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Review
. 2021 Jun 23;9(6):23259671211010409.
doi: 10.1177/23259671211010409. eCollection 2021 Jun.

Incidence of Associated Lesions of Multiligament Knee Injuries: A Systematic Review and Meta-analysis

Seong Hwan Kim  1   2 , Yong-Beom Park  2 , Boo-Seop Kim  3 , Dong-Hoon Lee  3 , Nicolas Pujol  1
Affiliations
Review

Incidence of Associated Lesions of Multiligament Knee Injuries: A Systematic Review and Meta-analysis

Seong Hwan Kim et al. Orthop J Sports Med. .

Abstract

Background: The incidence of concomitant injuries, including meniscal and cartilage injuries, has not been adequately reported in previous studies on multiligament knee injury (MLKI) because their primary focal points have been the degree of ligament injury, treatment strategy, involvement of other soft tissues, and neurovascular injury.

Purpose: To analyze the incidence of associated lesions in MLKIs, including medial and lateral meniscal injuries, cartilage lesions, and complications.

Study design: Systemic review; Level of evidence, 4.

Methods: The PubMed, Embase, Cochrane Library, CINAHL, and Scopus databases were searched between inception and April 30, 2020. Studies were included if they reported the incidence rates of medial and/or lateral meniscal tears and cartilage injuries in cases of MLKIs. For the meta-analysis, data were extracted on clinical outcomes measured according to the number of medial and/or lateral meniscal tears, cartilage injuries, and complications.

Results: A total of 45 studies were included in the MLKI analysis (3391 patients). The pooled rate of medial meniscal tears was 30.4% (95% CI, 24.1%-37.1%; P < .0001; I 2 = 85.8%). The pooled rate of lateral meniscal tears was 27.5% (95% CI, 20.3%-35.3%; P < .0001; I 2 = 89.6%). The pooled rate of cartilage injuries was 27.5% (95% CI, 22.1%-33.3%; P < .0001; I 2 = 86.8%). The pooled rates of peroneal nerve injuries, vascular injuries, and arthrofibrosis were 19.2% (95% CI, 14.2%-24.7%; P < .001; I 2 = 81.3%), 18.4% (95% CI, 13.2%-24.3%; P < .0001; I 2 = 81.0%), and 11.2% (95% CI, 8.1%-14.7%; P = .0018; I 2 = 54.0%), respectively.

Conclusion: The pooled rates of meniscal tears and cartilage injuries concomitant with MLKIs were high, ranging from 27% to 30%, and the pooled rates of peroneal nerve injury, vascular injury, and arthrofibrosis were considerable, ranging from 11% to 19%. The influence of these associated lesions on clinical results should be evaluated in future clinical studies.

Keywords: anterior cruciate ligament; cartilage; meniscus; meta-analysis; multiligament knee injury; outcomes.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: This research was supported by a research grant from Chung-Ang University (2019). N.P. has received educational consulting fees from Smith & Nephew, LimaCorporate, Stryker, and Zimmer Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flow diagram of the article selection process using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MLKI, multiligament knee injury.
Figure 2.
Figure 2.
Proportional forest plot with 95% CIs for medial meniscal tears in multiligament knee injuries. The squares represent the results of each study. The ends of the horizontal bars represent 95% CIs. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 30.4% with substantial heterogeneity (95% CI, 24.1%-37.1%; P < .0001; I 2 = 85.8%).
Figure 3.
Figure 3.
Proportional forest plot with 95% CIs for lateral meniscal tears in multiligament knee injuries. The squares represent the results of each study. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 27.5% with substantial heterogeneity (95% CI, 20.3%-35.3%; P < .0001; I 2 = 89.6).
Figure 4.
Figure 4.
Proportional forest plot with 95% CIs for concomitant cartilage injury in multiligament knee injuries. The squares represent the results of each study. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 27.5% with substantial heterogeneity (95% CI, 22.1%-33.3%; P < .0001; I 2 = 86.8%).
Figure 5.
Figure 5.
Proportional forest plot with 95% CIs for peroneal nerve injury in multiligament knee injuries. The squares represent the results of each study. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 19.2% with substantial heterogeneity (95% CI, 14.2%-24.7%; P < .001; I 2 = 81.3%).
Figure 6.
Figure 6.
Proportional forest plot with 95% CIs for vascular injuries concomitant with multiligament knee injuries. The squares represent the results of each study. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 18.4% with substantial heterogeneity (95% CI, 13.2%-24.3%; P < .0001; I 2 = 81.0%).
Figure 7.
Figure 7.
Proportional forest plot with 95% CIs for arthrofibrosis in multiligament knee injuries. The squares represent the results of each study. The diamond denotes the overall pooled proportion from all studies. The pooled proportion was 11.2% with substantial heterogeneity (95% CI, 8.1%-14.7%; P = .0018; I 2 = 54.0%).
Figure A1.
Figure A1.
Funnel plots for publication bias in the studies on multiligament knee injury (MLKI). No evidence of asymmetry was found: (A) medial meniscal injury (P = .062), (B) lateral meniscal injury (P = .103), (C) cartilage injury (P = .198), (D) peroneal nerve injury in MLKI group (P = .371), (E) vascular injury in MLKI group (P = .069), and (F) arthrofibrosis (P = .073).
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