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126

J Gandhara Med Dent Sci

October - December 2026

How to cite this article

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FUNCTIONAL OUTCOMES AFTER MULTILIGAMENT KNEE RECONSTRUCTION

AT A TERTIARY CARE HOSPITAL

Jawad Farooq

1

, Awal Hakeem

2

, Kashif Wakil

3

, Khalil Ur Rehman

4

, Arsalan Shah Roghani

3

, Muhammad Tufail

4

,

Imran Khan

5

ABSTRACT

OBJECTIVES

The

study

aimed

to

determine

short-term

functional

outcomes

after

multiligament

knee

reconstruction

and

identify

factors

associated

with

satisfactory recovery.

METHODOLOGY

This

observational

study

with

three-month

follow-up

included

142

patients

aged

20-70

years

with

magnetic

resonance

imaging-conrmed

injury

to

at

least two major knee ligaments at Khyber Teaching Hospital, Peshawar, from

October

2025

to

April

2026.

Patients

underwent

surgical

repair

and/or

reconstruction

according

to

injury

pattern,

followed

by

departmental

rehabilitation.

We

assessed

functional

outcome

at

three

months

using

the

Lysholm knee score and categorised it as excellent, good, fair, or poor. We

examined

associations

using

chi-square

or

exact

tests,

and

used

binary

logistic

regression

to

identify

independent

predictors

of

excellent/good

outcome.

RESULTS

Mean

age

was

36.17

±

12.37

years,

and

104

(73.2%)

patients

were

male.

Road

trac

accidents

accounted for

74 (52.1%)

injuries.

The

mean

three-

month

Lysholm

score

was

81.56

±

11.89.

Outcomes

were

excellent

in

29

(20.4%),

good

in

48

(33.8%),

fair

in

50

(35.2%),

and

poor

in

15

(10.6%)

patients;

77 (54.2%) therefore achieved a

satisfactory outcome.

Functional

outcome

was

associated

with

age,

body

mass

index,

timing

of

surgery,

number of ligaments involved, and meniscal injury. Delayed surgery beyond

14 days, greater ligament involvement, increasing age, and higher body mass

index independently reduced the odds of satisfactory recovery.

CONCLUSION

Multiligament knee reconstruction produced satisfactory short-term function

in

more

than

half

of

patients.

Earlier

management,

careful

assessment

of

injury

complexity,

weight

optimisation,

and

structured

rehabilitation

may

improve recovery, although longer-term multicentre evaluation is required.

KEYWORDS:

Multiligament

Knee

Injury;

Knee

Reconstruction;

Lysholm

Score; Functional Outcome; Anterior Cruciate Ligament; Posterior Cruciate

Ligament

Farooq J, Hakeem A, Wakil

K,

Rehman

KU,

Roghani

AS,

Tufail

M,

et al. Functional Outcomes After

Multiligament Knee Reconstruction at

a Tertiary Care Hospital. J Gandhara

Med Dent Sci.

2026;13(4):126-132.

Date of Submission:

09-06-2026

Date Revised:

10-09-2026

Date Acceptance:

10-09-2026

2

Associate Professor, Department

of

Trauma and Orthopedic, Khyber

Teaching Hospital, Peshawar

3

Trainee Medical Ofcer, Department

of Trauma and Orthopedic, Khyber

Teaching Hospital, Peshawar

4

Postgraduate Resident, Department of

Trauma and Orthopedic, Khyber

Teaching Hospital, Peshawar

Correspondence

1

Jawad Farooq, Resident, Department

of Trauma and Orthopedic, Khyber

Teaching Hospital, Peshawar

+92-345-9351940

Javadfarooq484@gmail.com

INTRODUCTION

Multiligament

knee

injury

involves

disruption

of

at

least two major stabilising ligaments and represents one

of the more complex problems in orthopaedic trauma.

Injury

may

involve

the

ligament

(ACL),

posterior

cruciate

ligament

(PCL),

medial

collateral

ligament

(MCL),

lateral

collateral

ligament

(LCL),

or

the

posteromedial

and

posterolateral

stabilising structures. These injuries may occur with or

without

frank

knee

dislocation

and

are

frequently

accompanied by meniscal tears, chondral damage, soft-

tissue

injury,

and

neurovascular

compromise.

