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Mayne AIW, Ebert JR, Edwards PK, Davies PSE, Evans R, Aujla RS, Malik SS, Grant MJ, Dalgleish S, Gohil S, D'Alessandro P. Modern multiligament knee injury surgical reconstruction techniques can achieve excellent knee function and patient satisfaction, with low complication rates. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38961756 DOI: 10.1002/ksa.12332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE To report on the recovery of strength and functional capacity symmetry following multiligament knee surgical reconstruction (MLKR), as well as the capacity of athletes to return to sport. METHODS This prospective cohort study recruited 47 patients undergoing MLKR between February 2018 and July 2021. Forty patients had full outcome assessment postoperatively at 6, 12 and 24 months and were included in the analysis, 75% were knee dislocation one injuries and 60% were injured playing sport. Patient-reported outcome measures (PROMs) assessed included the International Knee Documentation Committee score, the Knee Outcome Survey, the Lysholm Knee Score and the Tegner Activity Scale (TAS). Patient satisfaction was also assessed. Objective assessment included assessment of active knee flexion and extension range of motion (ROM), the single (single horizontal hop for distance [SHD]) and triple (triple horizontal hop for distance [THD]) hop tests for distance and peak isokinetic knee flexor/extensor torque. RESULTS All PROMs significantly improved (p < 0.001) from presurgery to 24 months postsurgery. At 24 months, 70% of patients were satisfied with their sports participation. Active knee flexion (p < 0.0001) and extension (p < 0.0001) ROM significantly improved over time, as did the limb symmetry indices (LSIs) for the SHD (p < 0.0001), THD (p < 0.0001), peak knee extensor (p < 0.0001) and flexor (p = 0.012) torque. While LSIs for the SHD, THD and knee flexor strength tended to plateau by 12 months, knee extensor strength continued to improve from 12 to 24 months. CONCLUSIONS The majority of patients undergoing modern MLKR surgical techniques and rehabilitation can achieve excellent knee function, with low complication rates. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Alistair I W Mayne
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Perth, Western Australia, Australia
| | - Jay R Ebert
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
- Health Function Rehabilitation Care (HFRC) Rehabilitation Clinic, Perth, Western Australia, Australia
| | - Peter K Edwards
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Peter S E Davies
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Perth, Western Australia, Australia
| | - Robert Evans
- Joondalup Health Campus, Perth, Western Australia, Australia
| | - Randeep S Aujla
- Leicester Knee Unit, University Hospitals of Leicester National Health Service Trust, Leicester, UK
| | - Shahbaz S Malik
- Worcestershire Acute Hospitals National Health Service Trust, Worcester, UK
| | - Michael J Grant
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Perth, Western Australia, Australia
| | | | - Satyen Gohil
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Perth, Western Australia, Australia
| | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley and Fremantle Hospitals Group, South Metropolitan Health Service, Perth, Western Australia, Australia
- School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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Ebadi H, Banks L, Khodaee M. Knee Dislocation as a Result of a Ski Injury. Cureus 2024; 16:e62841. [PMID: 39036149 PMCID: PMC11260426 DOI: 10.7759/cureus.62841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
Visible knee deformity as a result of a sporting activity is rare; however, it can be caused by a serious injury and have catastrophic consequences. Differential diagnosis includes patellofemoral or knee dislocations, fractures, and tendon or ligament ruptures. Immediate diagnosis and appropriate management are key. Diagnosis can be made using available tools such as plain radiography, ultrasound, CT scan, and MRI. Depending on the type and severity of the diagnosis, urgent transportation to a higher level of care facility may be indicated. We present a gentleman in his 20s with knee dislocation as a result of a ski injury. His knee was reduced and he was transported to a hospital with surgical capability. He underwent surgery to stabilize his injury and then staged reconstruction for rupture of multiple ligaments.
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Affiliation(s)
- Hoomaan Ebadi
- Orthopaedics, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IRN
| | - Landan Banks
- Family Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Morteza Khodaee
- Family Medicine, University of Colorado School of Medicine, Aurora, USA
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Miller D, Richards J, Nyland J. Tibiofemoral Dislocation Management in a Rural High School Football Scenario: Development of a Popliteal Artery Injury Suspicion Index. Pediatr Emerg Care 2024; 40:e61-e67. [PMID: 37962231 DOI: 10.1097/pec.0000000000003082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVE This study evaluated the knowledge and preparedness of athletic trainers (ATs) for diagnosing and managing an anterior tibiofemoral knee dislocation in a rural or limited-resource high school football setting scenario. The study hypothesis was that more experienced ATs would display greater preparedness than less experienced ATs. A secondary objective was to develop evidence-based guidelines to help the AT provide better emergency triage care. METHODS This prospective cross-sectional study distributed a rural high school football game scenario survey electronically to a random sample of 2000 certified ATs to determine their perceptions of readiness to diagnose and manage an anterior tibiofemoral knee dislocation with signs or symptoms of possible popliteal artery injury. RESULTS A total of 249 surveys (12.5%) were completed. Years of athletic training experience were ≤5 years (n = 82, group 1) and ≥6 years (n = 167, group 2). Both groups perceived that they could not "rule out" an arterial injury and had similar "red flag" sign and symptom rankings. Group 2 perceived a more serious situation than group 1 (77.5 ± 15 vs 70.8 ± 14, P < 0.0001) and were more likely to activate the emergency action plan (74.5 ± 25 vs 64.4 ± 26, P = 0.005). Both groups were "neutral" about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that evidence-based guidance was needed. CONCLUSIONS More experienced ATs perceived a more serious situation than less experienced ATs and were more likely to activate the emergency action plan. Both groups were neutral about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that they would benefit from evidence-based guidance. Proposed guidelines provide the AT with a more measured, evidence-based index of suspicion for potential popliteal artery injury in anterior tibiofemoral dislocation cases. This will complement existing hospital emergency department-based management algorithms, decreasing the likelihood of this condition progressing to limb loss or death.
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Affiliation(s)
- Drew Miller
- From the duPont Manual High School, UofL Health-Frazier Rehab Institute
| | - Jarod Richards
- Department of Orthopaedic Surgery, University of Louisville
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Szymski D, Huber L, Riedl M, Rupp M, Alt V, Weber J. No effect of dislocation status at arrival in emergency department on outcome of knee joint dislocations. Knee Surg Sports Traumatol Arthrosc 2024; 32:1376-1383. [PMID: 38544466 DOI: 10.1002/ksa.12154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Knee dislocation is a rare but severe injury of the lower extremities. The aim of this study was to report on the epidemiology, diagnostics and treatment of such injuries and to identify negative predictors of clinical outcomes. METHODS This retrospective analysis included all knee dislocations treated at a Level I Trauma Centre in Germany between 2009 and 2021. Medical records were categorised, collected and analysed in a standardised manner. A follow-up visit 1 year after the injury focused on limitations in knee mobility. RESULTS A total of 120 knee dislocations were included in the study. 29.3% of patients presented to the emergency department with a dislocated joint, and 17.5% (n = 21) had a neurovascular lesion. At follow-up 12 months after the injury, 65.8% of the patients reported limitations in the range of motion, and 11.7% (n = 14) reported severe limitations in daily activities. Site infections due to surgery occurred in 3.3% of patients. Increased body weight (r = 0.294; p < 0.001 and r = 0.259; p = 0.004), an increased body mass index above 25 kg/m2 (body mass index, r = 0.296; p < 0.001 and r = 0.264; p = 0.004) and deficits in peripheral perfusion as well as sensory and motor function (r = 0.231; p = 0.040 and r = -0.192; p = 0.036) were found to be negative predictive factors for clinical outcome. For posttraumatic neurovascular injury, lack of peripheral perfusion, insufficient sensory and motor function (r = -0.683; p < 0.0001), as well as a higher Schenck grade (r = 0.320; p = 0.037), were identified as independent risk factors. The status of dislocation at the site of the accident and on arrival at the emergency department had no impact on the outcome or neurovascular injury. CONCLUSION Knee dislocation is a rare injury with a high rate of severe complications such as neurovascular lesions. In particular, the initial status of neurovascular structures and injury classification showed a relevant negative correlation with the posttraumatic status of nerves and vessels. In particular, patients with these characteristics need close monitoring to prevent negative long-term consequences. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Dominik Szymski
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
- FIFA Medical Centre of Excellence, University Medical Centre Regensburg, Regensburg, Germany
| | - Lorenz Huber
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
- FIFA Medical Centre of Excellence, University Medical Centre Regensburg, Regensburg, Germany
| | - Moritz Riedl
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
- FIFA Medical Centre of Excellence, University Medical Centre Regensburg, Regensburg, Germany
| | - Johannes Weber
- Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
- FIFA Medical Centre of Excellence, University Medical Centre Regensburg, Regensburg, Germany
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Zhong J, Lee NJ, Crutchfield C, Mueller J, Ahmad C, Trofa D, Lynch TS. Perioperative outcomes in isolated versus multiligamentous anterior cruciate ligament reconstruction: a retrospective cohort analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1597-1607. [PMID: 38363347 DOI: 10.1007/s00590-024-03848-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE The outcomes of anterior cruciate ligament reconstruction in the setting of multiligamentous knee injury (M-ACLR) have not been well characterized compared to isolated ACLR (I-ACLR). This study aims to characterize and compare short-term outcomes between I-ACLR and M-ACLR. METHODS This is a retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017. Current Procedural Terminology codes were used to identify and compare elective I- and M-ACLR patients, excluding patients undergoing concomitant meniscal or chondral procedures. Patient demographics and outcomes after I- and M-ACLR were compared using bivariate analysis. Multiple logistic regression analyzed if multiligamentous ACLR was an independent risk factor for adverse outcomes. RESULTS There was a total of 13,131 ACLR cases, of which 341 were multiligamentous cases. The modified fragility index-5 was higher in multiligamentous ACLR (p < 0.001). Multiligamentous ACLR had worse perioperative outcomes, with higher rate of all complications (3.8%, p = 0.013), operative time > 1.5 h (p < 0.001), length of stay (LOS) ≥ 1 day (p < 0.001), wound complication (2.1%, p = 0.001), and intra- or post-op transfusions (p < 0.001). In multiple logistic regression, multiligamentous ACLR was an independent risk factor for LOS ≥ 1 (odds ratio [OR] 5.8), and intra-/post-op transfusion (OR 215.1) and wound complications (OR 2.4). M-ACLR was not an independent risk factor for any complication, reoperation at 30 days, readmission, urinary tract infection (UTI), or venous thromboembolism (VTE). CONCLUSION M-ACLR generally had worse outcomes than I-ACLR, including longer LOS, need for perioperative transfusions, and wound complications.
