What is a Multiple Knee Ligament Injury?

A multiple knee ligament injury (also called a multiligament knee injury) occurs when two or more of the major ligaments of the knee are damaged at the same time. These injuries are more severe than isolated ligament tears and often result in significant knee instability.

Knee ligaments provide essential stability for everyday movement and athletic performance. When two or more of these ligaments are torn or ruptured, such as due to either high energy motor vehicle accidents or low velocity sport injuries, a multiligament knee reconstruction becomes necessary. These injuries are complex, require precise planning, and demand a structured surgical and rehabilitation pathway to achieve the best outcomes possible.

In this comprehensive guide, we walk you through the step-by-step process of reconstructing multiple knee ligaments, including pre-surgery preparation, the surgical reconstruction phases, graft selection, intra-operative considerations, and rehabilitation strategy.

Four Major Ligaments

The knee joint is stabilized by four major ligaments:

• Anterior Cruciate Ligament (ACL): It controls forward movement and rotation
• Posterior Cruciate Ligament (PCL): It controls backward movement of the tibia
• Medial Collateral Ligament (MCL): It stabilizes the inner side of the knee
• Lateral Collateral Ligament (LCL), including the posterolateral corner (PLC): It stabilizes the outer side of the knee

A multiligament injury involves two or more of these structures, commonly occurring from sports injuries, falls, vehicle accidents, or knee dislocations. These injuries are rare but severe, often compromising knee stability and function.

Before Surgery: Essential Evaluation and Planning

1. Clinical Assessment and Imaging

A thorough physical exam is critical. The surgeon assesses laxity in all directions—anterior, posterior, varus, valgus—alongside special stability tests to understand which ligaments are compromised.

Imaging includes:

• MRI (Magnetic Resonance Imaging) to visualize soft-tissue damage
• Stress X-rays to assess stability
• Sometimes CT scans to evaluate bone alignment and tunnel planning

This assessment determines which ligaments need reconstruction versus repair and whether a single-stage or staged surgery is most suitable.

2. Counselling and Surgical Planning

Multiligament reconstructions are complicated, and patients should be educated about:

• Expected timeline (often 9–12+ months to full activity)
• Graft options (patient’s own tissue versus donor allograft)
• Risks such as stiffness, incomplete return to sport, and post-operative nerve issues

Planning includes graft choice, fixation methods, and detailed surgical sequencing to avoid tunnel convergence and maximize stability.

Graft Harvesting – Autograft vs Allograft

Surgeons commonly use:

• Autografts: Patient’s own tissue (e.g., hamstring tendons, patellar tendon)
• Allografts: Donor tissue

Each has advantages. Autografts reduce infection and rejection risks, whereas allografts reduce harvest site pain and may shorten surgery time. Graft choice is tailored to patient age, activity level, and surgeon preference.

Step-by-Step Surgical Process

Although specific techniques vary, most experienced surgeons follow these core steps:

1. Examination Under Anesthesia

Before making any incisions, the surgeon examines the knee to confirm ligament laxity and dynamic instability. This ensures accurate planning when the patient is anesthetized and relaxed.

2. Diagnostic Arthroscopy

Using tiny incisions and an arthroscope, the surgeon evaluates:

• Meniscus tears
• Chondral surface damage
• Ligament remnants

This minimally invasive step guides further reconstruction work.

3. Tunnel Preparation

To reconstruct cruciate ligaments, bone tunnels are created in the femur and tibia. These tunnels allow placement of grafts that restore stability.

For ACL: A tunnel is drilled in the femur and tibia following anatomical landmarks to mimic the native ACL pathway.

For PCL: A double-bundle reconstruction may be selected to optimize stability, requiring two tunnels for each bundle. Care is taken to avoid overlapping tunnels from previous operations.

Effective tunnel placement is among the most critical technical aspects, as improper positioning can lead to graft failure or loss of motion.

4. Ligament Graft Passage and Fixation

Once tunnels are drilled, grafts are carefully passed through them and fixed using devices such as screws, buttons, or suspensory fixation systems.

Typical sequence:

• PCL graft (often first)
• ACL graft
• Collateral ligaments or PLC structures as needed

Proper tensioning of each graft is essential to avoid over-constraint or residual laxity.

5. Repair of Other Structures

Associated structures such as menisci or capsule tears may be repaired concurrently to maximize joint stability and improve long-term outcomes.

6. Closure and Dressing

After fixation, the surgeon checks the full range of motion to ensure there is no impingement or instability. Incisions are then closed and sterile dressings applied.

Post-Operative Care and Early Recovery

1. Pain and Swelling Management

Pain relief combines prescribed medications with rest, ice, limb elevation, and gentle movement as tolerated.

2. Immobilization and Weight Bearing

The knee is often braced in extension immediately after surgery. Non-weight bearing with crutches is common for the first several weeks, depending on the ligaments reconstructed.

Rehabilitation – A Critical Component

Phase I: Immediate Post-Op (Week 0–4)

• Protect grafts
• Reduce swelling
• Prevent stiffness
• Initiate gentle quadriceps activation

Phase II: Early Strengthening (Week 4–12)

• Controlled knee flexion and extension
• Light strengthening exercises
• Gradual progression of weight bearing

Phase III: Functional Training (Month 3–6)

• Balance and proprioception
• Strength training
• Sport-specific drills

Phase IV: Return to Sport (Month 9+)

Return to sport is considered only after strength symmetry and functional performance tests are passed.

Common Challenges and How They’re Managed

1. Knee Stiffness

Consistent range of motion exercises and adherence to therapy are essential. Persistent stiffness may require manipulation under anesthesia.

2. Protecting Grafts

Premature aggressive activity can compromise graft integrity, making adherence to medical advice crucial.

Tips to Prevent Multiple Knee Ligament Injury

1. Strengthen the Muscles Around the Knee

Focus on quadriceps, hamstrings, gluteal, and calf muscles to improve stability and shock absorption.

2. Improve Balance and Proprioception

Exercises such as single-leg drills and balance board training reduce injury risk.

3. Learn Proper Movement Techniques

Avoid sudden twisting, land softly, and maintain proper knee alignment.

4. Warm Up and Stretch Before Activity

Dynamic warm-ups prepare muscles and ligaments for high-demand movements.

5. Use Appropriate Footwear and Equipment

Sport-specific shoes and protective equipment enhance knee safety.

6. Avoid Overtraining and Fatigue

Adequate rest and gradual training progression reduce injury risk.

7. Strengthen Core and Hip Muscles

Strong core and hips improve alignment and reduce valgus stress on the knee.

8. Practice Safe Sports Techniques

Controlled play, proper drills, and safe falling techniques reduce trauma.

9. Gradual Return After Injury

Complete rehabilitation and medical clearance are essential before returning to sport.

10. Road Safety and Accident Prevention

Seat belts, helmets, and safe driving significantly reduce high-energy knee injuries.

Why Choose an Expert Orthopedic Team?

Multiligament knee reconstructions require surgical precision, advanced expertise, and customized rehabilitation planning. Experienced centers improve outcomes and minimize complications.

Conclusion

Reconstructing multiple knee ligaments is a meticulously planned surgical journey. With proper evaluation, precise surgical technique, and structured rehabilitation, many individuals can successfully return to active and fulfilling lifestyles. Consulting a specialized orthopedic surgeon is the first step toward optimal recovery.