While multiligament knee injuries are rare, failure to diagnose and treat them properly can potentially lead to devastating outcomes. These knee injuries are usually the result of high-energy trauma, and knee dislocation and other associated injuries should be considered and evaluated as such. Initial evaluation and management include detailed history and physical examination, beginning with a complete neurovascular examination including ankle-brachial index, assessment of the soft tissues, and determination of the instability pattern. Imaging should include plain radiographs, stress views if necessary, and computed tomography if suspicion for fracture. Magnetic resonance imaging is modality of choice for detailed evaluation of the soft tissues. Once evaluation is complete, the decision to proceed with operative versus conservative management is made.

We favor surgical reconstruction of the anterior cruciate ligament (ACL) in most patients with more than one ligament injured, but not all patients are appropriate candidates. Some relative contraindications include advanced age, medical contraindications, morbid obesity, and limited functional demand prior to injury. These patients can initially be treated conservatively with immobilization, bracing, and rehabilitation. Surgery can be a viable option in a delayed fashion if patients are experiencing chronic instability.

The optimal timing of surgery varies considerably depending on nature of the injury, vascular status of the affected extremity, degree of swelling, soft tissue and condition of the skin, degree of instability, and surgeon preference. Some surgeons prefer early operative intervention at approximately 1–2 weeks to allow for repair of injured structures [1]. However, early surgery can be associated with arthrofibrosis. A recent systematic review of the literature suggested that delayed reconstruction of severe multiple-ligament knee injuries resulted in equivalent stability outcomes and resulted in lower rates of knee flexion loss after surgery, when compared to acute surgery (within 3 weeks) [2]. Ultimately, the timing of surgical management of the multiligament injured knee is controversial and debatable, and currently there is little evidence to suggest any differences between early versus delayed intervention. Further research is needed to provide definitive recommendations on timing of surgical management, and the decision on timing must be individualized for each patient.