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Anies EP, Sheppard SG, McDonald LS, Bailey JR. Bilateral Knee Dislocations in an Active Duty Service Member: A Case Report. Mil Med 2023; 188:3236-3241. [PMID: 35916477 DOI: 10.1093/milmed/usac222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/26/2022] [Accepted: 07/10/2022] [Indexed: 11/13/2022] Open
Abstract
This case highlights a staged operative approach for a patient who sustained bilateral knee dislocations and subsequent staged operative treatment and rehabilitation. This patient underwent bilateral multiligamentous knee reconstructions and left-sided peroneal nerve allografting because of complete peroneal nerve palsy. The initial treatment was bilateral medial collateral ligament reconstructions, posterolateral corner reconstructions, and capsular repairs with left leg peroneal nerve allografting and repair of avulsed biceps femoris tendon. The patient underwent physical therapy following the first stage procedure until he regained appropriate motion and soft tissue healing occurred. Subsequently, combined anterior cruciate and posterior cruciate ligament reconstructions were performed in a staged fashion to allow one leg to fully bear weight for rehabilitation purposes. With the help of a multidisciplinary surgical and rehabilitation team, the patient has regained the stability of his knees and achieved acceptable functional outcomes. A staged systematic approach to multiligamentous bilateral knee reconstruction can provide optimal pain management, obtain initial joint stability, minimize complications, and achieve acceptable functional outcomes. Surgical techniques to first restore medial and lateral structures can be utilized to provide initial valgus and varus stability while allowing for knee mobilization and, eventually, in-line ambulation, before staged anterior and posterior cruciate ligament reconstructions. This case demonstrates a multistaged approach to bilateral knee dislocations with favorable outcomes in a 23-year-old active duty patient.
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Affiliation(s)
- Ervin P Anies
- Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, MD 20814, USA
| | - Sean G Sheppard
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Lucas S McDonald
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - James R Bailey
- Department of Orthopaedics Sports Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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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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Epidemiology of complete knee dislocations: an updated classification system. Arch Orthop Trauma Surg 2022; 142:2711-2718. [PMID: 34296336 PMCID: PMC9474584 DOI: 10.1007/s00402-021-04079-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/12/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Current classifications of complete knee dislocations do not capture the extent of the complex concomitant ligamentous and bony injuries, which may have an impact on future outcomes. The purpose of this retrospective study was to evaluate the epidemiology of complete knee dislocations as well as to present an updated classification system based on the author's experience at a Level-I trauma center. MATERIALS AND METHODS Only patients with complete loss of contact of the articulating bones and ≥ 18 years of age who admitted in our level-I trauma center between 2002 and 2019 were included. Patients were identified using a retrospective systematical query in the Hospital Information System (HIS) using the International Statistical Classification of Diseases and Related Health Problems Version10 (ICD-10) codes of the German Diagnosis Related Groups (G-DRG). RESULTS Final data included 80 patients, with the majority of patients being male (n = 64; 80.0%). Mean age was 34.9 years (range: 18-70 years). External protective fixation was applied in 32 patients (40.0%). Reconstruction of the posterior cruciate ligament and the anterior cruciate ligament were performed in 56.3% (n = 45) and 55.0% (n = 44) of cases, respectively. The lateral collateral ligament complex was surgically addressed in 47.5% (n = 38), while the medial collateral ligament complex was reconstructed in 40% (n = 32). Surgery of the lateral meniscus and the medial meniscus was needed in 31.1% (n = 25) and 30.0% (n = 24). Neurovascular surgery occurred in 13.8% (n = 11). From the characteristic injury-patterns the authors of this study present a new classification system that ranks the injuries from Grade-A to Grade-D according to their severity. CONCLUSION This retrospective study demonstrates that the historically used classification systems for dislocations of the knee are insufficient for these severe injuries. Concomitant ligamentous, neurovascular, bony, and meniscal injuries were frequent, and required several staged procedures. Consequently, an updated classification system is proposed.
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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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Abstract
Knee dislocations leading to multiligament knee injuries are associated with a wide variety of bony, ligamentous, soft tissue, and neurovascular injury patterns. Numerous management strategies have been proposed including nonoperative treatment and surgical repair or reconstruction. In recent years, an emphasis has been placed on anatomic repair and reconstruction principles, which have shown superior outcomes compared with older techniques. However, despite these advances, clinical outcomes continue to vary widely, with many patients experiencing chronic pain, stiffness, loss of range of motion, instability, and failure to return to work or sports. The purpose of this chapter is to review clinical outcomes following combined anterior and posterior cruciate ligament, medial collateral ligament, and posterolateral corner injuries sustained during a knee dislocation. Understanding the available treatment options and reported outcomes will allow surgeons to individualize management to address each patient's specific injury pattern and functional goals.
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Evaluation and Management of Knee Dislocation in the Emergency Department. J Emerg Med 2020; 58:34-42. [PMID: 31711826 DOI: 10.1016/j.jemermed.2019.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/17/2019] [Accepted: 09/22/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Knee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them. OBJECTIVE This article provides a review of the diagnosis and management of knee dislocation for the emergency provider. DISCUSSION Knee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission. CONCLUSION Knee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.
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Complications in Posterior Cruciate Ligament Injuries and Related Surgery. Sports Med Arthrosc Rev 2019; 28:30-33. [DOI: 10.1097/jsa.0000000000000247] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Britt E, Covey DC. Subacute High-Energy Traumatic Knee Dislocation in an Ambulatory Patient: A Case Report. JBJS Case Connect 2019; 9:e0258. [PMID: 31688054 DOI: 10.2106/jbjs.cc.18.00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 62-year-old man presented with a posterolateral knee dislocation sustained in a motorcycle collision initially managed nonsurgically. His treatment was complicated by recurrent dislocation from noncompliance with bracing and weight-bearing restrictions and by comorbidities including peripheral artery disease, type 2 diabetes, and heavy smoking and drinking. He was treated with a multiplanar knee-spanning external fixator and patellar tendon repair without further ligamentous reconstruction. This treatment provided a stable, functional knee with minimal pain. CONCLUSIONS In this complex, noncompliant patient with a subacute knee dislocation, knee-spanning biplanar external fixation and patellar tendon repair without ligament reconstruction were crucial in achieving a satisfactory outcome.
