Review Article

Multiligamentous Knee Injuries: Acute

Mark P. Smith, MD
Jeff Klott, MD
Pete Hunter IV, BS
ABSTRACT
Robert G. Klitzman, MD Multiligamentous knee injuries (MLKIs) are devastating injuries. The
energy and severity of these injuries encompass a wide range from low-
energy single-joint mechanisms to high-energy polytrauma settings.
Currently, there is no consensus on surgical treatment approach,
surgical timing, or the return to preinjury activity levels after injury. There
does appear to be a difference in the rate of return to activity and level of
activity based on whether the injury was sustained during sport, in a
trauma setting, or while on active military duty. The purpose of this
descriptive review was to summarize current concepts related to (1) the
acute management of MLKIs; (2) the effect of concomitant
neurovascular, meniscal, and chondral injury on MLKI outcomes; (3)
the effect of surgical versus nonsurgical treatment of MLKI on
outcomes; and (4) rates and predictors of return to sport, work, and
active military service after an MLKI.

M
ultiligamentous knee injuries (MLKIs) are devastating injuries to
patients who can have long-lasting ramifications. An MLKI is
defined as injury to at least two of the major ligamentous structures
of the knee, including the anterior cruciate ligament (ACL), posterior cruciate
ligament (PCL), medial collateral ligament (MCL), and lateral collateral lig-
ament (LCL). Of note, most publications consider an injury to the LCL as a
From the Department of Orthopaedic Surgery, component of a posterolateral corner (PLC) injury. The Schenck classification
Sports Medicine, Indiana University, Indianapolis,
IN (Klott, Smith, and Klitzman), and the Indiana is one of the classification schemes used to describe the pattern of MLKI with
University School of Medicine, Indianapolis, IN knee dislocation (KD) (Table 1).1 These are rare injuries representing 0.02%
(Hunter).
to 0.20% of all orthopaedic injuries, but this may be an underestimation due
None of the following authors or any immediate
family member has received anything of value
to spontaneous reductions in the field.2 Dislocations can occur from a variety
from or has stock or stock options held in a of mechanisms, including high-energy traumas, sports injuries, and lower
commercial company or institution related
energy mechanisms. Ultra-low-energy mechanisms are also encountered in
directly or indirectly to the subject of this article:
Klott, Smith, Hunter, and Klitzman. obese patients, such as from simply stepping off of a curb. Figure 1 shows the
J Am Acad Orthop Surg 2022;30:1108-1115 radiographs of an obese patient who sustained an MLKI with a KD by the
DOI: 10.5435/JAAOS-D-21-00830 low-energy mechanism of stepping awkwardly while pitching a softball.
Copyright 2022 by the American Academy of
Although the energy of the injury varies, the severity of the injury has been
Orthopaedic Surgeons. shown to not correlate with the amount of energy absorbed.4 The treating