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Affiliation(s)
- Jack Zhong
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA.
- Department of Orthopaedic Surgery, New York University Langone Health, New York, 10010, USA.
| | - Nathan J Lee
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - Connor Crutchfield
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - John Mueller
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - Christopher Ahmad
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - David Trofa
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
| | - T S Lynch
- Department of Orthopedic Surgery, Columbia University, 301 E 17th St, 14th Floor, New York, NY, 10010, USA
- Department of Orthopedic Surgery, Henry Ford Health, Detroit, 48202, USA
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Reverté-Vinaixa MM, García-Albó E, Blasco-Casado F, Pujol O, Pijoan BJ, Joshi-Jubert N, Castellet-Feliu E, Portas-Torres I, Andrés-Peiró JV, Minguell-Monyart J. Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1349-1356. [PMID: 38147073 DOI: 10.1007/s00590-023-03807-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 12/03/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). MATERIALS AND METHODS Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. RESULTS MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6 years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. CONCLUSIONS We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.
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Affiliation(s)
- María Mercedes Reverté-Vinaixa
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
| | - Enrique García-Albó
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Ferran Blasco-Casado
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Oriol Pujol
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Bueno Joan Pijoan
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Nayana Joshi-Jubert
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Enric Castellet-Feliu
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Irene Portas-Torres
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - José Vicente Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Joan Minguell-Monyart
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain
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Hughes AJ, Li ZI, Garra S, Green JS, Chalem I, Triana J, Jazrawi LM, Medvecky MJ, Alaia MJ. Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up. Am J Sports Med 2024; 52:961-967. [PMID: 38400667 DOI: 10.1177/03635465241231032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. PURPOSE To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. RESULTS A total of 42 patients (25 male, 17 female) were assessed at a mean 6.5-year follow-up (range, 2.1-10.7 years). Twenty patients (47.6%) were found to have a documented KD; they reported significantly lower IKDC (49.9 vs 63.0; P = .043), Lysholm (59.8 vs 74.5; P = .023), and Tegner activity level (2.9 vs 4.7; P = .027) scores than the patients without documented dislocation. VAS pain was not significantly different between groups (36.4 vs 33.5; P = .269). The incidence of neurovascular injury was greater among those with documented dislocation (45.0% vs 13.6%; P = .040). Subgroup analysis found that patients with KD3-L injuries experienced a greater deficit in Tegner activity level than patients with KD3-M injuries (Δ: -3.4 vs -1.2; P = .006) and had an increased incidence of neurovascular injury (41.7% vs 11.1%; P = .042). Documented dislocation status was predictive of poorer IKDC (β = -2.15; P = .038) and Lysholm (β = -2.85; P = .007) scores. CONCLUSION Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.
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Affiliation(s)
- Andrew J Hughes
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Zachary I Li
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Sharif Garra
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut, USA
| | - Isabel Chalem
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jairo Triana
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Laith M Jazrawi
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
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Krause M, Drenck TC, Eggeling L, Frings J, Akoto R, Frosch KH. German S2e-Guideline "Knee Dislocation". ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:57-62. [PMID: 36063838 DOI: 10.1055/a-1884-0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.
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Affiliation(s)
- Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Tobias C Drenck
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Lena Eggeling
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Jannik Frings
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ralph Akoto
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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9
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Ng JPH, Wu C, Ooi DGS, Leong CR, Chan DYS. Review of peripheral artery trauma in a district hospital in northern Singapore. Singapore Med J 2024:00077293-990000000-00076. [PMID: 38189453 DOI: 10.4103/singaporemedj.smj-2022-081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 09/27/2022] [Indexed: 01/09/2024]
Affiliation(s)
- Julia Poh Hwee Ng
- Department of General Surgery, Vascular Surgery, Khoo Teck Puat Hospital, Singapore
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10
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Lu V, Chen X, Thahir A, Krkovic M. Open injuries and obesity as emerging risk factors for vascular injury in knee dislocations: A retrospective study. Knee 2024; 46:34-40. [PMID: 38061163 DOI: 10.1016/j.knee.2023.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 09/14/2023] [Accepted: 11/17/2023] [Indexed: 02/20/2024]
Abstract
PURPOSE Knee dislocations (KDs) are rare in orthopaedic trauma but can have devastating effects. Failing to diagnose a concomitant vascular injury can lead to amputation. Different methods are used for the diagnosis of a vascular injury and the best approach is under debate. This study aims to examine the risk factor(s) of vascular injury in patients with KDs, examine variables that differ between obese patients and non-obese patients with KDs, and analyse the modalities used to identify vascular injuries in the KD population. METHODS The electronic patient medical record system at a major trauma centre was retrospectively reviewed to identify knee dislocations from 2015 to 2022. These were stratified based on age, gender, BMI, mechanism of injury, vascular injury, non-vascular complications, and laterality. Co-variates were inputted into a univariable regression analysis, followed by a multivariable regression analysis to identify risk factors of vascular injury in patients with knee dislocations. Co-variates were also compared between obese and non-obese patients using two-tailed t-tests for continuous variables and chi-squared test for categorical variables. RESULTS Forty patients were identified with a KD, with twenty-eight males and twelve females. The average age was 42.9 years, seventeen patients had a BMI of thirty or over, and eleven patients (27.5%) had a vascular injury. Open injuries (OR: 2.21; 95% CI: 1.19-11.30; p = 0.038) and obesity (OR: 2.66; 95% CI: 1.45-18.69; p = 0.027) are risk factors for vascular injury in patients with knee dislocation. Compared to non-obese patients, obese patients had a higher rate of open injury (p = 0.028), vascular injury (p = 0.017), low-energy injuries (p = 0.014), non-vascular complications (p = 0.017), and amputation (p = 0.036). CONCLUSION Open injuries and obesity are risk factors for vascular injury in patients with KD. Compared to non-obese patients, obese patients have low-energy injuries and an increased rate of non-vascular complications, meaning that clinicians could err on the side of caution when investigating vascular injury. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Victor Lu
- School of Clinical Medicine, University of Cambridge, CB2 0SP, United Kingdom.
| | - Xiaoyu Chen
- School of Clinical Medicine, University of Cambridge, CB2 0SP, United Kingdom.
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, CB2 0QQ, United Kingdom.
| | - Matija Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, CB2 0QQ, United Kingdom.
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Li ZI, Green JS, Chalem I, Triana J, Rao N, Hughes AJ, Campbell KA, Jazrawi LM, Medvecky MJ, Alaia MJ. Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up. Knee 2024; 46:89-98. [PMID: 38070381 DOI: 10.1016/j.knee.2023.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old. METHODS This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores. RESULTS Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012). CONCLUSIONS Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports. LEVEL OF EVIDENCE IV, Case series.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States.
| | - Joshua S Green
- Frank H. Netter School of Medicine at Quinnipiac University, North Haven, CT, United States
| | - Isabel Chalem
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Jairo Triana
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Naina Rao
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Andrew J Hughes
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, United States
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, United States
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12
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Frings J, Behrendt P, Krause M, Frosch KH. [Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:882-888. [PMID: 37773214 DOI: 10.1007/s00132-023-04438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Knee dislocation (KD) is a rare but severe injury of the knee joint, with a high rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. TREATMENT STRATEGY Furthermore, a clear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10 days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require a modified approach, due to a limited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows a high success rate.
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Affiliation(s)
- Jannik Frings
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | | | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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13
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Qiu C, Cheng L, Wang L, Li Z, Liu X. Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1811-1819. [PMID: 36847787 DOI: 10.1007/s00068-023-02236-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors. METHODS From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared. RESULTS A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients. CONCLUSIONS Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.
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Affiliation(s)
- Cheng Qiu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lin Cheng
- Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, People's Republic of China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, 250012, Shandong, People's Republic of China
| | - Lianlei Wang
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China
| | - Zhenfeng Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
| | - Xinyu Liu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, People's Republic of China.
