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Medvecky MJ, Kahan JB, Richter DL, Islam W, McLaughlin WM, Moran J, Alaia MJ, Miller MD, Wascher DC, Treme GP, Campos TVO, Held M, Schenck RC. Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method. J Bone Joint Surg Am 2023:00004623-990000000-00801. [PMID: 37186688 DOI: 10.2106/jbjs.23.00079] [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] [Indexed: 05/17/2023]
Abstract
BACKGROUND Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.
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Affiliation(s)
- Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Dustin L Richter
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Wasif Islam
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - William M McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, New York, NY
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel C Wascher
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Gehron P Treme
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Túlio V O Campos
- Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Michael Held
- Department of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
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Shamrock AG, Hall JR, Hajewski CJ, An Q, Duchman KR. Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction. J Knee Surg 2022; 35:560-565. [PMID: 32898906 DOI: 10.1055/s-0040-1716378] [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
The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p < 0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p < 0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.
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Affiliation(s)
- Alan G Shamrock
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - James R Hall
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Christina J Hajewski
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Qiang An
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Kyle R Duchman
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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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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Marder RS, Poonawala H, Pincay JI, Nguyen F, Cleary PF, Persaud CS, Naziri Q, Zikria BA. Acute Versus Delayed Surgical Intervention in Multiligament Knee Injuries: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211027855. [PMID: 34671686 PMCID: PMC8521434 DOI: 10.1177/23259671211027855] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023] Open
Abstract
Background: The optimal timing of surgical intervention for multiligament knee injuries remains controversial. Purpose: To review the clinical and functional outcomes after acute and delayed surgical intervention for multiligament knee injuries. Study Design: Systematic review; Level of evidence, 4. Methods: We performed a search of the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to September 2020. Eligible studies reported on knee dislocations, multiligament knee injuries, or bicruciate ligament injuries in adult patients (age, ≥18 years). In addition to comparing outcomes between acute and delayed surgical intervention groups, we conducted 3 subgroup analyses for outcomes within isolated knee injuries, knee injuries with concomitant polytrauma/fractures, and high-level (level 2) studies. Results: Included in the analysis were 31 studies, designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n = 20). These studies reported on 2594 multiligament knee injuries sustained by 2585 patients (mean age, 25.1-65.3 years; mean follow-up, 12-157.2 months). At the latest follow-up timepoint, the mean Lysholm (n = 375), International Knee Documentation Committee (IKDC) (n = 286), and Tegner (n = 129) scores for the acute surgical intervention group were 73.60, 67.61, and 5.06, respectively. For the delayed surgical intervention group, the mean Lysholm (n = 196), IKDC (n = 172), and Tegner (n = 74) scores were 85.23, 72.32, and 4.85, respectively. The mean Lysholm (n = 323), IKDC (n = 236), and Tegner (n = 143) scores for our isolated subgroup were 83.7, 74.8, and 5.0, respectively. By comparison, the mean Lysholm (n = 270), IKDC (n = 236), and Tegner (n = 206) scores for the polytrauma/fractures subgroup were 83.3, 64.5, and 5.0, respectively. Conclusion: The results of our systematic review did not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes. Although previous evidence has supported acute surgical intervention, future prospective randomized controlled trials and matched cohort studies must be completed to confirm these findings.
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Affiliation(s)
- Ryan S Marder
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Husain Poonawala
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Jorge I Pincay
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Frank Nguyen
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Patrick F Cleary
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Christine S Persaud
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, USA
| | - Bashir A Zikria
- Department of Orthopaedic Surgery, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
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Ockuly AC, Imada AO, Richter DL, Treme GP, Wascher DC, Schenck RC. Initial Evaluation and Classification of Knee Dislocations. Sports Med Arthrosc Rev 2021; 28:87-93. [PMID: 32740459 DOI: 10.1097/jsa.0000000000000271] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.