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Mark P. Smith, MD, et al

Review Article
Table 1. Schenck Classification of MLKIs1 presentation, a high suspicion for KD and its sequelae
Schenck Classification
including vascular insult should persist if there is clinical
instability including opening to varus or valgus stress
KD I Multiligamentous injury with involvement of
the ACL or PCL
with the knee in full extension.3 Therefore, if the patient
does not have a KD on presentation but has a con-
KD II Injury to the ACL and PCL only (2 ligaments)
cerning mechanism and has laxity on examination, the
KD III Injury to ACL, PCL, and PMC or PLC (3 injury must be treated as a spontaneously reduced KD
ligaments)
and be treated appropriately.
KD IV Injury to ACL, PCL, PMC, and PLC (4
ligaments)
Vascular Assessment
KD V Multiligamentous injury with periarticular Both high-energy and low-energy mechanisms can result
fracture
in MLKIs, with Georgiadis et al4 citing 53% high-energy
ACL = anterior cruciate ligament, KD = knee dislocation, MLKI = etiology and 47% low-energy etiology. However, the
multiligamentous knee injury, PCL = posterior cruciate ligament, low-energy mechanism is not protective against neuro-
PLC = posterolateral corner, PMC= posteromedial corner
vascular injury.5 In fact, several studies have referenced
practitioner should have a high suspicion for vascular higher rates of neurovascular injury in low-energy
injuries, nerve injuries, and associated fractures when mechanism MLKIs compared with high-energy mech-
confronted with an MLKI or KD. There are still large anism.4,6 In the initial evaluation, one must be aware
variation and general lack of high-quality evidence for that 18% of MLKIs have associated vascular injuries.7
the preferred treatment of MLKIs. However, an The highest prevalence of vascular injury has been
understanding of the current evidence is important to found to be a Schenck classification KD III (dislocation
better educate patients on their ability to return to with disruption of ACL and PCL with either MCL or
preinjury levels of activity after injury. The purpose of LCL) (32%) or MLKI presenting as a frank posterior
this descriptive review was to summarize current dislocation (25%).7 A delayed diagnosis of vascular
concepts related to (1) the acute management of injury of even 8 hours can lead to increased risk of
MLKIs; (2) the effect of concomitant neurovascular, above-knee amputation.8 Medina et al7 noted that 80%
meniscal, and chondral injury on MLKI outcomes; (3) of all patients with a vascular injury required surgical
the effect of surgical versus nonsurgical treatment of intervention and 12% ultimately required amputation.
MLKI on outcomes; and (4) rates and predictors of Although this evaluation usually starts with palpation of
return to sport, work, and active military service after pulses, this is not the most reliable test to detect a
an MLKI. vascular issue. Mills et al9 argued that obtaining Ankle
Brachial Indices (ABIs) on a patient can be an accurate
screening examination for vascular injury. In this study,
patients with a screening ABI less than 0.9 were all
Initial Evaluation and Management of ultimately diagnosed with a vascular injury requiring
Multiligamentous Knee Injury in the Acute surgical intervention, but no patient with an ABI greater
Setting than 0.9 had a vascular injury that was identifiable by
The rarity and complexity of MLKIs and KDs can make ultrasonography or that required surgical intervention,
creating a standardized algorithm difficult. However, arguing for the effectiveness of the test for screening.
certain initial management principles are generally Prompt diagnosis and vascular surgery involvement are
agreed upon, some of which will be discussed below. key for successful management in these patients. Based
on current evidence, the authors recommend obtaining
Assessment of Stability, Reduction, and ABIs as a screening tool for all patients with KDs and
Concomitant Fracture spontaneously reduced KDs, with CT angiography to
When a patient presents with a KD or concerns of a follow in those with abnormal ABIs to identify the level
spontaneously reduced KD, the treating physician should and severity of the vascular injury.10
obtain orthogonal radiographs to assess for concomitant
fracture. Postreduction radiographs should be obtained Neurologic Assessment
if applicable to assess for adequate reduction. The prac- Patients with MLKI with a resulting transient or sus-
titioner should note that up to 50% of KDs may spon- tained KD are at high risk of neurologic injury. The
taneously reduce in the field.3 If the knee is reduced on common peroneal nerve is the most frequently injured

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Multiligamentous Knee Injuries: A Review

Figure 1

Representative injury XR (A) and MRI (B) images from a 39-year-old morbidly obese male revealing complete tears of the ACL, PCL, and
PLC. The patient injured his knee after stepping awkwardly while pitching a softball and subsequently dislocating his knee.