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Affiliation(s)
- Elise Britt
- University of California San Diego, San Diego, California
| | - D C Covey
- University of California San Diego, San Diego, California
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Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2710-2718. [PMID: 30631909 DOI: 10.1007/s00167-018-5317-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 12/04/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. METHODS In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. RESULTS Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0-3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. CONCLUSION In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. LEVEL OF EVIDENCE Prospective multicentre study, II.
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Matthewson G, Kwapisz A, Sasyniuk T, MacDonald P. Vascular Injury in the Multiligament Injured Knee. Clin Sports Med 2019; 38:199-213. [DOI: 10.1016/j.csm.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Porrino J, Wang A, Kani K, Kweon CY, Gee A. Preoperative MRI for the Multiligament Knee Injury: What the Surgeon Needs to Know. Curr Probl Diagn Radiol 2019; 49:188-198. [PMID: 30824164 DOI: 10.1067/j.cpradiol.2019.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/06/2019] [Indexed: 01/13/2023]
Abstract
The multiligament knee injury is devastating and potentially limb threatening. Preoperative magnetic resonance imaging for the evaluation of the multiligament knee injury is an invaluable clinical tool, and when the radiologist is familiar with how certain injury patterns influence management, optimal outcomes can be achieved. We provide a detailed description of the relationship between salient imaging features of the multiligament knee injury, focusing on the preoperative magnetic resonance imaging, and their influence on clinical decision-making.
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Affiliation(s)
- Jack Porrino
- Yale Radiology and Biomedical Imaging, New Haven, CT 06520.
| | - Annie Wang
- Yale Radiology and Biomedical Imaging, New Haven, CT 06520.
| | - Kimia Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD 21201.
| | - Christopher Y Kweon
- University of Washington, Department of Orthopaedics & Sports Medicine, Seattle, WA 98195.
| | - Albert Gee
- University of Washington, Department of Orthopaedics & Sports Medicine, Seattle, WA 98195.
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A National Collegiate Athletic Association Division I Athlete's Return to Play After Traumatic Knee Dislocation With Vascular and Nerve Injury. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e073. [PMID: 30656263 PMCID: PMC6324896 DOI: 10.5435/jaaosglobal-d-18-00073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Traumatic knee dislocations are thought to be relatively uncommon; however, they are a devastating injury that can be life altering. A concomitant vascular injury carries a particularly high morbidity rate, with some studies reporting as many as one in five patients losing a limb. Neurologic injury can pose problems as well, in particular for athlete populations that have structure and function as integral parts of their activities. This case study looks at the journey of an elite-level football player (NCAA Division I Pac-12 conference) who sustained a traumatic knee dislocation with vascular and neurologic injury and, eventually, his return to play. The study analyzes the treatment and management course, his ultimate performance after injury, and potential benefits in aiding the management of future knee dislocation with vascular and neurologic injuries.
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Sundararajan SR, Sambandam B, Rajagopalakrishnan R, Rajasekaran S. 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. Orthop J Sports Med 2018; 6:2325967118794367. [PMID: 30246039 PMCID: PMC6146330 DOI: 10.1177/2325967118794367] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
| | - Balaji Sambandam
- Department of Arthroscopy and Sports Medicine, Ganga Hospital, Coimbatore, India
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Unusual combined PCL and PLC pediatric multiligamentous knee injury treated with ligament repair procedure. Knee Surg Sports Traumatol Arthrosc 2018; 26:2804-2808. [PMID: 29119284 DOI: 10.1007/s00167-017-4771-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Abstract
The multiple ligament injured knee presents a challenge with regard to management and treatment. Immediate management of the acute injury requires special attention and thorough examination because knee dislocations have been associated with significant complications. Treatment options range from closed reduction and immobilization to surgical repair and/or reconstruction of the injured ligaments. This article focuses on complications that may result from surgical treatments of the multiple ligament injured knee and ways of prevention. These complications include vascular and neurologic complications, venous thromboembolic events, arthrofibrosis, compartment syndrome, wound problems, heterotopic ossification, fractures and avascular necrosis, tunnels positioning complications, and malalignment.
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Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis. Knee 2017; 24:909-916. [PMID: 28716470 DOI: 10.1016/j.knee.2017.06.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/27/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Whether early or delayed surgical intervention in patients with multi-ligament injuries results in better outcomes, is of current and controversial debate. PURPOSE The purpose of this study was to perform a meta-analysis comparing early versus late surgical treatment of multi-ligament knee injuries. METHODS We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant studies in the English and German literature. Eligibility criteria included studies comparing early or delayed surgical interventions for multi-ligament knee injuries, with a minimum follow-up of two years, reporting the primary clinical outcome using a validated functional scoring system and range of motion. Exclusion criteria were patients treated with multi-trauma, head injury, non-union, lower extremity fractures, or a documented history of previous knee injuries. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's risk of bias tool. Heterogeneity was assessed using χ2 and I2 statistic. RESULTS Eight studies (n=260 patients) were included in the analysis. 149 patients were treated early with a mean of 10.6days; 111 patients were treated late with a mean of 294days. The pooled estimate for clinical outcome demonstrated that early surgery resulted in significantly higher Lysholm scores (SMD 0.669, 95% CI: 0.379 to 0.959, p=0.0001, I2=0%). Thirty-one per cent of all patients with early surgery had a normal or near normal knee, whereas only 15% of patients with late reconstruction reported the knee to be normal or near normal. The pooled estimates for total ROM did not demonstrate a significant difference between the groups (SMD 0.113, 95% CI: -0.271 to 0.498, p=0.564, I2=35.57%). CONCLUSIONS The results of this meta-analysis suggest that early surgical intervention in multi-ligament injuries of the knee produces a significantly superior clinical outcome, compared to late reconstruction. Although an overall trend of improved total range of knee motion was also demonstrated, this was very small and unlikely to be clinically relevant. LEVEL OF EVIDENCE Level 4; Systematic review and meta-analysis.
