{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T09:49:38Z","timestamp":1777024178579,"version":"3.51.4"},"reference-count":27,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T00:00:00Z","timestamp":1776384000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Reports"],"abstract":"<jats:p>Background and Clinical Significance: Multiligamentous knee injuries (MLKIs) are uncommon but severe injuries associated with instability, neurovascular compromise, and long-term functional impairment. Irreducible knee dislocations are a distinct subgroup requiring urgent intervention because soft-tissue interposition may prevent closed reduction and place the limb at risk of skin necrosis and vascular compromise. This report reviews current concepts in MLKI management and presents a complex KD-IV irreducible knee dislocation treated with a staged surgical strategy. Case Presentation: A 56-year-old woman presented 24 h after a skiing injury with a grossly deformed knee, multidirectional instability, and an anteromedial \u201cpucker sign\u201d. Magnetic resonance imaging demonstrated a KD-IV injury with complete rupture of the anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament, associated with capsular disruption and intra-articular soft-tissue interposition causing irreducibility. Urgent open reduction was performed. The first stage included reduction of the incarcerated capsule, capsular repair, and reconstruction of the posteromedial corner and medial collateral ligament using a semitendinosus autograft. Delayed reassessment at 6 months demonstrated satisfactory stability, minimal residual anterior laxity, and no subjective instability; therefore, anterior cruciate ligament reconstruction was not performed. At final follow-up, the patient had near-full range of motion, no significant valgus instability, and no arthrofibrosis or vascular complications. Conclusions: Management of MLKIs should be individualized according to reducibility, soft-tissue condition, neurovascular status, and functional demands. Irreducible KD-IV dislocations with a pucker sign require urgent open reduction. In selected patients, staged reconstruction may reduce postoperative stiffness and allow selective omission of cruciate ligament reconstruction when satisfactory functional stability is achieved.<\/jats:p>","DOI":"10.3390\/reports9020123","type":"journal-article","created":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T16:30:36Z","timestamp":1776443436000},"page":"123","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Surgical Management of Multi-Ligamentous Knee Injuries: Current Concepts and Case Report of a Complex KD-IV Case"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-8280-5222","authenticated-orcid":false,"given":"Simone","family":"Giusti","sequence":"first","affiliation":[{"name":"Complex Operational Unit of Sports Medicine and Joint Reconstruction, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Geriatrics, Orthopaedics, and Rheumatology, Universit\u00e0 Cattolica del Sacro Cuore, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9966-1379","authenticated-orcid":false,"given":"Edoardo","family":"De Fenu","sequence":"additional","affiliation":[{"name":"Complex Operational Unit of Sports Medicine and Joint Reconstruction, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Geriatrics, Orthopaedics, and Rheumatology, Universit\u00e0 Cattolica del Sacro Cuore, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Simona","family":"Cerulli","sequence":"additional","affiliation":[{"name":"Complex Operational Unit of Sports Medicine and Joint Reconstruction, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Geriatrics, Orthopaedics, and Rheumatology, Universit\u00e0 Cattolica del Sacro Cuore, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ezio","family":"Adriani","sequence":"additional","affiliation":[{"name":"Complex Operational Unit of Sports Medicine and Joint Reconstruction, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy"},{"name":"Department of Geriatrics, Orthopaedics, and Rheumatology, Universit\u00e0 Cattolica del Sacro Cuore, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1108","DOI":"10.5435\/JAAOS-D-21-00830","article-title":"Multiligamentous knee injuries: Acute management, associated injuries, and anticipated return to activity","volume":"30","author":"Smith","year":"2022","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1097\/JSA.0000000000000274","article-title":"Results of treatment of the multiple ligament injured (dislocated) knee","volume":"28","author":"James","year":"2020","journal-title":"Sports Med. Arthrosc. Rev."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/j.arthro.2009.01.008","article-title":"Decision making in the multiligament-injured knee: An evidence-based systematic review","volume":"25","author":"Levy","year":"2009","journal-title":"Arthroscopy"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1051\/sicotj\/2021058","article-title":"Current concepts in the assessment and management of multiligament injuries of the knee","volume":"7","author":"Scheepers","year":"2021","journal-title":"SICOT J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1385","DOI":"10.1136\/bjsports-2024-108089","article-title":"Multiligament knee injury (MLKI): An expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation","volume":"58","author":"Murray","year":"2024","journal-title":"Br. J. Sports Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"607","DOI":"10.2106\/JBJS.20.02051","article-title":"STaR Trial for Multiple Ligament Knee Injuries Network. Presentation and surgical management of multiple ligament knee injuries: A multicenter study from the Surgical Timing and Rehabilitation (STaR) Trial for MLKIs Network","volume":"105","author":"Poploski","year":"2023","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1055\/s-0039-1695739","article-title":"Multiple ligament knee injuries: Does the knee dislocation classification predict the type of surgical management?","volume":"34","author":"Maxwell","year":"2021","journal-title":"J. Knee Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"35825","DOI":"10.52965\/001c.35825","article-title":"An evidence-based approach to multi-ligamentous knee injuries","volume":"14","author":"Fortier","year":"2022","journal-title":"Orthop. Rev."