nerve in KDs, with Medina et al7 citing that 25% of fixation may be necessary to allow for soft-tissue swelling
patients presenting with KD also had a concomitant to decrease before fracture fixation. In this case, some
peroneal nerve palsy. Variation in reported outcomes experts recommend delayed ligamentous reconstruction
could be due to the varying definitions of a until bony healing occurs, after 4 to 6 weeks.3 This delay
nerve palsy and whether partial nerve palsies were helps ensure adequate osseous tunnels for ligamentous
included. reconstruction. For purely ligamentous injuries, available
evidence for timing of surgery is varied. Levy et al11
Acute Workup and Management argued in a systematic review that early surgical treat-
When evaluating a patient with suspected KD or MLKI, ment within 3 weeks of injury yields improved clinical
an initial trauma evaluation for life threatening injuries is and functional outcomes. Alternatively, Mook et al12 in a
first indicated. A thorough physical examination of the systematic review noted that delayed and acute surgical
injured extremity is then required, including palpation for intervention yielded equivalent results. They noted that
pulses and evaluation of neurologic status distal to the acute intervention was associated with increased rates of
injury, as previously discussed. A radiographic assessment instability and flexion deficits than delayed treatment.12
with adequate orthogonal views is then required. If the Mook et al12 also stated that staged procedures, defined
knee is persistently dislocated, an urgent closed reduction as procedures both during the acute and delayed phases,
in the emergency department is required with placement may produce better subjective outcomes and lower rates
of a knee immobilizer. After the closed reduction, post- of stiffness than acute treatment.12 However, they theo-
reduction radiographs and repeat assessment of the limb rized that the difference may be prevented with more
should be obtained. ABIs should then be obtained with CT aggressive postoperative rehabilitation.12
angiography to follow, if applicable. MRI provides valu-
able information about the patient’s knee injury. It can
demonstrate nondisplaced fractures of the tibia or femur, Effect of Concomitant Injuries and
correlate ligament and tendon injuries with physical Treatment Approach on Outcomes
examination findings, and help prepare the treating Effect of Neurological Injury
surgeon for the possibility of having to address chondral Plancher and Siliski13 stated that the functional recovery
or meniscal pathology. MRI should be obtained before rate for a complete nerve palsy is 38%, but the rate of
any definitive surgical procedures are done. If a fracture is complete recovery in a partial common peroneal nerve
present, fracture fixation should first take place. External palsy is approximately 87% (Table 2), although no clear