1,2,3,4

Without

adequate

stabilisation

and

rehabilitation,

patients

may

experience

persistent

instability,

pain,

stiness, impaired mobility, diculty returning to work

or

sport,

and

later

post-traumatic

osteoarthritis.

1,2,5

High-energy

road

trac

trauma,

falls,

and

sporting

injuries

are

common

mechanisms.

Initial

management

requires

more

than

conrming

ligament

disruption:

assess

vascular

status,

peroneal-nerve

function,

associated

fractures,

soft-tissue

condition,

and

the

possibility

of

occult

knee dislocation systematically.

3,4

MRI is valuable for characterising the ligament pattern

and associated intra

-

articular pathology, while operative

planning

depends

on

injury

chronicity,

tissue

quality,

patient

factors,

and

the

structures

requiring

repair

or

reconstruction.

Operative

management

is

generally

favoured

for

active

patients

with

clinically

important

ORIGINAL ARTICLE

http://doi.org/10.37762/jgmds.13-4.953

5

Registrar, Department of Trauma and

Orthopedic, Khyber Teaching Hospital,

Peshawar

127

J Gandhara Med Dent Sci

October - December 2026

multiligament

instability,

although

treatment

must

be

individualised.

Cruciate

ligaments

are

commonly

reconstructed,

whereas selected collateral injuries may

be repaired or reconstructed depending on tissue quality

and timing. Functional recovery depends on more than

the

technical

reconstruction

itself.

Age,

body

mass

index, injury severity, associated meniscal or cartilage

injury,

rehabilitation

adherence,

and

the

interval

between

injury

and

denitive

surgery

may

all

aect

outcome.

5,6,7

The

optimal

timing

of

reconstruction

remains

debated.

Early

stabilisation

may

restore

joint

congruity,

limit

recurrent

instability,

and

facilitate

rehabilitation,

but

surgery

performed

in

an

acutely

inamed or poorly mobile knee can increase the risk of

stiness

and

arthrobrosis.

Systematic

reviews

have

not established one universally superior timing strategy

for

all

injury

patterns;

soft-tissue

recovery,

vascular

status,

range

of

motion,

associated

injuries,

and

rehabilitation readiness should therefore guide decision-

making.

8,9,10

This uncertainty is particularly relevant in

settings

where

delayed

referral

and

limited

access

to

specialised

rehabilitation

are

common.

Evidence

from

Pakistan

on

functional

recovery

after

multiligament

knee

reconstruction

remains

limited.

Local

trauma

patterns,

delay

in

presentation,

socioeconomic

constraints,

and

rehabilitation

access

may

dier

from

those

reported

in

specialised

sports-medicine

cohorts.

The

present

study

therefore

evaluated

three-month

functional

outcomes

using

the

Lysholm

knee

score

among

patients

treated

at

Khyber

Teaching

Hospital,

Peshawar.

It

examined

whether

age,

BMI,

injury

timing,

ligament

complexity,

and

associated

intra-

articular

injury

were

associated

with

satisfactory

recovery.

METHODOLOGY

This

descriptive

observational

study

with

prospective

three-month

follow-up

was

conducted

in

the

Department

of

Orthopaedics,

Khyber

Teaching

Hospital, Peshawar, from October 2025 to April 2026.

The

College

of

Physicians

and

Surgeons

Pakistan

Research

Evaluation

Unit

approved

the

synopsis

(CPSP/REU/OSG-2024-020-3111;

5

October

2025).

We

obtained

written

informed

consent

from

all

participants. The source manuscript does not provide a

separate institutional ethics-committee reference; please

supply or clarify this before publication. We calculated

the sample size using the WHO sample-size calculator,

assuming a 10.3% frequency of poor outcome, a 95%

confidence level, and a 5% margin of error, resulting in

142 patients. We enrolled consecutive

eligible patients

aged

20-70

years

of

either

sex.

Multiligament

knee

injury was dened as MRI-conrmed disruption or tear

of

at

least

two

of

the

ACL,

PCL,

MCL,

and

LCL.

Patients with an infected open wound, established knee

contracture, polytrauma, previous fracture of the same

knee, or a comorbid condition independently impairing

lower-limb

function

were

excluded.