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"bcr2013201279","DOI":"10.1136\/bcr-2013-201279","article-title":"\u201cPucker sign\u201d an indicator of irreducible knee dislocation","volume":"2013","author":"Jeevannavar","year":"2013","journal-title":"BMJ Case Rep."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e23.00149","DOI":"10.5435\/JAAOSGlobal-D-23-00149","article-title":"Successful management of impending skin necrosis after a posterolateral knee dislocation","volume":"8","author":"Santos","year":"2024","journal-title":"JAAOS Glob. Res. Rev."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1007\/s00590-023-03781-x","article-title":"Irreducible knee dislocation: Improved clinical outcomes of open and arthroscopic surgical treatment. A systematic review of the literature","volume":"34","author":"Giustra","year":"2024","journal-title":"Eur. J. Orthop. Surg. Traumatol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1903","DOI":"10.2106\/JBJS.23.00795","article-title":"Early compared with delayed reconstruction in multiligament knee injury: A retrospective propensity analysis","volume":"106","author":"Hoit","year":"2024","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"5117","DOI":"10.1007\/s00402-022-04730-9","article-title":"Arthrofibrosis is a common but poorly defined complication in multiligament knee injuries: A systematic review","volume":"143","author":"Fahlbusch","year":"2023","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"4448","DOI":"10.1007\/s00167-023-07514-9","article-title":"Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: A systematic review and meta-analysis","volume":"31","author":"Dadoo","year":"2023","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"23259671241252870","DOI":"10.1177\/23259671241252870","article-title":"Outcomes after single-stage anatomic multiligament knee reconstruction with early range of motion in adolescents","volume":"12","author":"Willimon","year":"2024","journal-title":"Orthop. J. Sports Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1007\/s43465-024-01318-w","article-title":"Graft options for the reconstruction of multi-ligament knee injury: A systematic review","volume":"59","author":"Amit","year":"2025","journal-title":"Indian J. Orthop."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1238","DOI":"10.1007\/s00167-020-06171-6","article-title":"Clinical studies of single-stage combined ACL and PCL reconstruction variably report graft tensioning, fixation sequence, and knee flexion angle at time of fixation","volume":"29","author":"Fayed","year":"2021","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"23259671221118587","DOI":"10.1177\/23259671221118587","article-title":"No difference in knee kinematics between anterior cruciate ligament-first and posterior cruciate ligament-first fixation during single-stage multiligament knee reconstruction: A biomechanical study","volume":"10","author":"Fayed","year":"2022","journal-title":"Orthop. J. Sports Med."},{"key":"ref_19","first-page":"97","article-title":"Posterolateral corner of the knee: Current concepts","volume":"3","author":"LaPrade","year":"2015","journal-title":"Arch. Bone Jt. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S371","DOI":"10.1016\/j.otsr.2014.09.010","article-title":"Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: A systematic review","volume":"100","author":"Rochecongar","year":"2014","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e29","DOI":"10.1016\/j.asmr.2021.08.020","article-title":"Postoperative rehabilitation and return to sport following multiligament knee reconstruction","volume":"4","author":"Monson","year":"2022","journal-title":"Arthrosc. Sports Med. Rehabil."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1097\/JSA.0b013e31821918b2","article-title":"Rehabilitation after multiple-ligament reconstruction of the knee","volume":"19","author":"Edson","year":"2011","journal-title":"Sports Med. Arthrosc. Rev."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1548","DOI":"10.1007\/s43465-024-01237-w","article-title":"Return to sport after multiligament knee injury: A systematic review of the literature","volume":"58","author":"Meena","year":"2024","journal-title":"Indian J. Orthop."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Li, T., Xiong, Y., Zhang, Z., Tang, X., Chen, G., Li, Q., Fu, W.L., and Li, J. (2021). Results of multiple ligament reconstruction after knee dislocation\u2014A prospective study with 95 patients and minimum 2-year follow up. BMC Musculoskelet. Disord., 22.","DOI":"10.1186\/s12891-021-04596-9"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"379","DOI":"10.13107\/jocr.2026.v16.i01.6706","article-title":"Evaluating surgical strategies and functional outcomes in multi-ligamentous knee injuries: A prospective study in Indian patients","volume":"16","author":"Mehta","year":"2026","journal-title":"J. Orthop. Case Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2325967121994203","DOI":"10.1177\/2325967121994203","article-title":"Risk factors associated with complications after operative treatment of multiligament knee injury","volume":"9","author":"Patel","year":"2021","journal-title":"Orthop. J. Sports Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/j.arthro.2021.05.027","article-title":"Intraoperative and early (90-day) postoperative complications and associated variables with multiligamentous knee reconstruction: 15-year experience from a single academic institution","volume":"38","author":"Axibal","year":"2022","journal-title":"Arthroscopy"}],"container-title":["Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2571-841X\/9\/2\/123\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T08:56:19Z","timestamp":1777020979000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2571-841X\/9\/2\/123"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,17]]},"references-count":27,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["reports9020123"],"URL":"https:\/\/doi.org\/10.3390\/reports9020123","relation":{},"ISSN":["2571-841X"],"issn-type":[{"value":"2571-841X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,17]]}}}