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 Mark P. Smith, MD, et al

Review Article
Table 2. Influence of Neurovascular Injury on Society (IKDC) scoring system for patient outcomes and
Outcomes After an MLKI found 78% of patients in their study had concomitant
injuries at the time of surgery. Forty percent had artic-
Nerve Injury With MLKI Recovery Lysholm
Knee Dislocation Rate, % Score
ular cartilage injuries, and 56% had meniscal injuries.
Patients with cartilage damage had significantly lower
Partial peroneal nerve palsy 87 89
IKDC scores than those without damage, and those with
Complete peroneal nerve 38 74.5 combined medial and lateral meniscus injuries had
palsy
significantly lower scores.17 Table 3 summarizes the
MLKI = multiligamentous knee injury IKDC scores for the study population.
a
Data extracted from Plancher and Siliski,13 P , 0.05 for both
columns.
Effect of Definitive Treatment Approach
definition for partial or complete injury was provided. A The current literature supports treating patients with
statistically significant difference in Lysholm scores has MKLI surgically instead of nonsurgically in most sit-
been demonstrated between patients who had a com- uations (Table 4). Wong et al18 evaluated 26 cases of KD
plete or partial nerve recovery (score of 89) and patients with an MLKI, 11 treated with cast immobilization and
who sustained permanent peroneal nerve palsies (score 15 treated surgically. Although the surgery group had
of 74.5). Woodmass et al14 conducted a systematic on average 3 degrees of less flexion, patients reported
review on the topic; the authors stated that if there is no knee instability in 26.7% of the surgery group versus
improvement in nerve conduction studies and EMG at 90.9% of the nonsurgery group (P = 0.002). IKDC
6 weeks and 3 months with no symptomatic improve- scores were improved in the surgery group (P = 0.005).
ment in function, they will offer patients a posterior The surgery group was further subdivided into repair of
tibial tendon transfer at 1 year postinjury. all ligaments versus partial repair of some ligaments.
More patients in the partial repair group reported
Effect of Meniscal or Chondral Injuries subjective knee instability than in the complete repair
Krych et al15 evaluated the association between time group. The mean AP translation and IKDC scores were
until surgery and presence of chondral and meniscal significantly better for the complete repair group com-
injuries in patients with MLKI and KD. Overall, 76% of pared with the partial repair group (P , 0.05).18 Thus,
patients had concomitant injuries with 55% having surgically treated patients had superior clinical results to
meniscal tears, and 43% had cartilage injuries. Lateral- nonsurgically managed patients, and those with com-
sided MLKIs had significantly more cartilage and me- plete repair did better than those who had partial
niscal injuries (80% versus 59% P = 0.04).15 A higher repairs.
prevalence of chondral injury in the patellofemoral and Richter et al19 evaluated 89 patients who sustained an
lateral articular compartments was encountered in pa- MLKI and were treated nonsurgically (26 patients), with
tients treated with delayed surgery compared with those repair of cruciate ligaments (49 patients), or with
who underwent acute surgical repair, defined as less reconstruction of cruciate ligaments (14). Significantly
than 1.5 months from time of injury.15 improved clinical outcome measures were seen in pa-
Moatshe et al16 evaluated the rate of chondral and tients treated surgically versus nonsurgically (P , 0.05).
meniscus injuries in patients with MLKI. Meniscal in- In addition, significantly improved clinical outcome
juries were present in 37.3% of patients, and these in- measures were seen in patients treated with transosseous
juries were equally distributed between the medial and ACL/PCL fixation with cortical screws versus suture
lateral side of the knee. Chondral injuries were present fixation. Finally, improved clinical outcomes measure-
in 28.3% of patients, with injuries to the femoral con- ment scores in the patients were seen in patients who
dyles being the most common area of injury. Patients underwent functional progression rehabilitation com-
with meniscal injuries had significantly higher odds of pared with postoperative immobilization.
having a chondral injury (P = 0.034). In addition, Plancher and Siliski13 discussed surgical versus non-
chronic injuries were more likely to have concomitant surgical treatment of MLKIs in a retrospective review of
chondral damage than acute injuries (47.7% in chronic 48 patients with 50 KDs. Nonsurgical treatment con-
injuries, 20.1% in acute; P , 0.001). sisted of patients treated with casting, bracing, or
King et al17 argued that meniscal tears and chondral external fixation. Of these 19 nonsurgical patients, 4
injuries can be predictive of inferior patient outcomes. required above-knee amputation and 2 required
They analyzed the International Knee Documentation arthrodesis. No patients in the surgically treated group

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Multiligamentous Knee Injuries: A Review

