The Consequences of Surgical Timing in Multiligament Knee Injury

Commentary A basic principle of orthopaedic care continues to remain true: stable fixation with early range of motion can ultimately benefit the patient. Hoit et al., when controlling for confounding variables, found no differences clinically or functionally when evaluating the effect of the timing of a surgical procedure. However, they did find that groups treated in under 6 weeks had a greater need for a manipulation under anesthesia compared with the delayed reconstruction group, in which higher rates of radiographic advancement of arthritis occurred. Surgeons can agree that a multiligament knee injury requires surgical intervention to allow for an optimal functional outcome1. However, due to the rarity of the injury and the lack of quality studies with longitudinal follow-up, no study to date has identified the benefits of early reconstruction compared with late reconstruction. As both surgical and therapeutic techniques advance, surgeons continue to push the envelope to provide optimal knee stability and return of function to avoid the long-term consequences of a delayed surgical procedure. The findings of this study coincide with single-ligament knee injury data in that early intervention may prevent long-term consequences of osteoarthritis2. Operative intervention and the timing of multiligament knee reconstruction reflect the saying “There is no free lunch.” Early reconstruction leads to higher rates of secondary surgical intervention due to stiffness. Late reconstruction leads to higher rates of radiographic advancement of osteoarthritis. Delaying knee reconstruction causes the patient to walk and maneuver with altered biomechanics, which have been known to increase the risk of associated meniscal and cartilage damage3. Interestingly, recent studies have shown that a delay in knee reconstructive procedures leads to a “second-hit” catabolic phenomenon resulting in a prolonged and greater release of catabolic cytokines implicated in the development of posttraumatic osteoarthritis2,4,5. In their propensity analysis, Hoit et al. confirmed that delayed reconstruction did indeed lead to the secondary consequence of more advanced osteoarthritis compared with the early reconstruction group. Due to the current paucity of literature related to multiligament knee reconstruction procedures and their timing, prior systematic reviews of small series have demonstrated conflicting results. Their findings in this specific patient population demonstrate and confirm the concerns of increased knee laxity when treated early, conflicting findings on early compared with late reconstruction in terms of functional outcomes, and high risks of arthrofibrosis in early-intervention groups6–8. In their critical analysis, Hoit et al. found that no increased residual laxity occurred when comparing early reconstruction with late reconstruction, which directly contradicts the findings by Mook et al. That is of great utility to surgeons, giving them peace of mind that their early surgical interventions will not compromise biomechanical stability6. Furthermore, functional outcomes remained equivalent across the early and late reconstruction groups. This study highlights the need for future high-quality studies to evaluate the long-term effects of surgical interventions in the setting of surgery for multiligament knee injury—specifically, a critical evaluation of techniques and graft types, return to sport, functional deficits associated with posttraumatic osteoarthritis, and conversion to total knee arthroplasty. The findings by Hoit et al. push the field forward in terms of choosing the optimal timing for surgical intervention and how to most accurately counsel patients on consequences inherent to their injury pattern.