Controversies in Timing of Surgery and Rehabilitation for Multiligamentous Knee Injuries

With an estimated incidence of 0.02% to 0.2%, multiligamentous knee injuries are rare, often devastating injuries that can occur with concomitant vascular or neurologic involvement. Generally, outcomes of surgical treatment have been superior to those of nonsurgical treatment for active individuals and the general population. Surgical treatment options include primary repair, reconstruction, or augmentation. However, the ideal timing of treatment, both surgery and rehabilitation, is unclear. Options include acute (ie, within 3 weeks), subacute (3 to 8 weeks), and delayed treatment of all ligaments simultaneously, or alternatively managed in two stages. Primary repair can be considered in avulsion injuries of the posterior cruciate ligament and posteromedial corner and distal posterolateral corner avulsions; however, treatment paradigms are still evolving. Reconstruction is preferred in younger patients, for most midsubstance injuries and cruciate ligament injuries, and when presentation is delayed. Early surgery may be associated with better outcomes and a lower incidence of cartilage lesions compared with delayed surgery, although there may be an increased risk of arthrofibrosis. More traditional protocols often restrict weight bearing in the first weeks to protect ligament healing. Although early range-of-motion exercises decrease the risk of stiffness following surgery for multiligamentous knee injury, concern remains regarding attenuation or loosening of the surgically repaired or reconstructed ligaments. The Surgical Timing and Rehabilitation trial has been designed to assess the outcomes of early versus delayed surgery and early versus delayed rehabilitation.