Table 3. Knee Function After Surgical Treatment of identified a subset of patients at risk for postoperative
MLKIs According to Cartilage and Meniscus Status stiffness, which is linked to a KD injury (P = 0.04) or
having three or more injured ligaments that required
Structure Injured Number IKDC Score
surgical fixation.21 Although most studies favor surgical
Cartilage
management, patient-specific factors must always be
1Lesion 38 64 (15-99) taken into account when indicating a patient for surgical
2Lesion 57 74 (12-100) repair. As such, patients with low functional demands or
Meniscus who have high surgical risks may benefit from non-
1Tear 53 69 (12-100)
surgical management.
2Tear 42 71 (19-100)
Cartilage 1 Meniscus injury 17 63 (15-100)
Expected Functional Outcome After MLKI
MLKI = multiligamentous knee injury, IKDC = International Knee
Documentation Society Return to Work
a
Data abstracted from the work of King et al.17 MLKIs often have adverse outcomes on patient’s lifetime
earning potential and ability to return to their previous
required either of these interventions. Thirty-one knees level of work (Table 5). Multiple studies have reported
underwent surgery with 29 undergoing surgery within on patients’ ability to return to work. Richter et al19
3 weeks. The mean Lysholm scores were significantly noted 75% of their patients were able to return to work;
different between surgical (84.3) and nonsurgical (70.5) reasons for not returning included knee pain, knee
treatment (P , 0.01), as well as the mean Hospital for instability, and concurrent injuries. Plancher and Sili-
Special Surgery scores for surgically (82.3) versus non- ski13 reported that between 69% and 84% of patients
surgically (63.7) treated knees (P , 0.01), favoring were able to return to work. Levy et al11 noted surgically
surgical management.13 treated patients were able to return to work more often
Peskun and Whelan20 published a systematic review than nonsurgically treated patients (72% versus 52%).
comparing nonsurgical and surgical treatment. The Peskun and Whelan20 combined the outcomes of eight
pooled average Lysholm score was 84.3 for the surgically studies of surgically treated patients and two studies of
treated group compared with 67.2 for the nonsurgically nonsurgically treated patients and found 80.9% of
treated group (P = 0.027), favoring surgical management. surgically treated patients returned to full employment
No statistically significant difference was observed in compared with 57.8% of nonsurgically treated patients
IKDC scores, Tegner scores, knee range of motion, or (P , 0.001).
instability according to the treatment strategy.20 Wajsifsz et al conducted a retrospective review of
In summary, current literature supports surgical surgically treated patients who sustained a cruciate lig-
treatment of MLKI due to improved outcomes. Surgi- ament injury along with a PLC injury. Of 30 patients,
cally managed patients have improved clinical outcome only 3 patients, all laborers, were unable to return to their
scores, better knee stability, decreased rates of early previous level of occupation and had to change jobs; the
arthritic change, and higher rates of return to work and other 27 were able to return to their previous line of
sport.15,18-20 However, not all patients treated with work.22 Mook et al12 conducted a systematic review
surgery will have a good outcome; Hanley et al21 and discovered that patients who were immobilized to
less than 30 degrees of passive and active range of
motion for 3 weeks after surgery were significantly less
Table 4. Influence of Surgical or Nonsurgical
likely to return to work than those who were mobilized
Treatment on MLKI Outcomes
early after surgery (P = 0.008). Everhart et al23
Mean Hospital for conducted a systemic review and stated that return to
Treatment Lysholm Tegner Special Surgery work with minimal to no modifications was higher for
Plan of MLKI Score Score Score
patients treated surgically for MLKI compared with
Surgically 84.3 4.0 82.3 nonsurgically treated patients (79.3% versus 65.2%,
Nonsurgically 67.2 2.7 63.7 P = 0.04). They noted that a lower percentage of patients
return to work who sustain a Schenck grade IV or V KD
MLKI = multiligamentous knee injury
a
Data extracted from the work of Plancher and Siliski13 and Richter compared with a lower grade KD (66% versus 100%,
et al,19 P , 0.01 for all three groups P = 0.017). They also noted a better chance of returning

