Diagnosis, Treatment, and Current Controversies in Multiligament Knee Injuries: A Narrative Review

Multiligament knee injuries are infrequent but potentially severe, defined by the simultaneous rupture of two or more major knee ligaments, with a considerable risk of neurovascular injury. This narrative review, based on a search of PubMed, the Cochrane Library, and Google Scholar covering 2010 to 2026, examines their diagnosis, treatment, and outcomes, with emphasis on current controversies in surgical management. The Schenck classification remains the reference system, but its initial category is imprecise, and it does not reliably predict neurovascular injury; it should be interpreted alongside the full injury profile. Diagnosis requires a high index of suspicion and systematic physical examination; magnetic resonance imaging is the diagnostic standard, with a low threshold for computed tomography angiography when vascular injury is suspected. Surgery is the treatment of choice in active patients. Single-stage anatomic reconstruction of all injured structures within the first two to three weeks is associated with less secondary meniscal and chondral injury. Autograft is preferred for the anterior cruciate ligament in young patients, whereas autograft and allograft perform comparably for the posterior cruciate ligament and collateral complexes. Early mobilization is associated with less arthrofibrosis without compromising the grafts. Functional outcomes are acceptable in the short and medium term but deteriorate from seven years onward, with post-traumatic osteoarthritis in up to 71.7% of patients in some series. This should be discussed in preoperative counseling. Arthrofibrosis and residual instability are the most frequent complications, and neurovascular injury is the most severe. Surgical timing, graft selection, and the sequence of reconstruction remain the main open questions and will require comparative studies.