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Lynch AD, Chmielewski T, Bailey L, Stuart M, Cooper J, Coady C, Sgroi T, Owens J, Schenck R, Whelan D, Musahl V, Irrgang J. Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury. Curr Rev Musculoskelet Med 2017; 10:328-345. [PMID: 28779476 DOI: 10.1007/s12178-017-9425-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation. RECENT FINDINGS MLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested. Consideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.
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Affiliation(s)
- Andrew D Lynch
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA.
| | | | - Lane Bailey
- University of Texas at Houston, Houston, TX, USA
| | | | | | - Cathy Coady
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Johnny Owens
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | | | - Volker Musahl
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
| | - James Irrgang
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
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Samson D, Ng CY, Power D. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2017; 1:362-367. [PMID: 28461914 PMCID: PMC5367548 DOI: 10.1302/2058-5241.160012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management. Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.
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Affiliation(s)
- Deepak Samson
- The Centre for Nerve Injury and Paralysis, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Chye Yew Ng
- The Upper Limb Unit, Wrightington Hospital, UK
| | - Dominic Power
- The Centre for Nerve Injury and Paralysis, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
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Abstract
BACKGROUND Multiple ligament injured knee is generally described for a scenario when at least 2 of the 4 major ligaments are ruptured. The most effective treatment for these injuries remains controversial. This study presents the clinical outcome of 3 surgical strategies based on personalized treatment. MATERIALS AND METHODS Thirty two patients with multiple ligament injured knee were treated by 3 surgical strategies in the acute phase. (1) One-stage: Twelve patients treated by repair and reconstruction of all ruptured ligaments in a single operation. (2) Staged: Eleven patients treated by repair or reconstruction of the extraarticular (EA) ligaments and then intraarticular ligaments in 2(nd) stage. (3) EA ligament repair: Nine patients underwent only EA ligaments repair. RESULTS The patients were followed up for an average of 34.7 ± 12.1 months. Significant improvements in knee stabilities (P < 0.01), Lysholm score (P < 0.01) and International Knee Documentation Committee grade (P < 0.01) were noticed in all groups. Of the 32 patients, none had gross mal alignment or gait abnormalities at the latest followup. Comparing the 3 groups, a significant difference in Lysholm score was shown between the one stage group and the EA repair group (P = 0.040); additionally, significant differences were found in 2 subscales of knee injury and osteoarthritis outcome score (P < 0.05). CONCLUSION Satisfactory clinical and functional outcomes could be achieved adopting the 3 surgical strategies based on personalized treatment. However, a combination of EA repair and intraarticular repair or reconstruction might be more reasonable options for the young and active patients.
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Affiliation(s)
- Lei Sun
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai’an City, Shandong Province, China,Address for correspondence: Prof. Lei Sun, Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai’an City, Shandong Province, China. E-mail:
| | - Bo Wu
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai’an City, Shandong Province, China
| | - Min Tian
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai’an City, Shandong Province, China
| | - Yong Zhong Luo
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai’an City, Shandong Province, China
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Meniscal tears and articular cartilage damage in the dislocated knee. Knee Surg Sports Traumatol Arthrosc 2015; 23:3019-25. [PMID: 25700677 DOI: 10.1007/s00167-015-3540-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE Knee dislocations can cause significant damage to intra-articular knee structures, but currently there are limited data reporting articular cartilage and meniscal injuries in this setting. The purpose of this study is to (1) report the rate of concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation, (2) determine whether the pattern of ligament injury is associated with the presence of chondral and meniscal injuries, and (3) assess the relationship between timing of surgery and incidence of chondral and meniscal injuries. METHODS The records of patients who sustained a knee dislocation between 1992 and 2013 were retrospectively reviewed. Patients included for further review had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. Patient demographics, ligament injury patterns, meniscal tears and chondral injuries at arthroscopy, and interval from injury to surgery were recorded. Early surgical intervention was defined as <3 months, delayed was between 3 and 12 months, and chronic was >12 months. Data analysis compared ligament injury pattern with chondral and meniscal injuries, as well as the rates of intra-articular injury by timing of surgery. RESULTS One-hundred and twenty-one patients (122 knees) were included (93 males, 28 females) with a median age at time of surgery of 31 years (range 15-62). Ninety-three knees (76 %) had associated chondral or meniscal injury. Sixty-seven knees (55 %) presented with meniscal tears (26 isolated medial, 27 isolated lateral, and 14 combined medial/lateral), while 52 knees (48 %) had chondral damage, most commonly in the medial compartment. Schenck classification as well as side of injury did not demonstrate consistent relationships with intra-articular injury. A higher incidence of damage to the lateral femoral condyle (20 % vs 3 %; p = 0.02), lateral tibial plateau (20 % vs 2 %; p < 0.01), and patella (40 % vs 13 %; p = 0.01) was found in the chronic group compared to the early group. The chronic group contained significantly more patients with bicompartmental and tricompartmental chondral lesions (25 % vs 6 %; p = 0.03 and 10 % vs 0 %; p = 0.02, respectively). CONCLUSION Meniscal tears and chondral damage occur frequently in patients with a knee dislocation. A longer interval from injury to surgical reconstruction is associated with higher rates of articular cartilage lesions, especially in multiple compartments. LEVEL OF EVIDENCE IV.
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Lachman JR, Rehman S, Pipitone PS. Traumatic Knee Dislocations: Evaluation, Management, and Surgical Treatment. Orthop Clin North Am 2015; 46:479-93. [PMID: 26410637 DOI: 10.1016/j.ocl.2015.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Knee dislocations are catastrophic injuries that demand emergent evaluation and often require a multidisciplinary approach. Long-term outcome studies are relatively scarce secondary to the variability in any given study population and the wide variety of injury patterns between knee dislocations. Multiple controversies exist with regard to outcomes using various treatment methods (early vs late intervention, graft selection, repair vs reconstruction of medial and lateral structures, rehabilitation regimens). Careful clinical evaluation is essential when knee dislocation is suspected.