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 Mark P. Smith, MD, et al

Review Article
Table 5. Return to Work After an MLKI in the nonsurgically treated group (P = 0.004).19 In
Percentage of Patients
addition, 58% of patients in the transosseous fixation
Treatment of Patients Who Who Successfully group were able to return to sport compared with 29% in
Sustained an MLKI Returned to Work, % the suture fixation group (P = 0.02), and in the different
Treated surgically 79.3 rehabilitation groups, 39% of patients treated with
Treated nonsurgically 65.2
immobilization were able to return to sport compared
with 63% in the functional rehabilitation group (P =
MLKI & grade I-III KD 100
0.05).19 Two other studies compared repair versus
MLKI & grade IV-V KD 66 reconstruction of MLKIs and return to sport. Stannard
MLKI = multiligamentous knee injury, KD = knee dislocation et al found 46% of patients treated with repair of PLC
a
Data extracted from the work of Everhart et al,23 P , 0.04 for both versus 68% of patients treated with reconstruction re-
groups turned to sport, and Mariani et al found 0% of patients
treated with repair of cruciate ligaments and 33% of
to work without restrictions if the patient did not
patients treated with reconstruction returned to
sustain a vascular or peroneal nerve injury.23
sport.24,25 Finally, Peskun and Whelan20 found that 50%
Return to Sport of surgically treated patients and 22.2% of nonsurgically
For some patients, return to sport is an important marker treated patients were able to return to preinjury level of
of functional recovery from an MLKI (Table 6). It should athletic activity (P = 0.001).
be noted that when analyzing studies’ return-to-sport Everhart et al23 noted that the rate of return to sport
rate, few studies specify what kind of sport their patients among studies where all patients were treated surgically
returned to. The level of knee function required to (59.1%) was significantly higher than studies with a
participate in contact sports and sports requiring rapid combined population of patients treated nonsurgically
cutting activities may be higher compared with that in and surgically (46%, P = 0.02). Hirschmann et al eval-
noncontact sports and sports requiring only linear uated return to sport of elite athletes with complex bi-
motion. cruciate knee injuries. They found 79% of patients were
Reported rates of return to sport are more varied able to return to their previous sport at a mean time of
across the literature than rates of return to work. Wong 5.5 months; however, only 33% returned to the preinjury
et al18 observed that of 26 patients analyzed, none of level of competition.26 In addition, Bakshi et al reported
their patient population was able to return to previous that the overall return-to-play rate of NFL football
level of sports participation. Plancher and Siliski13 players who sustained an MLKI was 64%. A statistically
noted a significant difference in the percentage of pa- significant difference was observed in mean time to return
tients able to return to sport with 74% in the surgery to play for athletes depending on the specific injury:
group and 31% in the nonsurgery group returning to MCL/ACL injuries took 305 days to return to play, ACL
sport (P = 0.015). Ritcher et al assessed rates of return to PCL/LCL injuries took 459 days, and KDs took 609 days
sport of patients with cruciate ligament avulsion injuries. to return. Finally, patients sustaining ACL/MCL injuries
They reported that 56% of patients were able to return to were more likely to return to prior performance level
sport in the surgically treated group, compared with 17% (43.5%) compared with those sustaining an ACL with
PCL/LCL injury (18.5%, P , 0.001).27
In summary, multiple studies have demonstrated that
Table 6. Return to Sport After an MLKI patients treated surgically for an MLKI have a better
Percentage of chance of returning to sport than patients not treated
Athletes Who surgically. Two studies demonstrate that patients treated
Type of MLKI Returned to Sport, Average Time to with ligament reconstruction have a higher percentage of
Sustained % Return to Sport, d return to sport than those treated with ligament repair,
ACL/MCL 43.5 305 one analyzing PLC and the other analyzing cruciate liga-
ACL/PCL/LCL 18.5 459 ments.24,25 In addition, after surgical treatment, functional
ACL & KD N/A 609 rehabilitation is superior to immobilization regarding re-
turn to sport. Finally, an MLKI can be a career altering or
ACL = anterior cruciate ligament, KD = knee dislocation, LCL = ending injury for elite athletes, with one study noting 33%
lateral collateral ligament, MCL = medial collateral ligament, MLKI =
multiligamentous knee injury, PCL = posterior cruciate ligament able to return to preinjury level and another noting only
a
Data extracted from Bakshi et al,27 P , 0.01 for both columns. 18.5% of athletes with ACL and PCL/LCL injury

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Multiligamentous Knee Injuries: A Review

