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  • Infographic. Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation

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Infographic. Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation
  1. Iain Robert Murray1,2,
  2. Navnit S Makaram1,2,
  3. Chryssa Neo1,
  4. Andrew G Geeslin3,
  5. Jorge Chahla4,
  6. Gilbert Moatshe5,6,
  7. Kay Crossley7,
  8. Michelle E Kew8,
  9. Aileen Davis9,
  10. Maria Tuca10,
  11. Hollis Potter11,
  12. Dina C Janse van Rensburg12,13,
  13. Carolyn A Emery14,
  14. SeungPyo Eun15,
  15. Hege Grindem6,
  16. Frank R Noyes16,
  17. Robert G Marx8,
  18. Chris Harner17,
  19. Bruce A Levy18,
  20. Enda King19,
  21. James L Cook20,
  22. Daniel B Whelan21,
  23. George F Hatch III22,
  24. Christopher J Wahl23,
  25. Kristian Thorborg24,
  26. James J Irrgang25,
  27. Nicolas Pujol26,
  28. Michael J Medvecky27,
  29. Michael J Stuart28,
  30. Aaron J Krych28,
  31. Lars Engebretsen5,6,
  32. James P Stannard29,
  33. Peter MacDonald30,
  34. Romain Seil31,32,33,
  35. Gregory C Fanelli34,
  36. Travis G Maak35,
  37. K Donald Shelbourne36,
  38. Evert Verhagen37,38,
  39. Volker Musahl39,
  40. Michael T Hirschmann40,
  41. Mark D Miller41,
  42. Robert C Schenck42,
  43. Robert F LaPrade43
  44. The MLKI International Expert Working Group
  1. 1 Edinburgh Orthopaedics, Edinburgh, UK
  2. 2 University of Edinburgh, Edinburgh, UK
  3. 3 University of Vermont Medical Center, Burlington, Vermont, USA
  4. 4 Rush University, Chicago, Illinois, USA
  5. 5 Orthopaedic Division, Oslo University Hospital, Oslo, Norway
  6. 6 Oslo Sports Trauma Research Center, Oslo, Norway
  7. 7 La Trobe University—Bundoora Campus, Bundoora, Victoria, Australia
  8. 8 Hospital for Special Surgery - Weill Cornell Medical Center, New York, New York, USA
  9. 9 University of Toronto, Toronto, Ontario, Canada
  10. 10 Pontificia Universidad Catolica De Chile School of Medicine, Santiago, Chile
  11. 11 Weill Cornell Medical College, New York, New York, USA
  12. 12 Section Sports Medicine, University of Pretoria Faculty of Health Sciences, Pretoria, Gauteng, South Africa
  13. 13 Medical Advisory Panel, World Netball Foundation, Manchester, UK
  14. 14 Sport Injury Prevention Research Centre, Faculty of Kinesiology and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  15. 15 Dr. Eun's Korea Orthopedic Clinic, Seoul, Korea (the Republic of)
  16. 16 Department of Orthopedic Surgery, Mercyhealth-Cincinnati Sports Medicine and Orthopedics, Cincinnati, Ohio, USA
  17. 17 Office of Health Technology 6, Office of Orthopedic Devices at the FDA, Silver Spring, Maryland, USA
  18. 18 Jewett Orthopedic Institute, Orlando Health, Orlando, Florida, USA
  19. 19 Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  20. 20 Mizzou Joint & Limb Preservation Center, University of Missouri Missouri Orthopaedic Institute, Columbia, Missouri, USA
  21. 21 St Michael's Hospital, Toronto, Ontario, Canada
  22. 22 USC Keck School of Medicine, Los Angeles, California, USA
  23. 23 Surgical Sports Medicine and Trauma, Proliance Orthopedics & Sports Medicine, Seattle, Washington, USA
  24. 24 Department of Orthopedic Surgery, Copenhagen University Hospital, Rødovre, Denmark
  25. 25 School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  26. 26 Department of Orthopedics, Centre Hospitalier de Versailles, Le Chesnay, Île-de-France, France
  27. 27 Section of Sports Medicine, Department of Orthopedics & Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
  28. 28 Mayo Clinic, Rochester, Minnesota, USA
  29. 29 University of Missouri School of Medicine, Columbia, Missouri, USA
  30. 30 University of Manitoba, Winnipeg, Manitoba, Canada
  31. 31 Department of Orthopaedic Surgery, Centre Hopsitalier de Luxembourg—Clinique d'Eich, Luxembourg, Luxembourg
  32. 32 Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg
  33. 33 Human Motion, Orthopaedics, Sports Medicine and Digital Methods (HOSD), Luxembourg Institute of Health (LIH), Luxembourg, Luxembourg
  34. 34 Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
  35. 35 University of Utah Health, Salt Lake City, Utah, USA
  36. 36 Shelbourne Knee Center, Community Hospital East, Indianapolis, Indiana, USA
  37. 37 Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam, Netherlands
  38. 38 Movement Sciences, Amsterdam, University Medical Centres – Vrije Universiteit Amsterdam, Amsterdam, Netherlands
  39. 39 Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  40. 40 Department of Orthopaedic Surgery and Traumatology, Kantonssspital Baselland, Bruderholz, Switzerland
  41. 41 Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia, USA
  42. 42 Department of Orthopedic Surgery and Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
  43. 43 Orthopedic Surgery, Twin Cities Orthopedics Edina-Crosstown, Edina, Minnesota, USA
  1. Correspondence to Robert F LaPrade; laprademdphd{at}gmail.com