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Affiliation(s)
- James R Lachman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, 3509 North Broad Street #5, Philadelphia, PA 19140, USA.
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, 3509 North Broad Street #5, Philadelphia, PA 19140, USA
| | - Paul S Pipitone
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554, USA
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Mabvuure NT, Malahias M, Haddad B, Hindocha S, Khan WS. State of the art regarding the management of multiligamentous injuries of the knee. Open Orthop J 2014; 8:215-8. [PMID: 25067977 PMCID: PMC4110392 DOI: 10.2174/1874325001408010215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/12/2014] [Accepted: 03/14/2014] [Indexed: 11/23/2022] Open
Abstract
Multiligamentous knee injuries are rare but serious injuries that can threaten limb viability. As such, they require careful management to give patients the best chance of immediate and ultimate functional recovery. However, as these injuries are rare, there is paucity in prospective comparative studies large enough to provide high level evidence for best practice. This lack of comprehensive and convincing evidence has made the management of multiligamentous knee injuries an area of active debate and controversy. The debate on whether surgical management leads to better outcomes than non-operative management, the optimal timing of surgery after injury and whether repair is better than reconstruction is still ongoing. Using the Oxford Levels of Evidence, this review summarises the latest high level evidence to provide answers to these issues. Recommendations for practice have also been offered and assigned a grade using a published scale.
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Affiliation(s)
| | - Marco Malahias
- Department of Plastic Surgery, Countess of Chester Hospital, Chester, CH2 1UL, UK
| | - Behrooz Haddad
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
| | - Sandip Hindocha
- Department of Plastic Surgery, Whiston Hospital, Merseyside, L35 5DR, UK
| | - Wasim S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, UK
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McKee L, Ibrahim MS, Lawrence T, Pengas IP, Khan WS. Current concepts in acute knee dislocation: the missed diagnosis? Open Orthop J 2014; 8:162-7. [PMID: 25067970 PMCID: PMC4110394 DOI: 10.2174/1874325001408010162] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 11/22/2022] Open
Abstract
Traumatic knee dislocation is a serious and potentially limb threatening injury that can be easily missed if meticulous history and examination have not been employed. Neurovascular injuries are common in this condition, and due diligence should be given to their thorough evaluation at time of secondary survey so as to avoid complications such as ischaemia, compartment syndrome and eventual amputation. There is growing evidence in the literature that morbid obesity is associated with low energy knee dislocation, therefore this should be considered when assessing this cohort of patients presenting with an acute knee injury. Early operative intervention especially with multi ligaments involvement is the preferable strategy in the management of this acute injury. Controversy exists whether to reconstruct or repair damaged structures, and whether to adopt a one stage or two stage reconstruction of the cruciate ligaments. Early rehabilitation is important and essential to achieve satisfactory outcomes. This article is an evidence-based overview of this rare but devastating injury.
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Affiliation(s)
- Lesley McKee
- Trauma and Orthopaedic Department, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Mazin S Ibrahim
- Trauma and Orthopaedic Department, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Trevor Lawrence
- Trauma and Orthopaedic Department, Heart of England NHS Foundation Trust, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - Ioannis P Pengas
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
| | - Wasim S Khan
- University College London Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
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Stannard JP, Nuelle CW, McGwin G, Volgas DA. Hinged external fixation in the treatment of knee dislocations: a prospective randomized study. J Bone Joint Surg Am 2014; 96:184-91. [PMID: 24500579 DOI: 10.2106/jbjs.l.01603] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our hypothesis was that patients treated with hinged external fixators as an adjunct to multiple-ligament reconstruction would have fewer reconstruction failures than patients treated without external fixation. METHODS In this prospective randomized study, patients with a knee dislocation either underwent ligament reconstruction with placement of an external hinged knee brace following surgery (Group A) or underwent ligament reconstruction with placement of a hinged external fixator (Compass Knee Hinge) for six weeks instead of the brace (Group B). The patients were followed clinically and were evaluated with physical examination, Lysholm and International Knee Documentation Committee knee scores, visual analog scale pain scores, and status regarding return to work and activities. RESULTS One hundred patients with 103 knee dislocations were enrolled. Seventy-seven patients with seventy-nine dislocations (thirty-two in Group A and forty-seven in Group B), with a minimum follow-up interval of twelve months, were available for evaluation. The mean duration of follow-up was thirty-nine months (range, twelve to eighty-six months). Nine patients (29%) in Group A had failed reconstructions compared with seven (15%) in Group B (p = 0.15). Group-A patients had twenty-two (21%) of 105 reconstructed individual ligaments fail compared with eleven (7%) of 157 reconstructed ligaments in Group B. The difference in ligament failure was significant (p < 0.001; power > 0.8), with more favorable results for the patients managed with the external fixation. CONCLUSIONS Hinged external fixation as a supplement to reconstruction following knee dislocation was associated with fewer failed ligament reconstructions compared with external bracing. Patients presenting with highly unstable knee dislocations should be considered for hinged external fixation to supplement initial reconstructive procedures.
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Affiliation(s)
- James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - Gerald McGwin
- University of Alabama at Birmingham, 510 South 20th Street, FOT 960, Birmingham, AL 35294-3409
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
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Nuelle CW, Stannard JP. Placement of a Compass Knee Hinge: Surgical Technique. JBJS Essent Surg Tech 2014; 4:e2. [PMID: 30775109 DOI: 10.2106/jbjs.st.m.00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The Compass Knee Hinge can be a useful part of the treatment regimen for highly unstable knee dislocations. Step 1 Initial Alignment of Wires Make sure to place the centering wire at the isometric point of the knee. Step 2 Placement of the Compass Knee Hinge Take the necessary steps to place the Compass Knee Hinge over the wire. Step 3 Application of the Compass Knee Hinge with Concurrent Procedures If repair or reconstruction of either the posteromedial or the posterolateral corner is part of the planned surgical procedure, place the centering wire prior to the repair or reconstruction of the injured corner. Step 4 Postoperative Protocol Postoperatively, use progressive protocols to enable the patient to regain knee motion following the application of the hinge. Results The above technique was used to treat fifty-five patients with a total of fifty-six knee dislocations who had various concurrent ligamentous reconstructions14.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
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Colen S, van den Bekerom MPJ, Truijen J. High-energy bilateral knee dislocations in a young man: a case report. J Orthop Surg (Hong Kong) 2013; 21:396-400. [PMID: 24366809 DOI: 10.1177/230949901302100328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bilateral knee dislocations are rare. We report one such case in a 22-year-old man. His clinical presentation, radiographical findings, and the operative and non-operative treatments are discussed, with emphasis on the timing of treatment and rehabilitation.