Table 7. Return to Military Active Duty After an MLKI work environment, higher job security, and less physi-
Service Men and Women Percentage Returned to
cally demanding work.28,30
Who Sustained an MLKI Active Duty In summary, most MLKIs are not sustained in a combat
Total (n = 24) 54
setting, but in a similar fashion to those sustained in
civilian lifestyle. However, compared with the civilian
Senior enlisted and officers 75
literature, soldiers who sustain combat-related MLKIs are
Junior enlisted and officers 33 more likely to experience extensive polytrauma injuries. In
MLKI = multiligamentous knee injury addition, the more stringent requirements of active service
a
Data extracted from the work of Ross et al.28 make it harder for these patients to return to active duty
compared with civilian rates of return to work.
returning to the previous level.26,27 This should help guide
treatment and guide counselling of athletes about the
reality of returning to sport after an MLKI.
Summary
Return to Active Service Although MLKIs are relatively rare orthopaedic injuries,
The last group of patients discussed are service men and they can be associated with high patient morbidity.
women who had sustained MLKIs (Table 7). One can MLKIs can affect a patient’s ability to return to work,
surmise that active service members may sustain very sport, or active duty. It is crucial in the initial man-
high-energy injuries, such as an improvised explosive agement to perform a thorough evaluation of the
device (IED) blast injury, that can be complicated by patient, as up to 50% of KDs can spontaneously reduce
polytrauma and limited early access to medical care. In in the field. In addition, missing a vascular injury in the
addition, like athletes, most military personnel must be initial evaluation can have dire consequences and
able to return to a high fitness level to return to active increase the chances that the patient may require
duty. We review the return to active duty rates for amputation.8 Vascular injuries, nerve injuries, chondral
combat personnel and how this patient population may injuries, and meniscal injuries can all lead to worse
differ compared with others previously described. satisfaction and functional outcomes.
Ross et al evaluated 24 patients with MLKI from motor Current evidence in the literature supports surgical
vehicle accident, parachute landing, and various sports management of MLKIs. There is still much debate
injuries. They found 54% of patients were able to return to regarding timing, surgical technique, and postoperative
active duty. In addition, a higher percentage of senior rehabilitation, but current evidence supports that patients
enlisted and officers (75%) were able to return to duty return to work and sport at a higher rate with surgical
compared with junior enlisted and officers (33%).28 treatment. Some research argues that ligament recon-
Barrow et al29 reviewed 46 service members who struction may lead to a better result than repair. Early
sustained a combat-related MLKIs; the overall return-to- functional rehabilitation may lead to better range of
duty rate was 41%. Factors that significantly decreased motion and return to sport than postoperative immobili-
patients’ ability to return to active duty included high- zation. Overall, the return-to-work rate for patients trea-
energy mechanism, peroneal nerve injury, vascular ted surgically is relatively high when considering the
injury, compartment syndrome, traumatic knee arthrot- overall morbidity associated with these injuries. The fact
omy, and intraarticular femur fracture (all P , 0.05). Of that the return-to-work rate is higher than return to sport
the patients unable to return to active duty, 70% were or active military duty may illustrate that a large amount
directly associated with the MLKI.29 In addition, Ri- of the work force is able to better control the factors where
chards and Dickens found most MLKIs sustained by they work to avoid pain, instability, or reinjury compared
service members are actually low-energy, non–combat- with those who want to return to sport or active duty.
related injuries from minor falls (less than 5 ft), sports Many unanswered questions remain with the treatment of
injuries, and low-speed bicycle accidents. These low- MLKIs. The rarity and variety of these injuries make
energy MLKIs have higher rates of return to duty than performing a robust, prospectively randomized clinical
their high-energy counterparts. Ross et al and Richard trial difficult. However, as more surgeons adopt modern
and Dickens both noted that senior enlisted members treatment strategies and postoperative rehabilitation
were more likely to return than more junior members. protocols, we may be better able to answer the questions
Proposed explanations include more control over their that remain with the treatment of MLKIs.

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 Mark P. Smith, MD, et al

Review Article
16. Moatshe G, Dornan GJ, Loken S, Ludvigsen TC, LaPrade RF,
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