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14
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Chun YS, Kim SJ, Lee SW. Characteristics of multi-ligament knee injuries accompanied with patellar tendon disruption. Eur J Trauma Emerg Surg 2023; 49:1821-1826. [PMID: 36881141 DOI: 10.1007/s00068-023-02243-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/08/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Patella tendon rupture with multi-ligament injury is a rare injury. We observed patients with patella tendon rupture (or patella inferior pole fracture) with multi-ligament injury. This study intends to inspect the mechanism of the injury and classify them. METHODS This is a case series involving patients from two hospitals. Twelve patients who had patella tendon rupture (PTR) with multi-ligament injury were studied. RESULTS The incidence of multi-ligament injury in patella tendon rupture patients found to be 13% in retrospective search. Two types of injury were observed. First type is relatively low energy injury involving ACL and patella tendon which does not involve rupture of PCL. Second type is high energy injury involving PCL and patella tendon. Treatment differed among the patients, due to severity of trauma. Two-staged operation was the basis of treatment. Patella tendon was repaired in first stage. Reconstruction of ligaments was done in second stage. The patients who had infection or stiffness did not have a second surgery. CONCLUSION Patella tendon rupture with multi-ligament injury can be classified into low energy rotational injury and high energy dashboard injury. Two-staged surgery is the basis of treatment.
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Affiliation(s)
- You Seung Chun
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Chunbo-Ro 271, Uijeongbu, Gyeonggi-Do, Republic of Korea
| | - Seok Jung Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Chunbo-Ro 271, Uijeongbu, Gyeonggi-Do, Republic of Korea
- Department of Orthopedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Se-Won Lee
- Department of Orthopedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
- Department of Orthopedic Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-Ro, Yeongdeungpo-Gu, Seoul, 07345, Republic of Korea.
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15
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Figueras JH, Johnson BM, Thomson C, Dailey SW, Betz BE, Grawe BM. Team Approach: Treatment of Traumatic Dislocations of the Knee. JBJS Rev 2023; 11:01874474-202304000-00004. [PMID: 37058579 DOI: 10.2106/jbjs.rvw.22.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. » Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. » Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.
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Affiliation(s)
- Jorge H Figueras
- Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
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16
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Abstract
Acute knee injury ranges among the most common joint injuries in professional and recreational athletes. Radiographs can detect joint effusion, fractures, deformities, and malalignment; however, MR imaging is most accurate for radiographically occult fractures, chondral injury, and soft tissue injuries. Using a structured checklist approach for systematic MR imaging evaluation and reporting, this article reviews the MR imaging appearances of the spectrum of traumatic knee injuries, including osteochondral injuries, cruciate ligament tears, meniscus tears and ramp lesions, anterolateral complex and collateral ligament injuries, patellofemoral translation, extensor mechanism tears, and nerve and vascular injuries.
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17
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Makaram NS, Murray IR, Geeslin AG, Chahla J, Moatshe G, LaPrade RF. Diagnosis and treatment strategies of the multiligament injured knee: a scoping review. Br J Sports Med 2023; 57:543-550. [PMID: 36822842 DOI: 10.1136/bjsports-2022-106425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs). DESIGN Scoping review. DATA SOURCES Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary. RESULTS Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups. CONCLUSIONS There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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18
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Vascular Injury After Knee Dislocation: A Meta-Analysis Update. J Am Acad Orthop Surg 2023; 31:e198-e206. [PMID: 36730697 DOI: 10.5435/jaaos-d-22-00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/30/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Multisystem injuries affecting vasculature and nerves can be detrimental sequelae of knee dislocations (KDs). The purpose of this study was to provide an update of the current literature since the conducted search used in the publication of Medina et al on May 3, 2013, to evaluate (1) the frequency of vascular and neurologic injury after KD, (2) the frequency with which surgical intervention was conducted for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury. METHODS A two-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the MEDLINE database. Frequency of vascular injury, surgical intervention, and amputation after KD were analyzed. Diagnostic modalities used in the acute-care setting were also evaluated. RESULTS Nineteen articles were analyzed for a total of 37,087 KDs. Of these, 10.7% sustained vascular injuries and 19.6% sustained nerve injuries. Overall, 62.2% of patients with vascular injury underwent surgical repair and 2.2% limbs resulted in amputation. Angiography was the most frequently used diagnostic modality (91.7%). DISCUSSION This review updates our understanding on the clinical implications of KDs including frequency of vascular injury (10.7%), amputation (2.2%), and nerve injuries (19.6%). Compared with prior literature, there was an increased prevalence of KD1 (32.4%) and lateral KDs (80.4%). Most vascular injuries after KD undergo surgical repair (62.2%).
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19
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Sanchez-Munoz E, Lozano Hernanz B, Zijl JAC, Passarelli Tirico LE, Angelini FJ, Verdonk PCM, Vuylsteke K, Andrade R, Espregueira-Mendes J, Valente C, Figueroa F, Figueroa D, Maestro Fernández A, Maestro Fernández A. Accuracy of Magnetic Resonance Imaging in the Diagnosis of Multiple Ligament Knee Injuries: A Multicenter Study of 178 Patients. Am J Sports Med 2023; 51:429-436. [PMID: 36625432 DOI: 10.1177/03635465221145697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) has shown limited diagnostic accuracy for multiple ligament knee injuries (MLKIs), especially posterolateral corner (PLC) injuries. HYPOTHESIS The diagnostic accuracy of MRI for MLKIs will only be moderate for some knee structures. Patient-related factors and injury patterns could modify the diagnostic accuracy of MRI. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All patients with MLKIs surgically treated between January 2014 and December 2020 in the centers participating in the study were reviewed. We recorded sex, age, mechanism of injury, time from injury to MRI, and vascular and neurological associated lesions. Lesions to the anterior cruciate ligament (ACL), posterior cruciate ligament, medial collateral ligament, lateral collateral ligament (LCL), popliteus tendon, popliteofibular ligament, iliotibial band, biceps tendon, medial and lateral meniscus, and articular cartilage from MRI reports and surgical records were also collected. The sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, diagnostic odds ratio, positive and negative likelihood ratio, and intraclass correlation coefficient of MRI were calculated for each knee structure. With logistic regression, associations between patient and injury characteristics and MRI accuracy were assessed. RESULTS A total of 178 patients (127 male; mean age, 33.1 years) were included. High-energy trauma was the most common mechanism of injury (50.6%), followed by sports trauma (38.8%) and low-energy trauma (8.4%). The ACL was the structure with the best diagnostic accuracy, diagnostic odds ratio, and positive predictive value (94.4%, 113.2, and 96.8%, respectively). PLC structures displayed the worst diagnostic accuracy among knee ligaments (popliteus tendon: 76.2%; LCL: 80.3%) and diagnostic odds ratio (popliteus tendon: 9.9; LCL: 17.0; popliteofibular ligament: 17.5). MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. Logistic regression found that the diagnostic accuracy was affected by the Schenck classification, with higher Schenck grades having worse diagnostic accuracy for peripheral structures (iliotibial band, popliteus tendon, and biceps tendon) and improved diagnostic accuracy for the ACL and posterior cruciate ligament. CONCLUSION The diagnostic accuracy of MRI for MLKIs largely varied among knee structures, with many of them at risk of a misdiagnosis, especially PLC, meniscal, and chondral lesions. The severity of MLKIs lowered the diagnostic accuracy of MRI for peripheral structures.
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Affiliation(s)
- Enrique Sanchez-Munoz
- Knee Unit, Department of Traumatology and Orthopaedic Surgery, Toledo University Hospital, Toledo, Spain
| | - Beatriz Lozano Hernanz
- Knee Unit, Department of Traumatology and Orthopaedic Surgery, Toledo University Hospital, Toledo, Spain
| | - Jacco A C Zijl
- Department of Orthopaedic Surgery, St Antonius Hospital, Utrecht, the Netherlands
| | - Luís Eduardo Passarelli Tirico
- Institute of Orthopedics and Traumatology, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabio Janson Angelini
- Institute of Orthopedics and Traumatology, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Peter C M Verdonk
- Orthopedic Center Antwerp, AZ Monica Hospital, Antwerp, Belgium; MoRe Foundation, Antwerp, Belgium
| | | | - Renato Andrade
- Clínica Espregueira, Porto, Portugal; Dom Henrique Research Centre, Porto, Portugal; Porto Biomechanics Laboratory, Faculty of Sport, University of Porto, Porto, Portugal
| | - João Espregueira-Mendes
- Clínica Espregueira, Porto, Portugal; Dom Henrique Research Centre, Porto, Portugal; School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal; 3B's Research Group [Biomaterials, Biodegradables and Biomimetics], University of Minho, Guimarães, Portugal
| | - Cristina Valente
- Clínica Espregueira, Porto, Portugal; Dom Henrique Research Centre, Porto, Portugal
| | - Francisco Figueroa
- Clinica Alemana, Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile; Hospital Sotero del Rio, Santiago, Chile
| | - David Figueroa
- Clinica Alemana, Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
| | - Antonio Maestro Fernández
- School of Medicine, University of Oviedo, Oviedo, Spain; Begoña Hospital, Gijón, Spain.,Investigation performed at Toledo University Hospital, Toledo, Spain
| | - Antonio Maestro Fernández
- School of Medicine, University of Oviedo, Oviedo, Spain; Begoña Hospital, Gijón, Spain.,Investigation performed at Toledo University Hospital, Toledo, Spain
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20
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Watrinet J, von Rüden C, Regenbogen S, Brand A, Bormann M, Stuby FM, Fürmetz J. Mid-Term Results following Traumatic Knee Joint Dislocation. J Clin Med 2022; 12:jcm12010266. [PMID: 36615066 PMCID: PMC9821045 DOI: 10.3390/jcm12010266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Although treatment strategies of knee joint dislocations have evolved, there is still no consensus on the best method and timing. New therapeutic concepts suggest that early one-stage treatment, including suturing and bracing of the cruciate ligaments in acute knee joint dislocation, are leading to improved functional results. This study aimed to evaluate the midterm functional outcome following traumatic knee joint dislocation and to determine whether the outcome is influenced by the surgical management, patient habitus or concomitant injuries. METHODS In this retrospective single center study, 38 patients with acute Schenck type II to IV knee dislocations were treated over an eight-year period in a level I trauma center. At follow-up, various clinical scores, such as the International Knee Documentation Committee (IKDC) Score, Lysholm Score, and Tegner Activity Scale (TAS), and individual questions about rehabilitation and activity levels of 38 patients were evaluated. RESULTS Mean follow-up was 5.5 ± 2.7 years. The mean IKDC Score was 65.6 ± 15.7 points, the average Lysholm Score was 70.5 ± 16.4 points and the median TAS was 4 (0-7), resulting in a loss of activity of 2 (range 0-6) points. There was no significant difference between a one-stage treatment compared to a two-stage approach. Ligament reconstruction of the ACL in a two-stage approach was required in only 33.3%. Further operations (early and late) were performed in 37% of cases. Being overweight was associated with more complications and worse outcomes, and external fixation with arthrofibrosis. CONCLUSIONS Knee dislocation is a severe trauma that often leads to a prolonged loss of function and increased knee pain over years, affecting the patient's activity. Clinical outcome is influenced significantly by concomitant injuries. Severe cases with initial external fixation are associated with a higher risk of knee stiffness and should be considered during rehabilitation. Obese patients present a challenge due to higher complication rates and lower postoperative knee function. LEVEL OF EVIDENCE Retrospective single center study, level III.