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Affiliation(s)
- Sascha Colen
- Department of Orthopaedic Surgery, Hospital East Limburg, Genk, Belgium & Department of Orthopaedic Surgery, University of Leuven, Pellenberg, Belgium
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Darabos N, Gusic N, Vlahovic T, Darabos A, Popovic I, Vlahovic I. Staged management of knee dislocation in polytrauma injured patients. Injury 2013; 44 Suppl 3:S40-5. [PMID: 24060017 DOI: 10.1016/s0020-1383(13)70196-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution. PATIENTS AND METHODS From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months). RESULTS Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant. CONCLUSION The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.
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Affiliation(s)
- N Darabos
- University Clinic for Traumatology, Clinical Hospital Center "Sisters of Charity", Zagreb, Croatia.
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Surgical management of multiple knee ligament injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:691-7. [DOI: 10.1007/s00590-012-1043-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 06/27/2012] [Indexed: 10/28/2022]
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Tuite MJ, Daffner RH, Weissman BN, Bancroft L, Bennett DL, Blebea JS, Bruno MA, Fries IB, Hayes CW, Kransdorf MJ, Luchs JS, Morrison WB, Roberts CC, Scharf SC, Stoller DW, Taljanovic MS, Ward RJ, Wise JN, Zoga AC. ACR appropriateness criteria(®) acute trauma to the knee. J Am Coll Radiol 2012; 9:96-103. [PMID: 22305695 DOI: 10.1016/j.jacr.2011.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/24/2011] [Indexed: 01/03/2023]
Abstract
There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Criteria-based management of an acute multistructure knee injury in a professional football player: a case report. J Orthop Sports Phys Ther 2011; 41:675-86. [PMID: 21885909 DOI: 10.2519/jospt.2011.3453] [Citation(s) in RCA: 7] [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
STUDY DESIGN Case report. BACKGROUND Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury. CASE DESCRIPTION A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity. OUTCOMES The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League. DISCUSSION This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction. LEVEL OF EVIDENCE Therapy, level 4.
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Hirschmann MT, Meier MD, Amsler F, Friederich NF. Long-term outcome of patients treated surgically for traumatic knee dislocation: does the injury pattern matter? PHYSICIAN SPORTSMED 2010; 38:82-9. [PMID: 20631467 DOI: 10.3810/psm.2010.06.1786] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To examine the difference in outcomes of patients treated surgically for traumatic knee dislocation with regard to different injury patterns. METHODS All patients who underwent reconstruction/repair of the cruciates and primary complete repair of collaterals, posterolateral, and posteromedial corner structures were allocated to 3 groups (group A: bicruciate injury with associated medial side injury [n = 31]; group B: bicruciate injury with associated lateral injury [n = 20]; group C: bicruciate injury with associated medial and lateral injury [n = 23]). Outcome was assessed at a mean of 12 years postoperatively using the International Knee Documentation Committee (IKDC) score, Short Form-36 (SF-36) health survey, Lysholm score, Tegner score, visual analog scale (VAS) pain score, and Knee Society score. Anterior-posterior laxity was also measured (KT1000 arthrometer; Medmetric Corp., San Diego, CA), and Pearson's correlation was used to compute associations between variables (P < 0.05) RESULTS: The mean time to return to work was 6 +/- 4 months in group A, 13 +/- 19 months in group B, and 11 +/- 12 months in group C. At final follow-up, 7 patients had a pain VAS of > 3 (group A: 6 patients; group B: 0 patients; group C: 1 patient). Seven patients could not flex their knee > 110 degrees (group A: 4 patients; group B: 0 patients; group C: 3 patients). Eighteen patients (24%) presented with an extension deficit of > 5 degrees . Valgus stress testing was > 3 mm in 12 patients (group A, 3 patients; group B, 4 patients; group C: 5 patients). Varus stress testing was > 3 mm in 9 patients (group A: 4 patients; group B: 3 patients; group C: 2 patients). The dial test at 30 degrees showed < 6 degrees (normal) and 6 degrees to 10 degrees (nearly normal) in 64 patients, and > 10 degrees (abnormal) in 10 patients (group A: 4 patients; group B: 2 patients; group C: 4 patients). At 90 degrees flexion, the difference was < 10 degrees in 70 patients and > 10 degrees in 4 patients (group A, 1 patient; group B: 1 patient; group C: 2 patients). Normal/nearly normal IKDC score values were found in 19 patients in group A, in 12 patients in group B, and in 14 patients in group C. There were no significant differences in outcome between the groups, except patients with an injury of the lateral collateral ligament and/or the peroneal nerve who had a greater need for workers compensation (P > 0.01). CONCLUSION Early complete 1-stage reconstruction/repair showed good subjective and functional results with restoration of working capacity, independent from the location of associated injuries (medial, lateral, and medial and lateral). A peroneal nerve lesion resulted in significantly poorer outcome.