A

structured

proforma recorded age, sex, BMI, residence, education,

occupation, socioeconomic status, laterality, time from

injury

to

surgery,

mechanism

of

injury,

number

and

pattern of ligaments involved, and associated meniscal

or chondral injury. MRI was used to conrm ligament

involvement.

All

patients

underwent

operative

management

under

general

anaesthesia.

We

generally

reconstructed

cruciate

ligament

injuries

and

repaired

collateral

ligament

injuries

when

appropriate;

graft

preparation, tunnel creation, graft passage, xation, and

final

stability

assessment

followed

departmental

practice.

Consult

operative

records

to

conrm

exact

graft

types,

xation

devices,

and

ligament-specic

protocols

for

full

procedural

reproducibility.

Postoperative

care

included

analgesia,

wound

care,

indicated

antimicrobial

therapy,

and

physiotherapy

according

to

the

departmental

rehabilitation

protocol.

Follow-up

assessed

wound

status,

pain,

swelling,

stiness, residual

instability,

and neurovascular status.

We measured functional outcome at three months with

the 100-point Lysholm knee score and categorised it as

excellent

(>90),

good

(84-90),

fair

(65-83),

or

poor

(<65). We combined the excellent and good categories

as

a

satisfactory

outcome

for

regression

analysis.

We

analysed the data using IBM SPSS Statistics version 26.

A p-value ≤0.05 was considered statistically signicant.

RESULTS

All

142

enrolled

patients

completed

a

three-month

functional

assessment.

Mean

age

was

36.17



12.37

years,

104

(73.2%)

were

male,

and

mean

BMI

was

25.73



4.21

kg/m.

Road

trac

accident

was

the

leading

mechanism

of

injury

(52.1%).

Two-ligament

injuries were most frequent (62.0%), followed by three-

ligament

(29.6%)

and

four-ligament

injuries

(8.5%).

ACL and PCL involvement were documented in 93.0%

and

77.5%,

respectively.

Meniscal

injury

occurred

in

26.1% and chondral injury in 13.4%. The mean three-

month

Lysholm

score

was

81.56



11.89.

Outcomes

were excellent in 29 (20.4%), good in 48 (33.8%), fair

in

50

(35.2%),

and

poor

in

15

(10.6%)

patients;

consequently,

77

(54.2%)

achieved

the

prespecied

satisfactory

outcome.

Functional

category

18.175

0.253

0.0

05

Normal

19 (30.6)

24

(38.7)

17

(27.4)

2

(3.2)

Continue...

Functional Outcomes After Multiligament Knee Reconstruction

129

J Gandhara Med Dent Sci

October - December 2026

Overweight

10 (17.2)

18

(31.0)

22

(37.9)

8

(13.8)

Obese

0 (0.0)

6

(27.3)

11

(50.0)

5

(22.7)

Laterality

of joint

1.017



0.7

96

Right knee

16 (20.3)

27

(34.2)

26

(32.9)

10

(12.7)

Left knee

13 (20.6)

21

(33.3)

24

(38.1)

5

(7.9)

Duration

from injury

to surgery

32.667

0.480

<0.

001

≤14 days

23 (37.7)

25

(41.0)

12

(19.7)

1

(1.6)

>14 days

6 (7.4)

23

(28.4)

38

(46.9)

14

(17.3)

Number of

ligaments

involved

13.934

0.222

0.0

29

Variable

Excellent

n (%)

Good

n (%)

Fair

n (%)

Poor

n (%)

χ

²

value

Cram

er's V

p-v

alue

Two

ligaments

24 (27.3)

32

(36.4)

27

(30.7)

5

(5.7)

Three

ligaments

5 (11.9)

13

(31.0)

17

(40.5)

7

(16.7)

Four

ligaments

0 (0.0)

3

(25.0)

6

(50.0)

3

(25.0)

Associated

meniscal

injury

9.258

0.255

0.0

26

Present

2 (5.4)

12

(32.4)

19

(51.4)

4

(10.8)

Absent

27 (25.7)

36

(34.3)

31

(29.5)

11

(10.5)

Associated

chondral

injury

4.564



0.2

03

Present

2 (10.5)