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Affiliation(s)
- Julius Watrinet
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian von Rüden
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Stephan Regenbogen
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute of Biomechanics, BG Trauma Center Murnau, 82418 Murnau, Germany
| | - Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | - Fabian M. Stuby
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Julian Fürmetz
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
- Correspondence:
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21
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Failure in Medical Practice: Human Error, System Failure, or Case Severity? Healthcare (Basel) 2022; 10:healthcare10122495. [PMID: 36554018 PMCID: PMC9778633 DOI: 10.3390/healthcare10122495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
The success rate in medical practice will probably never reach 100%. Success rates depend on many factors. Defining the success rate is both a technical and a philosophical issue. In opposition to the concept of success, medical failure should also be discussed. Its causality is multifactorial and extremely complex. Its actual rate and its real impact are unknown. In medical practice, failure depends not only on the human factor but also on the medical system and has at its center a very important variable-the patient. To combat errors, capturing, tracking, and analyzing them at an institutional level are important. Barriers such as the fear of consequences or a specific work climate or culture can affect this process. Although important data regarding medical errors and their consequences can be extracted by analyzing patient outcomes or using quality indicators, patient stories (clinical cases) seem to have the greatest impact on our subconscious as medical doctors and nurses and these may generate the corresponding and necessary reactions. Every clinical case has its own story. In this study, three different cases are presented to illustrate how human error, the limits of the system, and the particularities of the patient's condition (severity of the disease), alone or in combination, may lead to tragic outcomes There is a need to talk openly and in a balanced way about failure, regardless of its cause, to look at things as they are, without hiding the inconvenient truth. The common goal is not to find culprits but to find solutions and create a culture of safety.
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22
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Multiligamentous Knee Injuries: Acute Management, Associated Injuries, and Anticipated Return to Activity. J Am Acad Orthop Surg 2022; 30:1108-1115. [PMID: 36400057 DOI: 10.5435/jaaos-d-21-00830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 07/19/2022] [Indexed: 11/21/2022] Open
Abstract
Multiligamentous knee injuries (MLKIs) are devastating injuries. The energy and severity of these injuries encompass a wide range from low-energy single-joint mechanisms to high-energy polytrauma settings. Currently, there is no consensus on surgical treatment approach, surgical timing, or the return to preinjury activity levels after injury. There does appear to be a difference in the rate of return to activity and level of activity based on whether the injury was sustained during sport, in a trauma setting, or while on active military duty. The purpose of this descriptive review was to summarize current concepts related to (1) the acute management of MLKIs; (2) the effect of concomitant neurovascular, meniscal, and chondral injury on MLKI outcomes; (3) the effect of surgical versus nonsurgical treatment of MLKI on outcomes; and (4) rates and predictors of return to sport, work, and active military service after an MLKI.
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Malik SS, Osan JK, Aujla R, Aslam N, D'Alessandro P, MacDonald PB. A systematic review on management and outcome of irreducible knee dislocations. Orthop Traumatol Surg Res 2022; 108:103415. [PMID: 36126871 DOI: 10.1016/j.otsr.2022.103415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 07/24/2022] [Accepted: 08/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Irreducible knee dislocations (IKD) are rare and can often be missed or misdiagnosed. The incidence of knee dislocation is quoted between 0.01% and 0.2% of all orthopaedic injuries, with up to 4% of these dislocations sub-classified as irreducible. The primary aim of this systematic review was to analyse cases of IKD described in the literature, with a secondary aim of producing a streamlined approach for managing these patients. PATIENTS AND METHODS A systematic review of the literature was conducted on 1st September 2021 in accordance with the PRISMA guidelines using the online databases Medline and EMBASE. The review was registered prospectively in the PROSPERO database. Case reports or clinical studies or reporting on IKD were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle-Ottawa quality assessment scale. RESULTS The search strategy identified 60 studies eligible for inclusion, giving a total of 114 cases of IKD. Posterolateral dislocation was most common, seen in 85% of cases. The dimple sign was present in 70%. All cases required surgical intervention to achieve joint reduction. The most commonly involved structure blocking reduction was the medial collateral ligament (MCL)±medial structures, seen in 52.4%. MCL reconstruction or repair was carried out in 32.3% cases. The overall incidence of neurovascular injury was 9% and the overall complication rate was 14.4%. CONCLUSION Based on the findings of this SR we conclude that: the most common type of IKDs are PL dislocations, and the MCL, medial retinaculum and capsule and vastus medialis oblique form the most common structures involved in block to reduction and often will require open reduction and repair in acute setting if arthroscopic reduction fails. The most common pattern of injury to ligament is likely to be ACL, PCL, MCL±other structures but the MCL will be the most commonly repaired ligament. The dimple sign is often present and is highly pathognomonic of IKD. The incidence of neurovascular injury is uncommon. The most common post-operative complications likely to be encountered is medial skin necrosis and postoperative knee stiffness. Therefore, patients should be mobilised as early as possible with ROM in hinge brace. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Jess K Osan
- Orthopaedic Research Foundation of Western Australia, Australia
| | | | - Nadim Aslam
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
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Kniegelenkluxation Grad IIIL nach Schenck mit Ruptur der A. poplitea. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00580-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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25
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Relationship Between Peroneal Nerve and Anterior Cruciate Ligament Involvement in Multiligamentous Knee Injury: A Multicenter Study. J Am Acad Orthop Surg 2022; 30:e1461-e1466. [PMID: 36326829 DOI: 10.5435/jaaos-d-21-01252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/15/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Peroneal nerve injuries are rare injuries and usually associated with multiligamentous knee injuries (MLKIs) involving one or both cruciate ligaments. The purpose of our study was to perform a multicenter retrospective cohort analysis to examine the rates of peroneal nerve injuries and to see whether a peroneal nerve injury was suggestive of a particular injury pattern. METHODS A retrospective chart review was conducted in patients who were diagnosed with MLKI at two level I trauma centers from January 2001 to March 2021. MLKIs were defined as complete injuries to two or more knee ligaments that required surgical reconstruction or repair. Peroneal nerve injury was clinically diagnosed in these patients by the attending orthopaedic surgeon. Radiographs, advanced imaging, and surgical characteristics were obtained through a chart review. RESULTS Overall, 221 patients were included in this study. The mean age was 35.9 years, and 72.9% of the population was male. Overall, the incidence of clinical peroneal nerve injury was 19.5% (43 patients). One hundred percent of the patients with peroneal nerve injury had a posterolateral corner injury. Among patients with peroneal nerve injury, 95.3% had a complete anterior cruciate ligament (ACL) rupture as compared with 4.7% of the patients who presented with an intact ACL. There was 4.4 times of greater relative risk of peroneal nerve injury in the MLKI with ACL tear group compared with the MLKI without an ACL tear group. No statistical difference was observed in age, sex, or body mass index between patients experiencing peroneal nerve injuries and those who did not. CONCLUSION The rate of ACL involvement in patients presenting with a traumatic peroneal nerve palsy is exceptionally high, whereas the chance of having a spared ACL is exceptionally low. More than 90% of the patients presenting with a nerve palsy will have sustained, at the least, an ACL and posterolateral corner injury. LEVEL OF EVIDENCE IV, Case Series.
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Dianat S, Bencardino JT. Postoperative Magnetic Resonance Imaging of the Knee Ligaments. Magn Reson Imaging Clin N Am 2022; 30:703-722. [DOI: 10.1016/j.mric.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Smith JRH, Belk JW, Friedman JL, Dragoo JL, Frank RM, Bravman JT, Wolcott ML, McCarty EC. Predictors of Mid- to Long-Term Outcomes in Patients Experiencing a Knee Dislocation: A Systematic Review of Clinical Studies. J Knee Surg 2022; 35:1333-1341. [PMID: 33545729 DOI: 10.1055/s-0041-1723762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m2 are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m2, concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.
