Vascular Injury After Occult Knee Dislocation Presenting as Compartment Syndrome

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38 days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.

Compartment Syndrome Secondary to Vascular Transection from a Knee Dislocation

Acute knee dislocation is a rare orthopedic injury with an incidence of <0.02% annually. The authors discuss a case involving a vascular injury sustained from a mechanical fall at home causing compartment syndrome. The case illustrates known complications associated with knee dislocations: vascular injury and compartment syndrome as well as the high suspicion needed in certain patient populations, such as Down's syndrome. It highlights the importance of rapid diagnosis, a complete physical exam, and the need to involve consultants in a timely fashion. A high index of suspicion for vascular injury following trauma to the knee, regardless of the mechanism is imperative.

Popliteal artery transection associated with a minimally displaced tibial plateau fracture: a case report and review of the literature

BACKGROUND

Poplital artery transection injury is potentially catastrophic, or even life-threatening. Severe traumas, including open fracture, gunshot, stabs, and knee dislocation and complex fracture of proximal tibia or distal femur, are the common causes of high rate of amputation due to popliteal artery trauma. No report mentions vascular injury associated with minimally displaced tibial plateau fracture in adult.

CASE PRESENTATION

A 30-year-old male presented with popliteal artery transection injury associated with minimally displaced tibial plateau fracture. He presented to emergency department, 6 h after fall from ground into a 1-m height hole. Physical examination suggested acute ischemia, with signs of paleness, coldness, anesthesia, hemorrhagic bullae below the right knee level. There was severe swelling and ecchymosis in popliteal fossa and around the leg with significant calf tenderness and pedal edema. Tibialis posterior, dorsalis pedis, and popliteal arterial pulses were not palpable. Radiograph suggested minimally displaced tibial plateau fracture with no evidence of knee dislocation. The patient was taken up for emergency surgery after consultation with vascular surgeon. During the closed reduction external fixation and compartment decompression, popliteal artery trunk was found transected and end-to-end repair was performed. During the post-operational period, no complication was developed and the patient was followed-up for 1 year. At the one-year follow-up, he acquired good stability of his right knee with full range of motion.

CONCLUSION

Significant swelling and ecchymosis should alert the surgeons to the possibility of vascular injury in knee joint injury, even if there is no fracture or dislocation, or fracture is minimally displaced.

Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review

BACKGROUND

Acute compartment syndrome (ACS) is characterised by abnormal pressure inside a compartment, resulting in ischemia of muscles and nerves. Most orthopaedic surgeons, especially those who work in major trauma centres, have been or will be facing a case of ACS in their clinical activity. Fortunately, complications related to untreated compartment syndrome have become less frequent thanks to a better understanding of pathogenesis and to early recognition and prompt surgical treatment. The aim of this study is to identify the existing evidence regarding aetiology of trauma-related ACS of the leg.

METHODS

A systematic review of the literature was undertaken using PubMed Medline, Ovid Medline and the Cochrane library, extended by a manual search of bibliographies. Retrieved articles were eligible for inclusion if they reported data about aetiology of trauma-related compartment syndrome of the tibia.

RESULTS

Ninety-five studies that fulfilled the inclusion criteria were identified. By dividing the studies into three groups according to the traumatic aetiology, we were able to classify traumatic ACS as fracture related, soft tissue injury related and vascular injury related. Fracture related was the most represented group, comprising 58 papers, followed by the soft tissue injury related group which includes 44 articles and vascular injury related group with 24 papers.

CONCLUSIONS

Although traditionally ACS has been associated mainly with fractures of tibial diaphysis, literature demonstrates that other localisations, in particular in the proximal tibia, are associated with an increased incidence of this serious condition. The forms of ACS secondary to soft tissues injuries represent an extremely variable spectrum of lesions with an insidious tendency for late diagnosis and consequently negative outcomes. In the case of vascular injury, ACS should always be carefully considered as a priority, given the high incidence reported in the literature, as a result of primitive vascular damage or as a result of revascularisation of the limb. Knowledge of aetiology of this serious condition allows us to stratify the risk by identifying a population of patients most at risk, together with the most frequently associated traumatic injuries.

