Multiligament knee injuries constitute a complex and challenging entity, not only because of the diagnosis and reconstruction procedure itself, but also because of the rehabilitation programme after the index procedure. A high level of suspicion and a comprehensive clinical and radiographic examination are required to identify all injured structures. Concomitant meniscal, chondral and nerve injuries are common in multiligament injuries necessitating a detailed evaluation. Stress radiographs are valuable in evaluating patients preoperatively and postoperatively. The current literature supports surgical management of multiligament injuries, and reconstructions are recommended because repair of ligaments has higher failure rates. Reconstruction of all injured ligaments in one stage is advocated (if possible) in order to achieve early mobilisation and to avoid joint stiffness. Using biomechanically and clinically validated anatomic ligament reconstructions improves outcomes. In the setting of multiligament knee reconstructions, several technical aspects that require consideration are vital, such as the graft choice, the sequence of ligaments reconstruction, tunnel position and orientation to avoid tunnel interference and graft tensioning order. This review article discusses the use of stress radiographs in diagnosing ligament injuries and evaluating postoperative stability. Tunnel convergence and tensioning sequence are potential problems, and guidelines to address these are also discussed. Recovery after a multiligament reconstruction surgery typically requires 9 to 12 months of rehabilitation prior to returning to full activities. The purpose of this article is to review the specific principles of multiligament injuries, classification, diagnosis, treatment options and rehabilitation guidelines for addressing these complex injuries.
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