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Affiliation(s)
- John-Rudolph H Smith
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jamie L Friedman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jason L Dragoo
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Rachel M Frank
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan T Bravman
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michelle L Wolcott
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
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Held M, Scheepers W, von Bormann R, Wascher DC, Richter DL, Schenck RC, Harner CD. Inclusion of open injuries in an updated Schenck classification of knee dislocations based on a global Delphi consensus study. J ISAKOS 2022; 7:95-99. [PMID: 35604318 DOI: 10.1016/j.jisako.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/05/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. METHODS A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. RESULTS Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). CONCLUSION Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.
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Affiliation(s)
- Michael Held
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town, Western Cape, South Africa.
| | - Waldo Scheepers
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town, Western Cape, South Africa.
| | - Richard von Bormann
- University of Cape Town, Department of Orthopaedic Surgery, Cape Town Sports & Orthopaedics Clinic, Cape Town, Western Cape, South Africa.
| | - Daniel C Wascher
- University of New Mexico School of Medicine, Department of Orthopaedics, Albuquerque, New Mexico, USA.
| | - Dustin L Richter
- University of New Mexico Health Sciences Center, Department of Orthopaedics & Rehabilitation, Albuquerque, New Mexico, USA.
| | - Robert C Schenck
- University of New Mexico School of Medicine, Department of Orthopaedics, Albuquerque, New Mexico, USA.
| | - Christopher D Harner
- University of Texas Health Sciences Center Houston, Department of Orthopaedics, Houston, Texas, USA.
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29
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Fayed AM, Kanto R, Price TM, DiNenna M, Linde MA, Smolinski P, van Eck C. No Difference in Knee Kinematics Between Anterior Cruciate Ligament-First and Posterior Cruciate Ligament-First Fixation During Single-Stage Multiligament Knee Reconstruction: A Biomechanical Study. Orthop J Sports Med 2022; 10:23259671221118587. [PMID: 36186708 PMCID: PMC9523854 DOI: 10.1177/23259671221118587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background: For combined reconstruction of both the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), there is no consensus regarding which graft should be tensioned and fixed first. Purpose: The purpose of this study was to determine which sequence of graft tensioning and fixation better restores normal knee kinematics. The hypothesis was that ACL-first fixation would more closely restore normal knee kinematics, graft force, and the tibiofemoral orientation in the neutral (resting) position compared with PCL-first fixation. Study Design: Controlled laboratory study. Methods: A total of 15 unpaired human cadaveric knees were examined using a robotic testing system under the following 4 conditions: (1) 89.0-N anterior tibial load at different knee angles; (2) 89.0-N posterior tibial load at different knee angles; (3) combined rotational 7.0-N·m valgus and 5.0-N·m internal rotation load (simulated pivot shift) at 0°, 15°, and 30° of flexion; and (4) 5.0-N·m external rotation load at 0°, 15°, and 30° of flexion. The 4 evaluated knee states were (1) intact ACL and PCL (intact), (2) ACL and PCL deficient (deficient), (3) combined anatomic ACL-PCL reconstruction fixing the ACL first (ACL-first), and (4) combined anatomic ACL-PCL reconstruction fixing the PCL first (PCL-first). A 9.0 mm–diameter quadriceps tendon autograft was used for the ACL graft, tensioned with 40.0 N at 30° of flexion. A 9.5 mm–diameter hamstring tendon autograft (gracilis and semitendinosus, quadrupled loop, and augmented with an additional allograft strand if needed), tensioned with 40.0 N at 90° of flexion, was used for the PCL graft. Results: There were no statistically significant differences between ACL-first and PCL-first fixation regarding knee kinematics. ACL-first fixation restored anterior tibial translation to the intact state at all tested knee angles, while PCL-first fixation showed higher anterior tibial translation than the intact state at 90° of flexion (9.05 ± 3.05 and 5.87 ± 2.40 mm, respectively; P = .018). Neither sequence restored posterior tibial translation to the intact state at 30°, 60°, and 90° of flexion. At 15° of flexion, PCL-first fixation restored posterior tibial translation to the intact state, whereas ACL-first fixation did not. Conclusion: There were no differences in knee laxity between ACL-first and PCL-first fixation with the ACL graft fixed at 30° and the PCL graft fixed at 90°. Clinical Relevance: This study showed that there was no evidence to support the use of one tensioning sequence over the other in single-stage multiligament knee reconstruction.
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Affiliation(s)
- Aly M Fayed
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ryo Kanto
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Taylor M Price
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael DiNenna
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carola van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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30
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Lau BC, Varsheya K, Morriss N, Wickman J, Kirkendall D, Abrams G. Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment. Arthrosc Sports Med Rehabil 2022; 4:e1659-e1666. [PMID: 36312718 PMCID: PMC9596897 DOI: 10.1016/j.asmr.2022.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries. Methods The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ2 tests, and Fisher exact tests were used with an α level of .05 set as significant. Results We identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group. Conclusions Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured. Level of Evidence Level III, retrospective cohort study.
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31
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Said SM, Elsoe R, Mikkelsen C, Engström B, Larsen P. Clinical, functional, and patient-reported outcome of traumatic knee dislocations: a retrospective cohort study of 75 patients with 6.5-year follow-up. Arch Orthop Trauma Surg 2022; 143:2589-2597. [PMID: 35972573 DOI: 10.1007/s00402-022-04578-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/06/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION At present, limited knowledge regarding clinical, functional, and patient-reported outcomes at mid- and long-terms after surgical treatment of traumatic knee dislocations is available. This study aimed to investigate the mid-term recovery regarding clinical, functional, and patient-reported outcomes in patients following knee dislocation with associated multi-ligament injuries. MATERIALS AND METHODS The study design was a cross-sectional cohort study. Data were collected by retrospective chart review, clinical examination, and interview of patients. All patients treated surgically following a knee dislocation between January 2000 and December 2011 were included. The surgical technique was up to the decision of the individual surgeon. The main outcome was the Lysholm knee score. Secondary outcomes consist of clinical knee examination, functional performance test, pain, and patient-reported outcome across several domains in function, sport, pain, and quality of life. RESULTS Seventy-five patients (66.3%) accepted the invitation to participate. The mean age at the time of knee dislocation was 33.5 years, with a range of 16-65 years of age. The mean follow-up time was 78 months (R: 17-147). 75% of patient a Schenck's type 1 lesion and 23% a type 3. The median Lysholm knee score was 83 (R: 18-100). The mean KOOS for the five subscales were pain 84.5 (95% CI 80.5-88.5), symptoms 75.1 (95% CI 70.7-79.4), ADL 87.0 (95% CI 83.1-90.9), sport 59.9 (95% CI 53.3-66.4), and QOL 71.3 (95% CI 67.0-75.6). The mean Tegner activity level was 5.1 (95% CI 4.5-5.7). The median single assessment numeric evaluation (SANE) was 93 (R: 0-100). The pain intensity score for pain (VAS) during activity was reported with a mean of 2.7 (95% CI 2.1-3.3). The objective IKDC examination showed 76% of patients grouped by Grade A (normal knee function) or Grade B (nearly normal). CONCLUSION With a mean follow-up of 6.5 years, combined repair and reconstruction surgery following a knee dislocation shows good to excellent patient-reported outcome and more than 75% of patients experiencing normal knee functioned evaluated by the IKDC score.
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Affiliation(s)
- Sinan M Said
- Department of Orthopaedic Surgery, Aalborg University Hospital, 18-22 Hobrovej, DK-9000, Aalborg, Denmark.,Karolinska Institutet/Sports Trauma Research Center, Stockholm, Sweden
| | - Rasmus Elsoe
- Department of Orthopaedic Surgery, Aalborg University Hospital, 18-22 Hobrovej, DK-9000, Aalborg, Denmark
| | | | - Björn Engström
- Karolinska Institutet/Sports Trauma Research Center, Stockholm, Sweden
| | - Peter Larsen
- Department of Orthopaedic Surgery, Aalborg University Hospital, 18-22 Hobrovej, DK-9000, Aalborg, Denmark. .,Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark.
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32
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Gregersen MB, Freund KG. Total Knee Arthroplasty as the Primary Surgical Treatment After Knee Dislocation. Arthroplast Today 2022; 16:112-118. [PMID: 35677942 PMCID: PMC9168382 DOI: 10.1016/j.artd.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/12/2022] [Accepted: 04/23/2022] [Indexed: 11/30/2022] Open
Abstract
Traumatic knee dislocation (KD) is a rare but serious injury, and a missed diagnosis or incorrect treatment can be limb-threatening due to a significant risk of neurovascular injury. The mechanism of injury is often high-energy trauma, but there is a rising tendency of KD after low-energy trauma in the obese patient. KD often results in multiligament injury which can be a complicated surgical task with long recovery time, especially in older patients. This report presents 4 cases where patients older than 50 years with traumatic KD have been treated with a total knee arthroplasty of revision type as an alternative to multiligament reconstruction.