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Affiliation(s)
- Andrew C Ockuly
- Department of Orthopaedic Surgery, University of New Mexico, Albuquerque, NM
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Zhao D, Yang Z, Wu C, Zhong J, Zhou X, Li J, Li Y, Lu Y, Shen D. The outcomes of one-stage treatment for multiple knee ligament injuries combined with extensor apparatus rupture. BMC Musculoskelet Disord 2020; 21:450. [PMID: 32646403 PMCID: PMC7350637 DOI: 10.1186/s12891-020-03470-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/30/2020] [Indexed: 12/01/2022] Open
Abstract
Background Multiple knee ligament injuries combined with extensor apparatus rupture are serious and complex knee injuries that are rare in clinical practice. The management is extremely challenging and controversial. The aim of this study is to describe a patient collective with multiple knee ligament injuries combined with extensor apparatus injuries in detail and to report the mid-term outcomes of a one-stage surgical treatment regarding subjective outcome scores, complications, knee instability, and ROM. Methods Eleven of 425 patients with multiple knee ligament injuries combined with extensor apparatus injuries admitted to our hospital were reviewed from July 2008 to May 2017. All patients underwent one-stage repair and reconstruction of multiple knee ligaments and extensor apparatus. The Lysholm knee score and the International Knee Documentation Committee (IKDC) score were adopted to evaluate the surgical effect preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at the final follow-up. Results Ten patients were followed up with a mean time of 40 (range, 24–60) months. At the last follow-up, 8 patients had joint flexion range of motion greater than or equal to120 degrees, 2 patients had joint flexion range of motion of 100–120 degrees, and 1 patient had active knee extension limitation of 5 degrees. Stress radiographs showed that the mean differences in posterior displacement were reduced from 10.8 ± 3.0 mm preoperatively to 2.0 ± 2.5 mm at the last follow-up. There were significant improvements in stress radiographs from pre- to postoperative states for all patients with multiple knee ligament injuries. The Lysholm score ranged from 85 to 96, with a mean of 92.1 (compared with 33 before surgery, P < 0.05). The final IKDC scores were A in 2 patients (20%), B in 7 (70%), and C in 1 (10%). Nine of the 10 patients (90%) returned to their former activity level. Conclusion Multiple knee ligament injuries combined with extensor apparatus rupture are rare. Single-stage management of the repair and reconstruction of multiple knee ligaments and extensor apparatus with proper rehabilitation is an effective and reliable procedure to restore knee stability and function. Level of evidence Level IV, therapeutic case series.
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Affiliation(s)
- Daohong Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, No374, Dianmian road, Kunming, 650101, China.
| | - Zhongde Yang
- Department of Orthopaedics, The People's Hospital of WeiXin County, Zhaotong, China
| | - Changsha Wu
- Department of Orthopaedics, The People's Hospital of ZhenXiong County, Zhaotong, China
| | - Jia Zhong
- Department of Orthopaedics, The People's Hospital of XiShuangBanNa State, Jinghong, China
| | - Xizong Zhou
- Department of Orthopaedics, The People's Hospital of YanJin County, Zhaotong, China
| | - Jinghua Li
- Department of Orthopaedics, The Bone Special Hospital of JingHua Li, Zhaotong, China
| | - Yan Li
- Department of Orthopaedics, The People's Hospital of Dehong State, Mangshi, China
| | - Yongsheng Lu
- Department of Orthopaedics, The People's Hospital of NingLang County, Lijiang, China
| | - Duo Shen
- Department of Orthopaedics, The People's Hospital of LongChuan County, Dehong, China
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Zhao D, Li W, Liu L, Lu N, Chen L, Zhang J. Open tibia plateau fracture with intra-osseous dislocation of the patella and quadriceps tendon rupture: a case report. BMC Surg 2020; 20:114. [PMID: 32450823 PMCID: PMC7249650 DOI: 10.1186/s12893-020-00770-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 05/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background Both tibial plateau fractures and extensor apparatus injuries are serious injuries to the knee joint that generally do not occur in the same patient. We report a rare case of open tibial plateau fracture combined with quadriceps tendon rupture and complete displacement of the patella into the tibial plateau fracture. Case presentation The case involved a male who was 19 years old who had been in a motorcycle accident. The patient was admitted to our department with an open tibial plateau fracture 3 h post-injury. X-ray showed a tibial plateau fracture and complete displacement of the patella into the tibial plateau. CT showed an avulsion fracture in the patella and tibial intercondylar eminence. Concomitant quadriceps tendon injury and both anterior and posterior cruciate ligament tibial insertion avulsion fractures were considered. The operative findings of emergency surgery confirmed our preoperative diagnosis. Single-stage quadriceps tendon repair and ORIF for the tibial plateau fracture were performed. Satisfactory restoration of function was acquired at the last follow up. Conclusion The most difficult aspect of this case was the determination of the cause of the intra-osseous dislocation of the patella into the tibial plateau. The most likely mechanism of the injury may be that the patient experienced transient posterior dislocation of the knee during the injury. Rupture of the quadriceps tendon should be considered with posterior dislocation of the knee, and the patella was pushed into the tibial plateau fracture by force after the rupture of the quadriceps tendon.
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Affiliation(s)
- Daohong Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China.
| | - Weiqiang Li
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Luping Liu
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ning Lu
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Leijie Chen
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jun Zhang
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
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