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Hirschmann MT, Zimmermann N, Rychen T, Candrian C, Hudetz D, Lorez LG, Amsler F, Müller W, Friederich NF. Clinical and radiological outcomes after management of traumatic knee dislocation by open single stage complete reconstruction/repair. BMC Musculoskelet Disord 2010; 11:102. [PMID: 20507623 PMCID: PMC2894008 DOI: 10.1186/1471-2474-11-102] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 05/27/2010] [Indexed: 12/20/2022] Open
Abstract
Background The purpose of our study was to analyze the clinical and radiological long-term outcomes of surgically treated traumatic knee dislocations and determine prognostic factors for outcome. Methods Retrospective consecutive series of patients treated surgically for traumatic knee dislocation with reconstruction/refixation of the anterior (ACL) and posterior cruciate ligaments (PCL) and primary complete repair of collaterals and posteromedial and posteromedial corner structures. 68 patients were evaluated clinically (IKDC score, SF36 health survey, Lysholm score, Knee Society score, Tegner score, visual analogue scale - VAS pain and satisfaction, Cooper test) and radiologically (weight bearing and stress radiographs) with a mean follow up of 12 ± 8 years. Instrumented anterior-posterior translation was measured (Rolimeter, KT-1000). Pearson correlation and stepwise regression analysis was used. Results 82% of patients (n = 56) returned to their previous work. At final follow-up 6 patients (9%) suffered from pain VAS > 3. The mean side-to-side difference of anterior/posterior translation (KT-1000, 134N) was 1.6 ± 1.6 mm and 2.6 ± 1.4 mm. Valgus and varus stress testing in 30° flexion was <3 mm (normal) in 57 patients (86%). The IKDC score was normal/nearly normal in 38 (58%) patients and the mean Lysholm score 83 ± 17 (intact 98 ± 7). The median Tegner score decreased from 7 preinjury (range 3-10) to 5 at follow-up (range 0-10). The mean Knee Society score was 187 ± 15 (out of maximum 200). In 7 patients (10%) a secondary ligament reconstruction was performed. Three patients (4%) underwent a high tibial osteotomy and four (6%) received a primary unconstrained total knee replacement. According to the Kellgren Lawrence osteoarthritis score only mild degenerative changes were present. The stress radiographs showed stable results for anteroposterior translation. Injury of the lateral collateral ligament, refixation of the ACL/PCL and delayed surgery >40 days were significantly associated with worse outcome (p < 0.05). Conclusions Early complete reconstruction can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity. Negative predictive factors for outcome were injury pattern, type of surgical procedure and timing of surgery.
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Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, Bruderholz, CH-4101, Switzerland.
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Abstract
Knee dislocations are uncommon as isolated orthopaedic injuries, but their prevalence is increased in the setting of high-energy multiple trauma. In these circumstances, it is important for the orthopaedic clinician to recognize and appropriately treat the knee dislocation in parallel with other significant injuries. We report the case of an 18-year-old woman who was involved in a motor vehicle collision and sustained multiple injuries in addition to a posterolateral knee dislocation. An attempt at reduction was made in the initial trauma setting, and the patient was medically stabilized. She was discharged from the hospital in a splint with orthopaedic follow-up and presented 3 months after injury with an unreduced posterolateral dislocation. A single-stage operation was performed with reduction and stabilization of the knee. Postoperatively, the patient has done well and regained significant range of motion.
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Traumatic bilateral knee dislocations, unilateral hip dislocation, and contralateral humeral amputation: a case report. HSS J 2009; 5:40-4. [PMID: 19052715 PMCID: PMC2642548 DOI: 10.1007/s11420-008-9100-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 10/22/2008] [Indexed: 02/07/2023]
Abstract
Bilateral traumatic knee dislocations are a rarity. We report a case of bilateral traumatic knee dislocations with concomitant right hip dislocation and complete traumatic amputation of the left, nondominant upper extremity at the level of the proximal one-third of the humerus. Angiograms revealed no evidence of popliteal artery injury. Orthopedic treatment consisted of immediate reduction of the dislocations and urgent revision amputation of the upper extremity. Staged, bilateral knee ligamentous reconstructions were performed on hospital days 24 and 29, respectively. Despite this constellation of devastating injuries, the patient had a satisfactory outcome. In patients with high-energy hip or knee dislocations, the bilateral hips and knees should be carefully examined to check for associated fractures and/or dislocations.
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Concurrent arthroscopic bicruciate ligament reconstruction using Achilles tendon-bone allografts: experience with 15 cases. Chin J Traumatol 2008; 11:341-6. [PMID: 19032848 DOI: 10.1016/s1008-1275(08)60069-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcome of arthroscopically assisted combined anterior and posterior cruciate ligament (ACL/PCL) reconstructions using Achilles tendon-bone allografts. METHODS Associated meniscus injuries were treated according to established methods prior to ligament reconstructions during arthroscopic surgery. Thirty Achilles tendon-bone allografts were used to reconstruct torn ACL and PCL in 15 knees. At postoperative follow-up, all knees were graded using the modified IKDC and the Lysholm scoring systems just as done preoperatively. RESULTS were analyzed compared with the contralateral healthy knees. Results: Eleven men and 4 women with a minimum of 3-year follow-up (mean 38 months) were included in the study. Preoperatively, the group ratings by the modified IKDC standards were all severely abnormal. Twelve bicruciate reconstructions were performed in subacute or chronic stage (larger than 3-8 weeks), 3 for acute ligamentous deficiencies (less than or equal to 3 weeks). The noticeable early complication was transitory local fever combined with joint effusion in one case. At postoperative follow-up, 9 knees were normal, 5 nearly normal and 1 abnormal. On Lysholm score the difference was statistically significant (t- test, P less than 0.001) before and after operation. CONCLUSIONS Achilles tendon-bone allograft offers an alternative for simultaneous arthroscopic ACL/PCL reconstructions. However, further investigation is needed to eradicate its potential immunogenicity for better use.