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Affiliation(s)
| | - Knud Gade Freund
- Department of Orthopedic Surgery, Southwest Jutland Hospital Esbjerg, Esbjerg, Denmark
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Mortazavi SMJ, Kaseb MH, Maleki RG, Razzaghof M, Noori A, Rezaee R. The Functional Outcomes of Delayed Surgical Reconstruction in Nonsport-Induced Multiligament Knee Injuries: A Retrospective Cohort Study. J Knee Surg 2022; 35:1097-1105. [PMID: 33389731 DOI: 10.1055/s-0040-1721788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Multiligament knee injuries (MLKIs) are among the most detrimental injuries, which can cause significant compromise of joint stability and function. Our aim was to investigate the functional outcomes of nonsport-induced MLKIs who presented late after injury and underwent delayed arthroscopic reconstruction. In a retrospective cohort of 18 MLKI patients (19 knees, January 2012-2018) who had undergone arthroscopic reconstruction, we assessed the knee range of motion, return to work/sport, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner scores. The preoperative scores were retrieved from the patients' registry database. We reviewed their surgical notes and extracted the operation data, including the damaged ligaments, stages of the surgery, and associated meniscal injury. There were 14 males and 4 females with a mean age of 30.57 ± 10.31 years. The mean time from injury to surgery was 17.31 ± 11.98 months. The most common injury was anterior cruciate ligament/posterior cruciate ligament (31.6%). The mechanisms of injury were motor vehicle accidents (72.2%), falls (22.2%), and sports (5.6%). The reconstruction was either single (61.2%) or multiple stage (38.8%). The pre- and postoperative scores were 45.31 ± 7.30 versus 79.16 ± 11.86 IKDC, 3.84 ± 1.26 versus 8.37 ± 1.16 Tegner, and 60.42 ± 7.68 versus 89.42 ± 8.81 Lysholm, respectively. All the scores showed significant improvement at mean follow-up of 24.05 ± 9.55 months (p < 0.001). In conclusion, delayed arthroscopic reconstruction of MLKIs significantly improved the functional outcomes and return to work in patients presenting late to the orthopaedic clinic. There was no relationship between the demographic variables, mechanism of injury, number of injured ligaments, and the stages of surgery and the functional outcomes in this group of patients.
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Affiliation(s)
- S M Javad Mortazavi
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
| | - M H Kaseb
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
| | - R G Maleki
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
| | - M Razzaghof
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
| | - A Noori
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
| | - R Rezaee
- Department of Orthopedics, Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran, Iran
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Sobrado MF, Giglio PN, Bonadio MB, Pecora JR, Gobbi RG, Angelini FJ, Helito CP. High Incidence of Osteoarthritis Observed in Patients at Short- to Midterm Follow-Up after Delayed Multiligament Knee Reconstruction. J Knee Surg 2022; 35:1147-1152. [PMID: 33485275 DOI: 10.1055/s-0040-1722348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to evaluate the incidence of knee osteoarthritis, failure rate of reconstruction, and clinical outcomes of patients with chronic multiligament knee injuries subjected to surgical treatment. Sixty-two patients with chronic knee dislocation subjected to multiligament reconstruction between April 2008 and July 2016 were evaluated, with a minimum follow-up of 24 months. Anteroposterior and lateral radiographs were performed in the pre- and last postoperative evaluation; the progression of degenerative changes according to the Kellgren-Lawrence classification (KL) was assessed. The Schenck classification, Knee Injury and Osteoarthritis Outcome Score (KOOS), time between injury and surgery, type of postoperative rehabilitation protocol (brace vs. external fixator), and physical examination for ligament instability were also evaluated. Univariate and multivariate analysis were performed, p <0.05 was considered significant. Fifty-two (83.9%) patients were men and 16.1% (n = 10) were women, with a mean age of 38.8 ± 1.3 years. The time from injury to surgery was 31.1 ± 6.1 months, and the follow-up time was 6.1 ± 0.5 years. The mean final KOOS was 79.3 ± 10.4 and the overall reconstruction failure occurred in 25.8%. Of all patients, 64.5% (n = 40) presented a KL classification of ≥2 and were defined as having radiographic osteoarthritis (OA). As 11.7% (n = 7) also presented arthritis in the contralateral knee, in 53.2% (n = 33) the progression was most likely due to the initial injury. The failure of ligament reconstruction or residual instability was present in 15 (35.7%) of patients with OA, and only one patient (4.5%) without OA. In the multivariate analysis, only reconstruction failure was an independent predictor of OA (odds ratio = 13.2 [p = 0.028]). There is a high incidence of knee OA following ligament reconstruction for chronic multiligament knee injuries. Ligament reconstruction failure was the only independent predictor for the development of OA in our study.
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Affiliation(s)
- Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jose Ricardo Pecora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Janson Angelini
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
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Fortier LM, Stylli JA, Civilette M, Duran NS, Hanukaai S, Wilder H, Sherman WF, Kaye AD. An Evidence-Based Approach to Multi-Ligamentous Knee Injuries. Orthop Rev (Pavia) 2022; 14:35825. [PMID: 35769647 PMCID: PMC9235428 DOI: 10.52965/001c.35825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/12/2022] [Indexed: 01/19/2024] Open
Abstract
Multi ligament knee injuries (MLKIs) are highly complex injuries with associated complications and often present with difficult management strategies. MLKIs may affect the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (or posteromedial corner (PMC)), and lateral collateral ligament (or posterolateral corner (PLC)) in addition to other structures including the menisci, common peroneal nerve, and popliteal artery. MLKIs are highly associated with the male sex and are commonly seen in high-velocity motor vehicle accidents and low-velocity sports injuries. Given the multiple planes of movement in the knee and various primary and secondary stabilizers throughout those planes, there is great heterogeneity in an injury pattern and most involve the ACL and PCL. Initial evaluation of this injury includes assessment of lower extremity sensation, distal pulses, and ankle-brachial index (ABI). If vascular compromise is suspected, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are indicated to evaluate the vasculature. As opposed to CTA, MRA offers visualization of the soft-tissue structures that are commonly damaged in MLKIs. Initial management typically includes closed reduction of the knee with subsequent external fixation. Classification systems guide initial assessments; however, further management is unclear and leads the surgical team to decide the best, individualized management option for each patient. As a result, optimal surgical and postoperative treatment options remain complicated, and clinical outcomes remain difficult to predict. The purpose of this review is to consolidate the most up-to-date practices of the diagnostic workup, management, and treatment of MLKIs.
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Affiliation(s)
| | | | | | | | | | - Heath Wilder
- Department of Orthopaedic Surgery, Tulane University
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport
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The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury. Skeletal Radiol 2022; 51:981-990. [PMID: 34557951 DOI: 10.1007/s00256-021-03907-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.
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Bozkurt I, Ozdemir G, Bingol O, Kilic E, Korucu A, Ocguder DA. Demographic analysis of knee dislocation: A rare mechanism of injury. J Orthop Surg (Hong Kong) 2022; 29:23094990211061253. [PMID: 34872397 DOI: 10.1177/23094990211061253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The aim of this study was to present to the literature a rare injury mechanism that causes knee dislocation (KD) and describe its characteristics. METHODS A retrospective review of patients with KD who were treated between January 2014 and December 2019 at our hospital was performed. Patients with KD due to rotavator machine injury were included in Group 1 and all patients with KD due to other etiological reasons were included in Group 2. Patients' age, gender, side, injury mechanism, time to surgery, length of stay (LOS), operation time, follow-up time, neurological injury status, vascular injury status, open injury status, and surgical interventions were evaluated. RESULTS A total of 34 patients were evaluated in the study. There was no statistically significant difference between the groups in terms of age, gender, side, or follow-up time (p = .915, p = 1.000, p = .682, p = .374, respectively). However, LOS and time to surgery were statistically significantly longer in Group 1 (p = .037, p = .010, respectively). Moreover, neurovascular damage was statistically significantly more common in Group 1. CONCLUSION As a rare injury mechanism for KD, rotavator machine injuries cause more neurovascular injuries in patients compared to other injury mechanisms and increase the time to surgery and LOS due to preoperative soft tissue damage.
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Affiliation(s)
- Ibrahim Bozkurt
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Guzelali Ozdemir
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Olgun Bingol
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Enver Kilic
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Alperen Korucu
- Orthopedics and Traumatology Clinic, 536164Ankara City Hospital, Cankaya, Ankara, Turkey
| | - Durmus Ali Ocguder
- Medical Faculty, Orthopedics and Traumatology Department, 442146Yildirim Beyazit University, Cankaya, Ankara, Turkey
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Pinheiro IN, Pedrinha ISM, Maia PAV, Cortes ARDO, Albuquerque RPE, Barretto JM. Estudo epidemiológico das lesões multiligamentares do joelho. Rev Bras Ortop 2022; 57:675-681. [PMID: 35966442 PMCID: PMC9365474 DOI: 10.1055/s-0041-1731798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/08/2021] [Indexed: 12/05/2022] Open
Abstract
Objective
The present paper aims to describe multiligament knee injuries and to associate their features with the profile of the patients and trauma mechanisms.
Methods
This is a cross-sectional study evaluating 82 patients with multiligament knee injuries from September 2016 to September 2018. Evaluated parameters included age, gender, mechanical axis, affected side, range of motion, trauma mechanism, associated injuries, affected ligaments, and absence from work.
Results
The sample included patients aged between 16 and 58 years old, with an average age of 29.7 years old; most subjects were males, with 92.7% of cases. The most common trauma mechanism was motorcycle accident (45.1%). The most injured ligament was the anterior cruciate ligament (80.5%), followed by the posterior cruciate ligament (77.1%), the posterolateral corner (61.0%), and the tibial collateral ligament (26.8%). The most frequent type of dislocation was KD IIIL (30.4%). Only 1 patient had a vascular injury, and 13 (15.9%) presented with neurological injuries. Most subjects took medical leave from work (52.4%).
Conclusion
There is a big difference between patients with multiligament lesions in Brazil compared with international studies. Thus, it is advisable to carry out more specific studies on the topic with our population to improve the treatment of these patients.