4

(21.1)

10

(52.6)

3

(15.8)

Absent

27 (22.0)

44

(35.8)

40

(32.5)

12

(9.8)

Table 5: Binary Logistic Regression for Predictors of Satisfactory

Functional Outcome

Variable

B

Wald

Adjusted

OR

95% CI

for OR

p-value

Duration from

injury to

surgery >14

days

-4.604

15.256

0.010

0.001

0.101

<0.001

Number of

ligaments

involved

-2.698

13.335

0.067

0.016

0.287

<0.001

Associated

meniscal

injury

0.822

0.848

2.274

0.396

13.072

0.357

Age,

years

-0.421

22.285

0.656

0.551

0.782

<0.001

BMI, kg/m

-0.393

14.046

0.675

0.549

0.829

<0.001

DISCUSSION

Multiligamentous

knee

injuries

are

among

the

most

challenging

injuries

managed

in

orthopaedic

practice

because they involve disruption of two or more major

stabilising ligaments of the knee and may be associated

with meniscal, chondral, neurovascular, and soft-tissue

damage.

In

the

present

study,

multiligamentous

knee

reconstruction

resulted

in

a

mean

Lysholm

score

of

81.56



11.89

at

three

months.

Overall,

54.2%

of

patients achieved excellent or good functional outcome,

while 45.8%

had fair or poor outcome. These ndings

suggest

that

surgical

reconstruction

can

provide

acceptable

short-term

functional

recovery

in

a

considerable

proportion

of

patients,

although

postoperative

function

remains

variable.

Boos

et

al.

reported

that

patients

undergoing

surgical

reconstruction

of

multiligamentous

knee

injuries

showed subjective improvement and high satisfaction at

long-term follow-up, although functional scores varied

and

were

inuenced

by

patient

and

injury

characteristics.

14

Similarly,

Lang

et

al.

reported

encouraging

functional

recovery

after

operative

treatment

of

multiligament

knee

injuries

in

an

adolescent

population,

supporting

the

role

of

surgical

stabilisation in restoring knee function.

15

However, age

was

signicantly

associated

with

better

functional

outcome in the present study. The best results were seen

in those aged 20-30 years, with fair and poor results at

older

ages.

Multivariate

regression

analysis

also

showed

that

age

was

an

independent

predictor

of

an

unfavourable

functional

outcome.

This

aligns

with

Boos

et

al.,

who

assessed

long-term

outcomes

after

surgical

reconstruction

and

emphasised

that

patient-

such

as

age

are

important

in

recovery

following

a

multiligamentous

knee

injury.

14

Zhang

et

al.

also

noted

that

the

long-term

consequences

of

multiligament knee injuries can be restricted in certain

individuals, especially if degenerative changes occur, or

if

symptoms

or

functional

decits

persist

over

time.

16

The

cause

of

this

poorer

outcome

in

older

patients

in

the

present

study

is

not

completely

understood.

However,

it

may

be

due

to

reduced

healing

capacity,

delayed

response

to

rehabilitation,

lower

recovery

of

muscle

strength,

and

more

severe

pre-existing

degenerative

joint

changes.

Road

trac

accident

was

the

most

common

mechanism

of

injury

in

this

study,

followed by sports injury and fall from height. This is

the

trend

seen in

many

multiligament

knee injuries in

tertiary-care

trauma

settings,

which

are

high-energy

injuries. Fortier et al. stated that multiligament injuries

of

the

knee

were

complex

injuries

that

are

often

associated

with

high-energy

trauma,

knee

dislocation,

neurovascular

compromise,

and

associated

intra-

articular

disease.

3

Similarly,

Scheepers

et

al.

emphasised that

careful

assessment

of

vascular

status,

nerve function, ligament pattern, and associated injuries

is

essential

before

planning

denitive

treatment.

4

The

male predominance observed in this study is clinically

plausible,

as

males

are

more

likely

to

be

involved

in

road

trac

accidents,

outdoor

work,

manual

labour,

and sporting activities. In the present study,

timing of

Functional Outcomes After Multiligament Knee Reconstruction

130

J Gandhara Med Dent Sci

October - December 2026

surgery

was

one

of

the

most

important

factors

correlated

with

outcome.