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Mauro CS, Irrgang JJ, Williams BA, Harner CD. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy 2008; 24:146-53. [PMID: 18237697 DOI: 10.1016/j.arthro.2007.08.026] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 08/21/2007] [Accepted: 08/22/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine the incidence of and factors associated with loss of extension (LOE) 4 weeks after anterior cruciate ligament (ACL) reconstruction using the new IKDC Knee Ligament Evaluation Form criteria for loss of motion. METHODS A retrospective review of patients who had undergone arthroscopic ACL reconstruction between 1995 and 2000 was performed. An endoscopic single tunnel technique with autograft or allograft was used in all cases. A standardized physical therapy program was prescribed to all patients. Subjects with revision ACL reconstruction, concomitant ligament surgery, meniscal transplantation, or any articular cartilage surgery were excluded. LOE was defined as greater than a 5 degrees side-to-side difference in passive knee extension 4 weeks after surgery, the need for repeat arthroscopy to restore extension, or use of a drop-out cast to restore extension. RESULTS Fifty-eight of 229 (25.3%) patients developed LOE 4 weeks after ACL reconstruction. LOE was not associated with age, sex, presence of nerve block, concomitant meniscal procedures, specific graft type, or tourniquet time (P > .05). LOE was significantly associated with preoperative extension, time from injury to surgery, and use of autograft (P < .05). Twenty-eight (12.2%) patients underwent an arthroscopic procedure to recover loss of motion. Following arthroscopy, 4 (1.7%) patients had passive motion deficits between 6 degrees and 10 degrees , with none greater than 10 degrees . CONCLUSIONS Preoperative range of motion and time to surgery are intimately related to a patient's postoperative extension. While 48% of patients that lacked full extension by 4 weeks eventually required arthroscopic debridement to achieve satisfactory extension, our treatment algorithm led to an overall incidence of LOE greater than 5 degrees at final follow-up of 1.7%. LEVEL OF EVIDENCE Level III, therapeutic, retrospective, comparative study.
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Affiliation(s)
- Craig S Mauro
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Shelbourne KD, Haro MS, Gray T. Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side. Am J Sports Med 2007; 35:1105-16. [PMID: 17379923 DOI: 10.1177/0363546507299444] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Knee dislocations with lateral side injury are rare and disabling if not treated. HYPOTHESIS An en masse surgical technique to repair the lateral side will provide good stability, and the posterior cruciate ligament will heal when left in situ. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twenty-three patients underwent an en masse lateral side repair after knee dislocation injury; all but 1 patient had anterior cruciate ligament reconstruction. Physical examination included the International Knee Documentation Committee score, isokinetic strength testing, KT-2000 arthrometer testing, radiography (including varus stress), and magnetic resonance imaging scan. Patients were evaluated subjectively with several surveys. RESULTS Mean objective evaluation occurred for 17 patients at 4.6 years postoperatively, and 21 subjective evaluations occurred for 21 patients at 5.6 years postoperatively. The objective overall grade was normal for 10 patients and nearly normal for 7 patients. Lateral laxity was graded as normal in 15 patients and 1+ in 2 patients. The posterior drawer was normal in all but 3 patients, who had 1+ posterior laxity. The postoperative varus stress radiography demonstrated a mean increase of 1.1 +/- 1.7 mm (range, -1.2-4.7) between knees. Magnetic resonance scans showed that the lateral side was thickened but intact in all patients. The posterior cruciate ligament was viewed as healed or intact in all patients but was sometimes seen as elongated or buckled. The mean subjective total scores were 91.3 points for the IKDC survey, 93.0 for the modified Noyes survey, and 8.0 for an activity score, but scores were higher for patients who underwent surgery within 4 weeks from the injury. CONCLUSIONS The en masse surgical technique to repair the lateral side combined with an anterior cruciate ligament reconstruction after knee dislocation provides excellent long-term stability. The repaired lateral side and untreated posterior cruciate ligament heal with continuity. Patients can return to high levels of activity.
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Affiliation(s)
- K Donald Shelbourne
- The Shelbourne Clinic at Methodist Hospital, 1815 North Capitol Avenue, Indianapolis, IN 46202, USA
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Karataglis D, Bisbinas I, Green MA, Learmonth DJA. Functional outcome following reconstruction in chronic multiple ligament deficient knees. Knee Surg Sports Traumatol Arthrosc 2006; 14:843-7. [PMID: 16565877 DOI: 10.1007/s00167-006-0073-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Accepted: 11/16/2005] [Indexed: 10/24/2022]
Abstract
Multiligament knee injuries are rare but potentially limb-threatening conditions. In this study we aim to evaluate the mid- and long-term functional outcome of patients who underwent arthroscopically assisted multiple ligament reconstruction for chronic multiple knee ligament deficiency. Thirty-five patients (27 males and 8 females) with an average age of 35.1 years (range: 17-60) were included in this study. Follow-up ranged from 12 to 124 months (average: 40.3). On final follow-up patients had a mean loss of extension of 3.1 degrees , while flexion ranged from 95 degrees to 135 degrees (average: 118.4 degrees ). The functional outcome according to Clancy's criteria was excellent in 7 patients (20%), good in 14 (40%), fair in 11 (31.4%), while 3 reconstructions resulted in failure (8.6%). Patients scored an average of 4.03 (range: 1-9) in their Tegner Activity Scale, while their score in Activities of Daily Living Scale of the Knee Outcome Survey ranged from 25 to 98 with an average of 72.7. Sixteen patients returned to sporting activities and all but three returned to work. Early operative treatment of multiple ligament injuries is preferable, as it may allow for anatomic repair instead of reconstruction of ligamentous structures. This study demonstrates though, that even if acute reconstruction has not or could not be performed, reconstruction in chronic multiple ligament deficient knees should be attempted. Although this complex and technically demanding procedure rarely results in a "normal" knee, it offers in most cases very satisfactory stability and a significant improvement in knee function.
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Affiliation(s)
- D Karataglis
- Royal Orthopaedic Hospital, Bristol Road South, Birmingham, UK.
