klasan, A. , Maerz, A. , Putnis, S.E. , Ernat, J.J. , Ollier, E. & Neri, T. (2025) Outcomes after multiligament knee injury worsen over time: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 33, 1281–1298. 10.1002/ksa.12442

DATA AVAILABILITY STATEMENT

All studies included are openly available. Our analysis can be shared upon request.

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Data Availability Statement

All studies included are openly available. Our analysis can be shared upon request.

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