Pearls and Pitfalls in the Management of the Chronic Multiple Ligament-Injured Knee

This article focuses on the clinical presentation, examination, evaluation, and management of the patient who presents with a multiple ligament knee injury (multiple-ligament injured knee [MLIK]) in the chronic setting. The intent is to focus on the patient who presents in the office setting with a complaint of knee instability and pain, dysfunction after having sustained a knee dislocation, or multiple ligament injury. These patients may have been managed with conservative care to allow neurovascular injuries to heal or may present with partial extra-articular ligament repair as an initial form of treatment. This article also addresses the patient who has sustained an MLIK injury and reconstruction but presents with recurrent instability and failure. The primary purpose of this article was to highlight the pearls and pitfalls as they relate to the physical examination, the crucial role of proper imaging (plain radiography and magnetic resonance imaging), the technical aspects of successful reconstruction, the role adjunctive extra-articular knee ligament surgery, osteotomy, and the importance of surgical judgment. It was the intent of this article to present a framework and emphasize key points to improve management of this difficult problem.