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Affiliation(s)
- Igor Natário Pinheiro
- Centro de Atenção Especializada ao Joelho, Instituto Nacional de Traumatologia Jammil Haddad, Rio de Janeiro, RJ, Brasil
| | - Igor Stefano Menescal Pedrinha
- Centro de Atenção Especializada ao Joelho, Instituto Nacional de Traumatologia Jammil Haddad, Rio de Janeiro, RJ, Brasil
| | - Phelippe Augusto Valente Maia
- Centro de Atenção Especializada ao Joelho, Instituto Nacional de Traumatologia Jammil Haddad, Rio de Janeiro, RJ, Brasil
| | | | - Rodrigo Pires e Albuquerque
- Centro de Atenção Especializada ao Joelho, Instituto Nacional de Traumatologia Jammil Haddad, Rio de Janeiro, RJ, Brasil
| | - João Maurício Barretto
- Centro de Atenção Especializada ao Joelho, Instituto Nacional de Traumatologia Jammil Haddad, Rio de Janeiro, RJ, Brasil
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Hsieh YH, Lee MC, Hsu CC, Chen SH, Lin YT, Lin CH, Lin CH. Popliteal Artery Injury After Fracture and/or Dislocation of the Knee: Risk Stratification for Revascularization Outcome. Ann Plast Surg 2022; 88:S50-S55. [PMID: 35225847 DOI: 10.1097/sap.0000000000003076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Managing complex knee trauma involving both vascular and osseous injuries is challenging, yet the available guidelines for efficient popliteal artery injury management after high-velocity blunt knee trauma remain conflicting and inconsistent. In this study, the authors aim to identify the risk factors associated with delayed limb amputation and ischemic muscular sequela postrevascularization. Furthermore, we propose a treatment algorithm to improve the limb salvage rate. METHODS Patients who presented with traumatic popliteal artery injury resulting in vessel occlusion or rupture, followed by fracture and/or dislocation of the knee from January 2008 to December 2013, were included for retrospective review. RESULTS Overall delayed amputation rate was 24% (7/29) and 16% (4/25) after successful revascularization. Mangled Extremity Severity Score is higher in the delayed amputation group than the limb-salvaged group (P = 0.02). Higher-impact force (P = 0.03), ischemic limb on presentation (P = 0.03), prolonged ischemia time (P = 0.04), unstable hemodynamics (P = 0.01), longer operation time (P = 0.04), and prolonged intensive care unit stay (P = 0.03) are risk factors of delayed amputation. Longer ischemia time (P = 0.04) and length of popliteal artery injury (P = 0.02) are associated with ischemic muscular sequela. CONCLUSIONS Mangled Extremity Severity Score is a reliable predictor of limb salvage. An algorithmic approach may improve the outcome of popliteal artery injury after high-velocity blunt knee trauma.
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Affiliation(s)
- Yun-Huan Hsieh
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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Constantinescu D, Pavlis W, Berge DV, Barnhill S, Geller J, Vilella FE. Anterior prosthetic knee dislocation with acute vascular injury: A case report. Ann Med Surg (Lond) 2022; 75:103425. [PMID: 35386803 PMCID: PMC8977930 DOI: 10.1016/j.amsu.2022.103425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction and Importance: Anterior dislocation of a prosthetic knee is rarely encountered. Acute vascular injury following anterior prosthetic dislocation has only been reported once in the literature with extremely poor outcomes. Case presentation The authors report the case of a 70-year-old woman who presented with anterior prosthetic knee dislocation after a fall from slipping. After closed reduction, CT angiography found transection and active extravasation of the left popliteal artery. An emergent fasciotomy and popliteal bypass were performed with concurrent external fixation of the joint. Recovery was complicated by bacteremia requiring eventual explant of total knee arthroplasty (TKA). Clinical discussion We report the only case of successful vascular repair after acute vascular injury from traumatic anterior prosthetic dislocation. External fixation of the knee allowed for better stabilization of the joint and preservation of the repaired vascular injury; however, it carries a risk for infection, as seen in this case. Conclusions While there are no clear guidelines for management, we highlight the importance of rapid diagnosis with CT angiography and shared decision making with the vascular surgery team to repair the injury and stabilize the joint. 70-year-old woman with acute popliteal injury following anterior prosthetic knee dislocation. First case of successful vascular repair following such injury. Rapid CT angiography, vascular repair, and stabilization of the joint essential in management.
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Affiliation(s)
| | - William Pavlis
- University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Corresponding author. 1600 NW 10th Ave #1140, Miami, FL, 33136, USA.
| | | | - Spencer Barnhill
- Department of Orthopaedics, University of Miami, Miami, FL, 33136, USA
| | - Joseph Geller
- Department of Orthopaedics, University of Miami, Miami, FL, 33136, USA
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Acute Femoropopliteal Bypass Graft Occlusion After Knee Manipulation Under Anesthesia: A Case Report and Review of Current Literature. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202202000-00001. [PMID: 35134016 PMCID: PMC8812637 DOI: 10.5435/jaaosglobal-d-21-00197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/19/2021] [Indexed: 11/18/2022]
Abstract
Bilateral tibiofemoral knee dislocations are a relatively rare injury, and there is a scarcity of literature on its appropriate evaluation and treatment. Even less knee dislocations with concomitant popliteal artery injury have been described. Postoperative graft occlusion accounts for approximately half of the overall complication rate, occurring in up to 18% of the patients undergoing femoropopliteal bypass grafting. Furthermore, anticoagulation and antiplatelet therapy after graft placement is a point of contention. Here, we describe a case of a knee dislocation with associated popliteal artery transection treated initially with successful knee-spanning external fixation and arterial grafting, respectively. At 6 weeks after injury, the patient underwent external fixation removal and closed manipulation of the knee for arthrofibrosis. After manipulation, yet still under anesthesia, distal pulses were acutely diminished and subsequent CTA demonstrated femoropopliteal graft thrombosis. This case demonstrates successful recognition, thrombectomy, and restoration of arterial blood flow, which has since been maintained. Written consent by the patient involved in this case report was obtained.
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Ramírez-Bermejo E, Gelber PE, Pujol N. Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review. Arch Orthop Trauma Surg 2022; 142:255-261. [PMID: 33222023 DOI: 10.1007/s00402-020-03684-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator. MATERIAL AND METHODS The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports. RESULTS Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups. CONCLUSIONS External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Eduard Ramírez-Bermejo
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain.
| | - Pablo Eduardo Gelber
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
- ICATME, Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Nicolas Pujol
- Department of Orthopaedic Surgery and Traumatology, Versailles Hospital, University of West Paris-St Quentin, Versailles-Paris, France
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Moreno B, Vaz P, Melo B, Cunha M, Vaz R. Knee Dislocation With Vascular and Nerve Injury in a Professional Football Player: Return to Play. Cureus 2022; 14:e21607. [PMID: 35106263 PMCID: PMC8789321 DOI: 10.7759/cureus.21607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 12/02/2022] Open
Abstract
Traumatic knee dislocations are serious and complex injuries, defined as clinical and/or radiological loss of tibiofemoral congruence, which may represent real emergencies to the integrity of the affected limb. This lesion is responsible for multi-ligament tears but the most serious possible complications are related to vascular and peripheral nerve injuries. Recent studies show that surgical treatment has better functional results and higher return rates to sports practice compared to conservative treatment. However, there is still no consensus on the ideal surgical technique and the timing of surgery. After conservative management or surgical treatment, rehabilitation treatment plays a key role in the recovery process. There are few studies evaluating the return to competition after traumatic knee dislocation and those athletes who return have difficulty reaching the pre-injury level. Here, we report the case of a professional football player who suffered a traumatic knee dislocation, with multiple ligament tears associated with vascular and neurological damage. Three hours after the initial lesion a double interposition bypass was done with the great saphenous vein, returning flow distally. It was decided not to perform ligament surgery. Two years after a long and intense rehabilitation program the athlete successfully returned to competition.
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黄 锡, 李 韬, 赵 廷, 李 俊, 李 箭. [Effectiveness of knee dislocation and multiple ligament injury based on Hua Xi-knee dislocation and multiple ligament injury diagnosis and treatment system]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:1-9. [PMID: 35038793 PMCID: PMC8844615 DOI: 10.7507/1002-1892.202112064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 12/31/2021] [Accepted: 12/31/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the effectiveness of personalized treatment based on Hua Xi-knee dislocation and multiple ligament injury (HX-KDMLI) diagnosis and treatment system. METHODS A clinical data of 36 patients (36 knees) with KDMLI met the selective criteria between February 2019 and September 2020 was retrospectively analyzed. There were 24 males and 12 females with an average age of 45.7 years (range, 21-62 years). The KDMLI was caused by traffic accident in 15 cases, heavy pound in 8 cases, sports sprain in 7 cases, falling from height in 4 cases, and machine cutting in 2 cases. The interval between injury and operation was 1-9 weeks (mean, 3.6 weeks). All patients were categorized according to HX-KDMLI diagnosis and treatment system. Twenty patients were categorized as acute period and 16 patients as chronic period. Three patients were type HX-Ⅰ-A, 1 type HX-Ⅰ-P, 10 type HX-Ⅲ-L, 13 type HX-Ⅲ-M, 4 type HX-Ⅳ-S, 3 type HX-Ⅴ-F, and 2 type HX-Ⅴ-T. Thirty-five patients were positive in both the anterior drawer test and Lachman test, 31 were positive in the posterior drawer test; 19 patients were positive in varus stress test, 23 were positive in valgus stress test. According to the Internation Knee Documentation Committee (IKDC) grading, there was 1 case of grade A, 5 cases of grade B, 8 cases of grade C, and 2 cases of grade D. Surgical interventions included arthroscopic surgery, open surgery, or arthroscopy combined with open surgery, ligament suture or reconstruction, and internal fixation after anatomical reduction of the fracture. Different rehabilitation protocols were assigned to patients during different postoperative period, according to patient's individualized classification. RESULTS All incisions healed by first intention with no obvious complications. All patients were followed up 12-19 months (mean, 15 months). At 12 months after operation, all patients retained muscle strength of grade Ⅴ, and range of motion of the knee joint could reach 0° extension and over 120° flexion. Radiographic examination showed no sign of knee instability, healed fractures, ideal joint alignment, good continuity and tension, and clear image of repaired or reconstructed ligaments. The anterior and posterior drawer tests were all negative. Lachman test was degreeⅠpositive in 5 cases, valgus stress test was degreeⅠpositive in 2 cases, varus stress test was degreeⅠpositive in 2 cases; the other patients were all negative. At 12 months after operation, according to the IKDC grading, there were 9 cases of grade A, 19 cases of grade B, 5 cases of grade C, and 3 cases of grade D, showing significant differences when compared with the preoperative ones ( Z=-5.328, P=0.000). There were significant differences in the IKDC, Lysholm, and Tegner scores between pre- and post-operation (P<0.05). CONCLUSION The promising effectiveness of KDMLI can obtain under the guidance of HX-KDMLI.
