Objectives: Historically, combined ligament injuries of the knee have been considered career ending for elite athletes. The objective of this paper was to assess an approach to treatment that consisted of reconstructing cruciate ligament injuries and repairing and reconstructing collateral ligament injuries in elite athletes.
A retrospective assessment of all elite athletes (professionals or amateurs at a national level) who had sustained a combined ligament knee injury in the period February 2001 to December 2015 was performed. Cases with a minimum of 2 ligaments needing surgery were included (of note, all medial collateral ligament (MCL) injuries were grade 3). The minimum follow up was 2 years. The outcomes recorded were: return to play or not, level of play returned to, time to return to play, and complications. This data was available in 100% of cases.
118 elite athletes underwent multiple ligament knee surgery during this period and a mean age of 24.6 +/- 4.4 years old.
104 (88.1%) of athletes returned to play at an elite level. ACL and PCL based injuries returned at a similar rate (88.8% vs 92.3%, p=1.00) although those with PCL based injuries took longer to RTP (16.0 vs. 11.8 months, p=0.004). Bicruciate injuries were slowest to RTP after surgery (16.7 vs. 12.4 months , p=0.007); but were able to return at a similar rate compared to unicruciate injuries (12 of 15 80% vs. 91 of 102 89.2%, p=0.386). Medial and lateral sided injuries had similar RTP rates (41 of 46 89.1% vs. 53 of 60 88.3%, p = 1.00) though lateral sided injuries took longer before returning to play after surgery (13.5 vs. 11.2 months, p = 0.020).
Further surgery was required in 45 (38.1%) patients. 34 (28.7%) underwent one further procedure at an average of 8.4 ± 5.9 months post primary reconstruction. 11 patients required 2 or more subsequent procedures with the first procedure undertaken at an average of 3.1 ± 1.8 months after reconstruction. These procedures included 21 (18.3%) manipulations under anaesthesia (MUA), 11 (9.6%) debridements including 2 cyclops lesion excisions, 9 (7.8%) cases of hardware removal, 7 (6.1%) partial meniscectomies, one (0.9%) revision lateral meniscal repair and one osteochondral allograft procedure.
By restoring joint congruity through a combination of anatomic ligament repair and biomechanically effective reconstructions that allow for early rehabilitation, high rates of return to play can be achieved in elite athletes with multiple ligament knee injuries.