Patients

undergoing

surgery

within

14

days

had

signicantly

improved

functional

recovery;

surgery

performed

after

14

days

was

an

independent

risk factor for signicantly decreased odds

of excellent or good outcomes. This nding aligns with

the

idea

that

early

stabilisation

could

help

minimise

chronic instability, rehabilitation needs, and secondary

meniscal

or

chondral

damage.

However,

when

to

operate on a multiligament knee remains debated. In a

systematic

review,

Marder

et

al.

found

insucient

evidence to determine which surgery (acute or delayed)

produced better clinical and functional outcomes in all

patients.

8

Herman

et

al.

further

reported

limited

consensus

on

when

to

perform

surgery

and

rehabilitation, and these decisions should be tailored to

the

patient's

soft-tissue

status,

injury

severity,

vascularity, and rehab status.

9

Vaishya et al. also noted

that early surgery can improve function and stability but

may

also

aect

stiness

risk,

depending

on

patient

selection

and

rehabilitation

protocols.

8

Hence,

the

results

of

the

present

study

corroborate

those

of

Another

important

factor

was

BMI,

which had a negative impact on postoperative recovery.

The

patients

with

normal

BMI

had

better

functional

outcomes, while the patients who were overweight and

obese

had

a

higher

percentage

of

fair

and

poor

outcomes. In addition, regression analyses showed that

higher

BMI

independently

predicted

poor

recovery

outcomes.

This may be because

higher BMI increases

mechanical

strain

on

the

rebuilt

knee,

makes

rehabilitation

more

challenging,

slows

quadriceps

recovery, or increases the likelihood of pain or stiness

afterwards.

In

a

systematic

review

and

meta-analysis,

Klasan

et

al.

found

that

at

2

years,

patients

with

multiligament

knee injuries can attain a

knee function

of

around

80-85%.

17

The

results

suggest

that

injury-

related and patient-related factors aect recovery after

surgery.

BMI

is

one

modiable

factor,

and

it

is

suggested that this should be addressed during pre- and

postoperative

counselling

and

rehabilitation

planning.

The

number

of

ligaments

involved

was

signicantly

associated with functional outcome

in the current study.

Patients

with

two-ligament

injuries

had

better

functional

outcomes

than

those

with

three-

and

four-

ligament

injuries.

This

makes

clinical

sense,

as

more

ligament

involvement

indicates

a

more

severe

injury,

more

complex

reconstruction,

greater

instability,

and

greater

rehabilitation

needs.

Similarly,

Pizza

et

al.

reported

good

long-term

results

in

surgically

treated

posterior

cruciate

ligament-based

multiligament

knee

injuries

and

indicated

that

certain

injury

patterns

and

corner

involvement

may

be

associated

with

increased

failure risk.

18

A systematic review and meta-analysis by

Jaibaji

et

al.

found

that

staged

reconstruction

might

oer

superior

functional

results

and

reduced

arthrofibrosis

and

complication

rates

in

a

subset

of

multiligament knee injuries. These results are consistent

with

the

current

recommendation

for

a

more

complex

approach

to

counselling

patients

about

recovery.

19

In

univariate

analysis,

associated

meniscal

injury

was

associated

with

functional

outcome,

but

was

not

independent

in

logistic

regression

analysis

after

adjusting

for

other

variables.

Thirteen

point

four

per

cent of

patients

had associated

chondral injury,

which

did

not

reach

statistical

signicance

in

the

nal

association analysis. In a systematic review and

meta-

analysis,

Kim et al.

found that

approximately 27-30%

of multiligament knee injuries have associated meniscal

and/or

cartilage

injuries.

11

Figueroa

et

al.

also

emphasised

that

meniscal

lesions

are

frequent

in

multiligament

knee

injuries

and

should

be

carefully

identified

and

treated

because

they

may

aect

long-

term

joint

preservation.

20

The

lower

incidence

of

chondral

injuries

in

the

present

study

could

be

attributed

to

injury

mechanism,

diagnostic

sensitivity,

documentation, or the relatively short follow-up period.

Postoperative

complication

rates

were

comparable

in

this

study.