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Affiliation(s)
- 锡豪 黄
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 韬 李
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 廷崴 赵
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 俊樵 李
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 箭 李
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
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Paterson-Byrne PA, Wilson WT, Hopper GP, MacKay GM. Primary repair of multiligament knee injury with InternalBrace ligament augmentation. BMJ Case Rep 2022; 15:e247173. [PMID: 34983813 PMCID: PMC8728444 DOI: 10.1136/bcr-2021-247173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 11/04/2022] Open
Abstract
Multiligament injury of the knee usually occurs as a result of high-energy trauma causing tibiofemoral dislocation. These are rare but potentially limb-threatening injuries, frequently involving nerve or arterial damage and often leading to severe complex instability. Management generally favours surgical reconstruction of the affected ligaments, with controversy regarding optimal treatment. We present a severe multiligament knee injury (Schenk classification KD-IV involving both cruciate and both collateral ligaments) in a competitive showjumper. A combined arthroscopic/open technique of single-stage surgical repair and suture augmentation was used, repairing all affected ligaments. The patient made an excellent recovery, returning to work after 12 weeks and riding after 22 weeks. After 5-year follow-up, she has regained her previous level of competition without subsequent injury. Multiligament repair with suture augmentation is a viable approach to the management of knee dislocation injuries. We propose that this could provide superior outcomes to traditional reconstruction techniques using autograft or synthetic reconstruction.
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Essilfie AA, Alaia EF, Bloom DA, Hurley ET, Doran M, Campbell KA, Jazrawi LM, Alaia MJ. Distal posterolateral corner injury in the setting of multiligament knee injury increases risk of common peroneal palsy. Knee Surg Sports Traumatol Arthrosc 2022; 30:239-245. [PMID: 33558949 DOI: 10.1007/s00167-021-06469-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to identify if the location of posterolateral corner (PLC) injury was predictive of clinical common peroneal nerve (CPN) palsy. METHODS A retrospective chart review was conducted of patients presenting to our institution with operative PLC injuries. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. A fellowship-trained musculoskeletal radiologist reviewed the PLC injury and categorized it into distal, middle and proximal injuries with or without a biceps femoral avulsion. The CPN was evaluated for signs of displacement or neuritis. RESULTS Forty-seven operatively managed patients between 2014 and 2019 (mean age-at-injury 29.5 ± 10.7 years) were included in this study. Eleven (23.4%) total patients presented with a clinical CPN palsy. Distal PLC injuries were significantly associated with CPN palsy [9 (81.8%) patients, (P = 0.041)]. Nine of 11 (81.8%) patients with CPN palsy had biceps femoral avulsion (P = 0.041). Of the patients presenting with CPN palsy, only four (36.4%) patients experienced complete neurologic recovery. Three of 7 patients (43%) with an intact CPN had full resolution of their clinically complete CPN palsy at the time of follow-up (482 ± 357 days). All patients presenting with a CPN palsy also had a complete anterior cruciate ligament (ACL) rupture in addition to a PLC injury (P = 0.009), with or without a posterior cruciate ligament (PCL) injury. No patient presenting with an isolated pattern of PCL-PLC injury (those without ACL tears) had a clinical CPN palsy. CONCLUSION Distal PLC injuries have a strong association with clinical CPN palsy, with suboptimal resolution in the initial post-operative period. Specifically, the presence of a biceps femoris avulsion injury was highly associated with a clinical CPN palsy. Additionally, CPN palsy in the context of PLC injury has a strong association with concomitant ACL injury. Furthermore, the relative rates of involvement of the ACL vs. PCL suggest that specific injury mechanism may have an important role in CPN palsy. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anthony A Essilfie
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA.
| | - Erin F Alaia
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - David A Bloom
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - Eoghan T Hurley
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - Michael Doran
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - Kirk A Campbell
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - Laith M Jazrawi
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
| | - Michael J Alaia
- New York University Langone Orthopedic Hospital, 333 East 38th Street, New York, NY, 10016, USA
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Monson J, Schoenecker J, Schwery N, Palmer J, Rodriguez A, LaPrade RF. Postoperative Rehabilitation and Return to Sport Following Multiligament Knee Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e29-e40. [PMID: 35141534 PMCID: PMC8811527 DOI: 10.1016/j.asmr.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/30/2021] [Indexed: 12/18/2022] Open
Abstract
Multiligament knee injuries (MLKIs) are debilitating injuries that increasingly occur in young athletes. Return to sport (RTS) has historically been considered unlikely due to the severity of these injuries. Reporting in the literature regarding objective outcomes following MLKI, including RTS, is lacking, as are clear protocols for both rehabilitation progressions and RTS testing. RTS following MLKI is a complex process that requires an extended recovery duration compared to other surgery types. Progressions through postoperative rehabilitation and RTS should be thoughtful, gradual, and criterion based. After effective anatomic reconstruction to restore joint stability, objective measures of recovery including range of motion, strength, movement quality, power, and overall conditioning guide decision-making throughout the recovery process. It is important to frame the recovery process of the athlete in the context of the severity of their injury, as it is typically slower and less linear. Improved reporting on objective outcomes will enhance our understanding of recovery expectations within this population by highlighting persistent deficits that may interfere with a full recovery, including RTS.
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Affiliation(s)
- Jill Monson
- Twin Cities Orthopedics, Eagan, Minnesota, U.S.A.,Training HAUS, Eagan, Minnesota, U.S.A
| | - Jon Schoenecker
- Twin Cities Orthopedics, Eagan, Minnesota, U.S.A.,Training HAUS, Eagan, Minnesota, U.S.A
| | | | - Jamie Palmer
- Twin Cities Orthopedics, Edina, Minnesota, U.S.A
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Scheepers W, Khanduja V, Held M. Current concepts in the assessment and management of multiligament injuries of the knee. SICOT J 2021; 7:62. [PMID: 34870591 PMCID: PMC8647687 DOI: 10.1051/sicotj/2021058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.
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Affiliation(s)
- Waldo Scheepers
- Department of Orthopedic Surgery, Groote Schuur Hospital, Orthopedic Research Unit, University of Cape Town, 7925 Cape Town, South Africa
| | - Vikas Khanduja
- Consultant Orthopedic Surgeon, Addenbrooke's - Cambridge University Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Michael Held
- Department of Orthopedic Surgery, Groote Schuur Hospital, Orthopedic Research Unit, University of Cape Town, 7925 Cape Town, South Africa
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Harris BT, Eichman EA, Burrus MT. Traumatic Simultaneous Bilateral Knee Dislocation: A Case Report. Cureus 2021; 13:e18989. [PMID: 34853734 PMCID: PMC8607962 DOI: 10.7759/cureus.18989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/05/2022] Open
Abstract
Bilateral knee dislocation is an extremely rare and devastating injury to the knee joint. This injury is a true emergency as concomitant injuries may threaten life and limb. Here, we report the case of a 26-year-old male patient who sustained bilateral knee dislocation due to a high-velocity motor vehicle accident. In this case, the patient suffered a feared complication associated with knee dislocation, popliteal artery disruption with peroneal nerve damage. Abdominal and skeletal injuries were also discovered and treated appropriately by a multidisciplinary team. A staged surgical approach to ligament reconstruction was used without any postoperative complication. Postoperatively, the patient successfully returned to his preoperative activity level.
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Affiliation(s)
- Benjamin T Harris
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Elizabeth A Eichman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Matthew T Burrus
- Orthopedic Surgery, Orthopedic Associates of Central Texas, Austin, USA
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50
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Anazor FC, Baryeh K, Davies NC. Knee joint dislocation: overview and current concepts. Br J Hosp Med (Lond) 2021; 82:1-10. [PMID: 34983230 DOI: 10.12968/hmed.2021.0466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Knee joint dislocation is a relatively uncommon injury but its management is important because of the associated high risk of vascular, neurological and multi-ligamentous knee injuries. Clinicians must be aware that not all knee dislocations are diagnosed on plain X-rays; a high index of suspicion is required based on clinical evaluation. Multidisciplinary specialist care is required in all cases to achieve best outcomes. Early one-stage or multiple staged ligament repair and reconstruction offer better outcomes, but most patients have some long-term functional limitation. This article provides insights into the epidemiology and management of this injury and its devastating effects.
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Affiliation(s)
- Fitzgerald C Anazor
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Kwaku Baryeh
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Neville C Davies
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading, UK
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