The present study found that the accuracy of MRI was good for detecting cruciate ligament injuries, moderate for collateral ligament injuries, low for meniscus injuries. We reviewed the literature and did not find research that investigated the value of MRI in classifying MLKIs. Though MRI performs better in classifying KD-V MLKIs, the overall agreement with intraoperative findings was poor. In short, MRI helps early detection of MLKIs, however, it has limited value in classifying the MLKIs preoperatively. The management of MLKIs should be based on comprehensive assessment including preoperative imaging, physical exam, and intraoperative exploration.

The diagnostic value of MRI in detecting multi-ligament injuries was evaluated by comparing the MRI results with clinical examination and/or intraoperative findings, but the results differ a lot [9,10,11, 14]. In most studies, MRI was reliable in detecting ligament injuries, however, in terms of meniscus and PLC, the conclusions were controversial [7, 8]. In the present study, the accuracy of MRI in detecting cruciate ligaments was consistent with previous studies. The accuracy was demonstrated moderate in detecting injuries to collateral ligaments, which was rarely reported in MLKIs. Research has suggested that oblique coronal and oblique sagittal MRI, which was parallel to the long axis of the ACL, improved the accuracy of the diagnosis of an ACL tear and the grading of ACL injury [18,19,20]. However, the application of oblique MRI in multiple ligaments injuries is limited. The evaluation of the value of MRI in diagnosing MLKIs should also consider the interpretation of MRI results [21]. Since the MLKIs were complex injuries, the accuracy of MRI for diagnosing isolated ligament injuries was not comparable with that of the multi-ligament injuries. In short, this study concluded that MRI was valuable for the early diagnosis of MLKIs.

The value of MRI in classifying MLKIs according to Schenck classification was explored in this study. We find that MRI has a moderate agreement in classifying KD-V, poor agreement in classifying KD-I and KD-IIIM, meaningless in KD-II and KD- IIIL. We speculate that the meaningless agreements in the KD-II and KD-IIIL were due to the small numbers of those two injuries, the diagnostic value cannot be reflected well. Though inferior to the CT scan, the present study revealed that MRI helps detect periarticular fractures (moderate consistency with intraoperative findings in classifying KD-V). Besides, we found that MRI has high sensitivity in detecting ACL and PCL injuries, but the overall agreement was poor compared to intraoperative findings. The results were not surprising because the MLKIs are complex injuries, a precise MRI-based classification is challengeable. Though the sensitivity and specificity in this study differ from previous studies, we concluded MRI has limited value in classifying MLKIs preoperatively, the management of MLKIs should be based on a comprehensive evaluation, including physical exam, combined X-Rays, CT, and mechanisms of injuries until intraoperative evidence was obtained.

In the present study, only one of the PLC injuries was revealed by preoperative MRI, suggesting a limited value of MRI in detecting PLC injuries, there were no false-positive cases, the sensitivity and specificity were not calculated because the number of samples was small. In fact, few studies have reported the results of PLC reconstruction because of the low incidence rate. Derby et al. [8] investigated the value of MRI in detecting the PLC for patients with knee dislocations, including LCL (76% accuracy, 100% sensitivity, 67% specificity) and iliotibial tract (89% accuracy, 97% specificity). In the present study, only 9 cases were diagnosed with PLC injuries according to the intraoperative findings. Precise detection of PLC injuries using MRI is challenging. The value of MRI in detecting PLC injuries remains unknown, the diagnosis should be based on clinical examination under anesthesia and intraoperative findings.

The present study has some limitations. First, this is a retrospective analysis with a small number of samples, there was a lack of systematic methods used to include/exclude patients, thus inherent bias can not be avoided. Second, there was a variation of the incidence of injury patterns between groups, the intraoperative findings were considered as gold standard during the statistical analysis, which may lead to bias. Third, only a 1.5 T MRI magnet was used for scanning and the severity of the injured ligaments was not graded using the MR images, partial and complete tears were not divided into subgroups and evaluated. Fourth, the number of PLC injuries was small and only one of them was successfully revealed by the MRI, thus the accuracy of MRI in detecting PLC injuries can not be evaluated. Furthermore, MRI results were not compared with clinical examination. Future studies should be based on larger samples and a more specific evaluation system.

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