Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Increased Risk of Revision, Reoperation, and Implant Constraint in TKA After Multiligament Knee Surgery

Steven I. Pancio MD, Paul L. Sousa MD, Aaron J. Krych MD, Matthew P. Abdel MD, Bruce A. Levy MD, Diane L. Dahm MD, Michael J. Stuart MD



The risk of major complications and revision arthroplasty after TKA in patients who previously underwent multiligament knee surgery have been poorly characterized.


Is multiligament knee surgery before TKA associated with (1) worse implant survival, (2) increased use of TKA design constraint, (3) a greater risk for major complications, and (4) poorer scores for pain and function compared with similar patients receiving TKA for primary osteoarthritis?


Fifty-nine TKAs were performed at our institution between 1985 and 2014 in 59 patients (36 men, 23 women; mean age, 53 years) with a history of previous multiligament knee surgery (≥ two ligaments). Of those, we had followup for 39 (66%), 18 (31%), and six (10%) patients at 5, 10, and 15 years, respectively; mean followup was 5.4 years (range, 1–25 years). A two-to-one matched control group consisting of patients undergoing primary TKA for the diagnosis of osteoarthritis was selected for comparison. Patients were matched based on gender, age at primary TKA (within 5 years), and date of the TKA (within 5 years). Medical records were reviewed for survivorship, TKA design, complications (reoperation, revision, infection, manipulation under anesthesia, and periprosthetic joint infection), TKA design, and clinical outcomes (Knee Society Scores [KSS], Knee Society Function Score [KSS-F]).


The overall 15-year revision-free survival in patients with prior multiligament knee surgery was decreased in comparison to the matched controls (42% [95% CI, 16%–73%] vs 94% [95% CI, 81%–99%]; p < 0.001). Varus-valgus constraint implant design was used for more patients in the multiligament cohort at index TKA than in the matched control group (9/59 [15%] vs 0/110 [0%], respectively; odds ratio [OR], 45; 95% CI, 3–781; p = 0.009). Patients with a history of multiligament knee surgery also were at increased risk of reoperation for any cause (14/59 [24%] vs 7/118 [6%]; OR, 5; 95% CI, 2–14; p = 0.001). With the numbers available, there was no difference in the frequency of manipulation under anesthesia after TKA (10% [6/59] versus 3% [4/118]; p = 0.08) A higher proportion of patients in the multiligament cohort had infections develop compared with the matched controls (4/59 [7%] vs 1/118 [< 1%)], respectively; p = 0.04). There was no difference in the KSS improvement after TKA between the multiligament group and the control group (34 ± 18 vs 28 ± 15; p = 0.088). The final KSS and KSS-F scores likewise showed no difference between those groups (88 ± 13 vs 85 ± 10; p = 0.232) (85 ± 17 vs 84 ± 14; p = 0.75).


A history of multiligament surgery is associated with lower long-term survivorship, higher use of constrained TKA designs, and higher risk of major complications, including reoperation and infection. Further research is necessary to determine if a particular multiligamentous surgical technique can prevent posttraumatic arthritis and TKA complications.

Level of Evidence

Level III, therapeutic study.

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