Persistent Knee Pain After Falling Off a Bicycle

We present the case of an 18-year-old young man with severe persistent knee pain secondary to a popliteal artery thrombosis. This occurred as a result of a fall from a bicycle. Acute compartment syndrome refers to the sequelae that can occur because of increased fascial compartment pressures, such as crush injuries, burns, traumatic or spontaneous hemorrhage, or constrictive casts. Increased pressures in nonelastic fascial compartments result in decreased perfusion distally, leading to ischemia of muscles and neurovascular tissue. In addition to highlighting recognition of the classic signs and symptoms of this limb-threatening condition, this case illustrates the importance of obtaining a thorough history; this is necessary in order to have a high index of suspicion for this diagnosis. A significant degree of clinical insight and prompt surgical intervention may save the functions of both the muscles and the nerves. These are at risk of permanent damage due to possible elevated compartment pressures.

Comparison of KD3-M and KD3-L Multiligamentous Knee Injuries and Analysis of Predictive Factors That Influence the Outcomes of Single-Stage Reconstruction in KD3 Injuries

Background:

The knee dislocation–3 (KD3) injury pattern is the most common form of multiligamentous injury. Medial KD3 (KD3-M) and lateral KD3 (KD3-L) are 2 anatomically different varieties of this injury.

Purpose:

To compare the surgical outcomes of KD3-M and KD3-L multiligamentous knee injury patterns and to determine the factors that could influence the outcomes after single-stage reconstruction.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A cohort of 45 patients with multiligamentous knee injuries (31 KD3-M, 14 KD3-L) who were operated on between 2011 and 2015 were compared. The cruciate ligaments were reconstructed, and the collateral ligaments were managed either conservatively or surgically depending on intraoperative laxity, tissue condition, injury site, and chronicity. The mean follow-up was 36 months (range, 24-72 months). The International Knee Documentation Committee (IKDC) score, Lysholm score, knee flexion range of motion (ROM), and laxity on stress radiographs were compared. Various factors likely to influence the outcomes were also analyzed.

Results:

The mean IKDC score, Lysholm score, and knee flexion ROM for the 45 patients were 74.74, 87.66, and 126.78°, respectively. There was no significant difference between the KD3-M and KD3-L groups in terms of the postoperative IKDC score (P = .768), Lysholm score (P = .689), knee flexion ROM (P = .798), and laxity on stress radiographs (P = .011). Patients with a transient dislocation had better outcomes (76.51, 89.41, and 128.61°, respectively) than those with a frank dislocation (67.62, 80.66, and 119.44°) (P = .037, .007, and .043). The acute group had better outcomes (77.00, 89.51, and 127.86°) when compared with the subacute (66.26, 86.00, and 121.00°) and chronic groups (67.40, 76.40, and 125.00°) (P = .045, .006, and .486). Regression analysis showed the influence of these factors on outcomes. The presence or absence of dislocations, time frame in which surgery was performed, and follow-up duration were found to influence the outcome. All other factors had no bearing on outcomes. Two patients had knee stiffness and underwent arthrolysis.

Conclusion:

Despite anatomic and biomechanical differences between KD3-M and KD3-L injuries, single-stage management did not produce any significant difference in results. The presence of a frank dislocation, delay in surgery, and duration of follow-up were found to influence outcomes.

A unique case of popliteal artery transection after a motorcycle collision

Popliteal artery injuries may have devastating consequences if not recognized in a timely fashion. The risk of delayed diagnosis of a vascular injury is particularly high in blunt trauma to the lower extremity. We present a case of popliteal artery injury that is unusual in two respects: severity (a complete transection in the setting of a blunt injury) and lack of clinical and radiographic signs of the commonly associated musculoskeletal injuries.

Acute Thrombotic Occlusion of the Popliteal Artery following Knee Dislocation: A Case Report of Management, Local Unit Practice, and a Review of the Literature

Arterial complications following traumatic knee injury are relatively rare but mandate timely recognition and treatment to avoid significant comorbidity and medicolegal ramifications. In this report we describe a case of acute thrombotic occlusion of the popliteal artery occurring after knee dislocation, successfully repaired by intimal fixation and a limited venous patch reconstruction. We present a review of local practice in screening vascular injuries following knee dislocation, aligned with a review of the literature and considerations for practice.

Popliteal artery injury associated with blunt trauma to the knee without fracture or dislocation

Popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. Concern about arterial injury and early recognition of the possibility of arterial injury is crucial for the salvage of the extremity. This article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating injury, knee dislocation, fracture, or high-velocity trauma mechanism. The importance of a detailed vascular examination of a blunt trauma patient is emphasized.

Knee Dislocations: Lessons Learned From 20-Year Follow-up

Background:

Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.

Purpose:

To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee.

Study Design:

Review and case reports.

Methods:

Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form–36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability.

Results:

The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject’s IKDC score to “C.”

Conclusion:

Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.