Use of Internal Bracing in Multi-ligamentous Knee Injury Reconstruction: A Systematic Review.

Background: Multi-ligament Knee Injuries (MLKI) are often caused by a high-energy impact resulting in dislocation of the knee joint. Given the higher degree of instability associated with these MLKIs, surgical fixation with adjunctive internal bracing and the use of suture augmentation have been proposed with the intention of better restoring knee stability and improving the long-term outcomes of surgery. This systematic review seeks to appraise the current literature in relation to the role of internal bracing in the management of MLKI. Methods: All randomised control trials, observational studies, cohort studies, and cross-sectional studies containing patients with multi-ligamentous knee injuries managed with the use of internal bracing or suture tape augmentation were included in this review. The primary outcomes of interest were re-operation and failure rates, with secondary outcomes focussed on patient-reported outcome measures (PROMs) and examination findings of knee stability. Results: 282 studies were identified for screening, 13 of which were suitable for inclusion and five of these had injuries with Schenck grade III or above. Of the studies identified, failure rates ranged from 0 to 13.6%. Lysholm score was the most commonly utilised PROM tool with scores ranging from 61.8 to 95. Stiffness requiring MUA ± adhesiolysis was a common complication identified across studies. Conclusions: The use of internal bracing in Multi-ligament Knee Injuries appears to be as effective as not using an internal bracing technique. The post-operative PROMs and relatively low failure rates reflect promising outcomes for the ongoing use of internal bracing in MLKI. However, further prospective studies directly comparing braced versus non-braced ligamentous repairs are required in order to definitively determine if the use of the internal brace does allow for increased joint stability and early rehabilitation.