https://doi.org/10.1136/bjsports-2024-109051

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    Multiligament knee injuries (MLKIs) represent a heterogeneous spectrum of pathology. Clinical evaluation, diagnosis and management of these injuries remains controversial. In order to assess the existing literature evaluating the diagnosis and management of MLKIs, we performed a scoping review1 based on established methodology.2 3 This process established that the majority of the 417 articles identified relating to MLKI were composed of small retrospective studies, 30% were composed of narrative reviews presenting no original data and only 1% of articles represented level 1 evidence.1 Overall, 70% of included studies were published within the last 12 years, with over half (57%) originating from the USA.1 The lack of diversity within author and patient groups that comprise MLKI research was highlighted. Consistently contentious themes within MLKI management were highlighted, including nomenclature, choice of imaging, timing of surgical intervention, operative versus non-operative management and strategies for rehabilitation. Most importantly, this study highlighted a lack of current consensus on an accepted approach within multiple domains of management of MLKI.

    Infographic summarising the recently published international consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for the care of patients with MLKI.

    The findings of this scoping review led the author group to seek an international consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for the care of patients with MLKI, while also identifying important research priorities.4 An international, multidisciplinary consensus process was conducted, involving 39 experts in MLKI care from 14 countries, employing validated Delphi methodology.5 6 Specific attention was given to achieving a diverse, representative expert group using objective and reproducible methodology. In total, 50 items (92.6%) achieved consensus with >75% agreement and <10% disagreement, which were included in the final consensus document. Key recommendations included a consensus definition for MLKI : ‘a traumatic high-grade partial or …

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    Footnotes

    • X @MurraySportOrth, @makortho, @theladypod, @GilbertMoatshe, @kaymcrossley, @CarolynAEmery, @Hegegrindem, @enda_king, @larsengebretsen, @Evertverhagen

