Approach to the Neglected Multiligament Knee Injury: A Systematic Review

Neglected multi-ligament knee injury (MLKI) or tibial-femoral knee dislocation is a rare injury with significant consequences. This review aims to summarise injury patterns, treatment recommendations, and outcomes.

MEDLINE, PubMed, and EMBASE were searched on 28 January 2025. Neglected MLKI was defined as untreated or inadequately treated MLKI or knee dislocations where definitive surgical management was unintentionally delayed for ≥3 weeks without appropriate interim management. PRISMA, R-AMSTAR and Cochrane guidelines were followed.

Eighteen case reports (19 patients; 20 knees) were included. Mean age was 41.5 years (range: 17-65 years) with 11.1% being female. Mean time from injury to surgery was 47.8 months (range: 0.75-360), most (85%) presented unreduced. Most injuries were either KD-II (20%) or KD-IIIM (30%), the main reason for neglect was initial treatment by local "bone-setters". Arthroscopic multiligament knee reconstruction (MLKR) was performed in two patients. Open MLKR was performed in seven patients with KOOS scores ≥70 (aside from Sports/Recreation subscale). Three patients received open reduction with temporary trans-articular pinning, all having postoperative arthrofibrosis (≤50° flexion). Six patients received total knee arthroplasty (TKA), with four (66.7%) receiving a hinged implant. Postoperative flexion ranged from 80 to100 degrees, with 83.3% ambulating independently. Two patients received arthrodesis.

Reconstruction for neglected MLKI is recommended in younger patients without joint degeneration, older patients may benefit from TKA often requiring higher constraint. Arthrodesis and trans-articular pinning should be avoided due to significant flexion contractures. Regardless of treatment, patients should still be counselled on arthrofibrosis.

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The online version contains supplementary material available at 10.1007/s43465-025-01674-1.