No

major

neurovascular

complication

was

reported,

but

12.0%

of

patients

reported

pain

that

persisted,

9.9% reported swelling, 9.2% reported knee

stiness, 6.3% reported continued instability, and 3.5%

reported a supercial wound infection. Studies by Patel

et al. have shown that patient-related factors, smoking,

surgical

timing

and

staged

procedures

may

aect

the

likelihood

of

complications

following

operative

treatment

of

multiligament knee injuries.

12

Rodríguez-

Merchán

also

noted

that

stiness,

residual

instability,

infection,

thromboembolic

events,

and

neurovascular

complications

still

are

signicant

problems

after

surgical reconstruction of multiligament knee injuries.

13

Compared

with

these

reports,

the

complication

frequency

in

the

present

study

appears

acceptable,

possibly

because

we

excluded

polytrauma

patients,

patients

with

infected

wounds,

and

patients

with

established contractures. These results are

most

useful

for

preoperative

counselling

and

service

planning.

Surgery

alone

did

not

determine

functional

recovery;

age,

body

mass

index,

injury

complexity,

and

timing

were

all

outcome.

Early referral to a centre

capable

of

vascular

assessment,

ligament

reconstruction, and structured rehabilitation may reduce

avoidable

delay.

At

the

same

time,

the

association

between

surgery

within

14

days

and

better

outcome

should

not

be

interpreted

as

proof

that

every

multiligament injury requires immediate reconstruction,

because

soft-tissue

condition,

vascular

injury,

associated

fractures,

stiness

risk,

and

rehabilitation

readiness

must inuence

timing.

The

ndings

support

individualised decision-making rather than an inexible

time threshold.

Functional Outcomes After Multiligament Knee Reconstruction

131

J Gandhara Med Dent Sci

October - December 2026

LIMITATIONS

This

single-centre

observational

study

used

non

probability

consecutive

sampling

and

a

short

three-

month

outcome

window.

Consequently,

the

study

cannot

determine

long-term

graft

survival,

return

to

work

or

sport,

revision

surgery,

post-traumatic

osteoarthritis,

or

sustained

patient

satisfaction.

The

Lysholm

score

was

the

principal

functional

measure;

the

authors

did

not

include

IKDC,

KOOS,

Tegner

activity level, objective laxity measurements, or generic

quality-of-life measures. Surgical technique, graft type,

fixation

method,

rehabilitation

adherence,

and

ligament-specific reconstruction strategy were not fully

characterised

in

the

submitted

manuscript

and

may

confound outcome. Several regression eect estimates

were large, and model performance

may be optimistic

in a single sample. Multicentre prospective studies with

standardised

surgical

and

rehabilitation

protocols

and

longer follow-up are required.

CONCLUSIONS

At

three

months,

multiligament

knee

reconstruction

produced

excellent

or

good

Lysholm

outcomes

in

54.2%

of

patients.

Younger

age,

lower

BMI,

earlier

surgery,

and

less

complex

ligament

injury

were

associated

with

better

recovery.

The

ndings

support

timely

specialist

assessment,

individualised

surgical

planning,

optimisation

of

modiable

patient

factors,

and structured rehabilitation, while longer follow-up is

necessary

to

determine

durability

and

late

complications.

CONFLICT OF INTEREST:

None

FUNDING SOURCES:

None

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October - December 2026

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Jawad

Farooq -

Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Awal

Hakeem

-

Concept

&

Design;

Data

Acquisition;

Data

Analysis/Interpretation;

Drafting

Manuscript;

Critical

Revision; Supervision; Final Approval

Kashif Wakil

-

Concept & Design; Data Acquisition;

Drafting

Manuscript; Critical Revision; Final Approval

Khalil

Ur

Rehman

-

Concept

&

Design;

Data

Acquisition;

Drafting

Manuscript; Supervision; Final Approval

Arsalan Shah Rohani

-

Concept & Design; Data Acquisition;

Drafting

Manuscript;

Critical

Revision;

Supervision;

Final

Approval

Muhammad

Tufail

-

Concept

&

Design;

Data

Acquisition;

Drafting

Manuscript; Supervision; Final Approval

Imran Khan

-

Concept & Design; Data Acquisition; Drafting

Manuscript; Supervision; Final Approval

Functional Outcomes After Multiligament Knee Reconstruction