    • Contributors IRM and NM: conceptualisation, methodology, formal analysis, data curation, writing—original draft, writing—review and editing. RFL: conceptualisation, writing—review and editing, supervision. AG, JC, GM, KMC, MEK, AD, MT, HP, DCJvR, CAE, SE, HG, FRN, RGM, CH, BL, EK, JLC, DBW, GFH III, CJW, KT, JJI, NP, MM, MS, AJK, LE, JPS, PM, RS, GCF, TGM, KDS, EV, VM, MTH, MDM and RCS: writing—review and editing. RFL is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests IRM reports the following disclosures: Arthrex: paid consultant. Bone and Joint Research: editorial or governing board. Journal of Bone and Joint Surgery British: editorial or governing board. Stryker: paid consultant. AG reports the following disclosures: American Orthopaedic Society for Sports Medicine: board or committee member. Arthroscopy: editorial or governing board, Infographics Editor. Ossur: paid presenter or speaker. Smith & Nephew: paid consultant; paid presenter or speaker. JC reports the following disclosures: American Orthopaedic Society for Sports Medicine: board or committee member. Arthrex: paid consultant. Arthroscopy Association of North America: board or committee member. CONMED Linvatec: paid consultant. International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine: board or committee member. Ossur: paid consultant. Smith & Nephew: paid consultant. GM reports the following disclosures: Smith & Nephew: paid consultant. IBSA: paid consultant. International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine: board or committee member. Arthroscopy: editorial board. JBJS: editorial Board. RFL reports the following disclosures: American Journal of Sports Medicine: editorial or governing board. American Orthopaedic Society for Sports Medicine: board or committee member. Arthrex: IP royalties. International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine: board or committee member. Journal of Experimental Orthopaedics: editorial or governing board. Knee Surgery, Sports Traumatology, Arthroscopy: editorial or governing board. Ossur: IP royalties; paid consultant; research support. Smith & Nephew: IP royalties; paid consultant; research support. Journal of Knee Surgery: editorial or governing board. Orthopaedic techniques in Sports Medicine: editorial or governing board. JJI reports the following disclosures: receives funding as PI from Department of Defense Congressionally Directed Medical Research Programme Peer-Reviewed Orthopaedic Research Programme for the Surgical Timing and Rehabilitation (STaR) Trial for Multiple Ligament Knee Injuries (MLKIs): A Multicenter Integrated Clinical Trial (W81XWH-17-2-0073) and serves as President, Board of Directors for Movement Science Media/Journal of Orthopaedic and Sports Physical Therapy. GM reports the following disclosures: Smith & Nephew, IBSA: Consultant. ISAKOS: committee memberJBJS and arthroscopy: Editorial. BoardSmith & Nephew: fellowship funding. GFH III reports the following disclosures: Arthrex: consultant. MS reports the following disclosures: Arthrex: consultant and Royalties Stryker, USA Hockey Foundation: Research Funding. MEK reports the following disclosures: AANA: Research committee. AOSSM: Enduring Education committee Arthrex, Smith and Nephew: education funds. PM reports the following disclosures: Arthrex and Conmed: Consultant Arthrex, Conmed, Zimmer Biomet, Smith and Nephew, Ossur: research and fellowship support. KC reports the following disclosures: BJSM: Senior advisor. BL reports the following disclosures: Arthrex: Consultant and Royalties. JKS and KSSTA: editorial board. MM reports the following disclosures: Smith and Nephew: paid speaker. KT reports the following disclosure: deputy editor: BJSM. TGM reports the following disclosures: Arthrex: Speaker, Consultant. CORR: editorial board. EV reports the following disclosures: associate editor: BJSM Editor-in-Chief: BMJ Open SEM. AJK reports the following disclosures: Arthrex: Consultant, IP royalties, JRF Orthopaedics, Vericel, Responsive Arthroscopy: Consulting fees. DJO: Grants Musculoskeletal Transplant Foundation: Board of Trustees. RCS reports the following disclosures: Arthrex: education editorial board: AJSM and JBJSJPS reports the following disclosures: Thieme: Publishing Royalties DePuy: consulting fees/teaching courses Arthrex: consulting fees/teaching courses AO NA: research support, teaching and travel support. AO Foundation—teaching/travel support. Journal of Knee Surgery—Editor-In-Chief. CE reports the following disclosures: Canadian Institutes of Health Research, Canada Foundation for Innovation, Canada Research Chairs Programme and National Football League Play Smart Play Safe Programme: peer-reviewed research support. Associate Editor: BJSM. External Advisory Board: HitIQ Chairperson: Sport injury Prevention Research Centre, an IOC Research Centre for Prevention of Injury and Protection of Athlete Health. HG reports the following disclosures: associate editor: BJSM, JOSPT. RGM reports the following disclosures: mend nutrition. Royalties from Springer and Demos for books. JLC reports the following disclosures: AANA: research support. AO trauma: research support. Arthrex: IP royalties; paid consultant; research support. Bioventus: paid consultant. Boehringer Ingelheim: paid consultant. Collagen Matrix: paid consultant; research support. GE healthcare: research support Journal of Knee Surgery: editorial or governing board. Midwest Transplant Network: board or committee member. Musculoskeletal Transplant Foundation: board or committee member; IP royalties; research support. National Institutes of Health (NIAMS & NICHD): research support. OREF: research support. Orthopaedic Trauma Association: research support. PCORI: research support. Regenosine: research support. SITES Medical: research support Thieme: publishing royalties, financial or material support. Trupanion: paid consultant. VM reports the following disclosures: Smith & Nephew, Newclip: Consultant Ostesys: Shareholder Arthrex, Smith & Nephew: educational grants. ISAKOS: board or committee member. KSSTA: Deputy Editor-In-Chief. MTH reports the following disclosures: Knee Surgery Sports Traumatology Arthroscopy (KSSTA): Deputy Editor-In-Chief. APKASS journal, MLT journal, Arthroskopie, Das Knie (DKG), board or committee member. European Knee Associates (EKA): Past Chairman. ESSKA Milan 2020 and 2021: Scientific Chairman. ISAKOS: Arthroplasty Committee, ESSKA: Cartilage Committee. German Knee Society: board or committee member. Personalized Arthroplasty Society (PAS): 2nd vice president DepuySynthes, Smith & Nephew, Symbios, Medacta: Consultant DepuySynthes, Finceramica, Symbios, Mathys, Arthrex, SIWF, Deutsche Arthrose-Hilfe, Bangerter-Rhyner-Stiftung: research grants. NM, HP, SPE, KDS, CJW, FRN, MT, DCJvR, EK, DBW, MDM, GCF, CH, LE, RS and NP report no competing interests.

    • Provenance and peer review Not commissioned; externally peer reviewed.