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Wang VM, Banack TM, Tsai CW, Flatow EL, Jepsen KJ. Variability in tendon and knee joint biomechanics among inbred mouse strains. J Orthop Res 2006; 24:1200-7. [PMID: 16705702 DOI: 10.1002/jor.20167] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hereditary factors are thought to be responsible for impaired tendon function and joint laxity. The present study investigated the genotypic variability of knee laxity and stiffness and tendon mechanical and geometric properties among 16-week-old female A/J, C57BL/6J (B6), and C3H/HeJ (C3H) inbred mice. In one group of mice, knee mechanics were quantified using a custom loading apparatus enabling translation of the tibia against a stationary femur. In a second group, flexor digitorum longus and Achilles tendons from the left hind limb underwent biomechanical testing, while those of the contralateral limb were analyzed histologically for determination of cross-sectional area. Our results demonstrate that tendon and joint mechanics varied significantly among the inbred mouse strains, indicating that biomechanical properties are genetically determined. A/J mouse knees exhibited greater laxity (p < 0.001) and lower stiffness (p < 0.001) compared to those of the B6 and C3H mice. The genotypic differences in whole joint properties were similar to those of the tendons' structural biomechanical traits. Although body mass did not differ (p > 0.2) among the three strains, significant genotypic differences were found at the whole tendon, material quality, and morphological levels of the tissue hierarchy. Furthermore, genetic regulation of tendon mechanical properties varied with anatomic site. Patterns of genotypic differences in tendon size were not consistent with those of biomechanical properties, suggesting that unique combinations of structural and compositional factors contribute to tendon growth, adaptation, and development. Therefore, the three inbred strains constitute a useful experimental model to elucidate genetic control of structure-function relationships in normal and healing tendons and ligaments.
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Affiliation(s)
- Vincent M Wang
- Department of Orthopaedic Surgery, Rush University Medical Center, 765A Armour Academic Facility, 600 South Paulina Street, Chicago, IL 60612, USA.
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Lubowitz JH, Elson W, Guttmann D. Complications in the Treatment of Medial and Lateral Sided Injuries of the Knee Joint. Sports Med Arthrosc Rev 2006; 14:51-5. [PMID: 17135946 DOI: 10.1097/00132585-200603000-00009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complications may result from nonoperative and surgical management of medial or lateral sided knee injuries. Because these injuries are often associated with injury to the medial or lateral meniscus and the anterior or posterior cruciate ligaments (ACL and PCL, respectively), injury to these structures will also be considered. We group these complications in 3 categories: (1) complications associated with either operative or nonoperative management, (2) intraoperative complications, and (3) postoperative complications. Greater understanding of complications of medial and lateral knee ligament injuries may result in improved clinical outcomes.
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Affiliation(s)
- James H Lubowitz
- Taos Orthopaedic Institute Research Foundation, Taos, New Mexico 87571, USA.
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Kaeding CC, Pedroza AD, Parker RD, Spindler KP, McCarty EC, Andrish JT. Intra-articular findings in the reconstructed multiligament-injured knee. Arthroscopy 2005; 21:424-30. [PMID: 15800522 DOI: 10.1016/j.arthro.2004.12.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Intra-articular chondral and meniscal injury in the multiligament-injured knee has not been examined. The purpose of this study was to determine the pattern of intra-articular chondral and meniscal damage in subjects with multiligament knee injuries undergoing surgery. TYPE OF STUDY Prospective cohort study. METHODS Analysis was performed on prospectively collected data for the presence of meniscal tears and significant chondral injury on subjects who underwent knee ligament surgery. Subjects were grouped by their multiligament injury combination. Chondral injury was graded using the Modified Outerbridge Classification system. Criteria for significant chondral defect were any grade 2 lesion involving 50% or more of condylar width and all grade 3 or 4 lesions. Groups with more than 10 subjects were compared against the anterior cruciate ligament (ACL)-only group. RESULTS Data were collected on 2,265 subjects. The ACL/medial collateral ligament (MCL) injury pattern was the most common multiligament injury, comprising 70.5% of all multiligament injuries. Lateral meniscal damage was significantly higher in the ACL/MCL group (P < .01). Medial meniscal damage was significantly lower in the ACL/MCL group (P < .01). Medial and lateral meniscal damage was significantly lower in the ACL/lateral collateral ligament (LCL) group (P < .01). Articular damage to the medial tibial plateau was significantly lower in the ACL/MCL group (P < .01). All other multiligament injury patterns showed chondral damage similar to the ACL-only group. Ligament injuries repaired acutely had significantly less articular and medial meniscal damage than chronic repairs (P < .01). CONCLUSIONS The ACL/MCL injury pattern was the most common multiligament injury pattern and showed a high incidence of lateral meniscal tears. ACL/LCL injuries had fewer meniscal injuries. Multiligament-injured knees showed increased risk of a torn medial meniscus as chronicity increased. LEVEL OF EVIDENCE Level IV.
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Abstract
Sideline management of acute knee injuries requires medical personnel to have knowledge of injury patterns, mechanisms, physical findings, and treatment strategies. Fractures and multiple-ligament injured knees need to be rapidly diagnosed and stabilized to allow for timely transfer to a location where further evaluation and definitive treatment can be provided.
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Affiliation(s)
- James R Gardiner
- Division of Orthopedic Surgery, University of Kentucky Medical Center, K401 Kentucky Clinic, Lexington, KY 40536, USA
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Complications of Surgery for Multi-ligament Injuries of the Knee. Sports Med Arthrosc Rev 2004. [DOI: 10.1097/01.jsa.0000131851.05075.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Acute knee dislocations are uncommon orthopaedic injuries. Because they often spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee, resulting in multidirectional instability. Associated meniscal, osteochondral, and neurovascular injuries are often present and can complicate management. The substantial risk of associated vascular injury mandates that vascular integrity be confirmed by angiography in all suspected knee dislocations. Evaluation and initial management must be performed expeditiously to prevent limb-threatening complications. Definitive management of acute knee dislocation remains a matter of debate; however, surgical reconstruction or repair of all ligamentous injuries likely can help in achieving the return of adequate knee function. Important considerations in surgical management include surgical timing, graft selection, surgical technique, and postoperative rehabilitation.
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Affiliation(s)
- Jeffrey A Rihn
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
The management of motion loss of the knee is challenging. A clear understanding of the pathoanatomic causes of motion loss is necessary to establish a careful and rational approach to treatment. Early recognition and physical therapy are effective for the majority of patients, but when these conservative measures fail, operative intervention is indicated. The purpose of this article is to outline a comprehensive approach to the arthroscopic evaluation and treatment of the arthrofibrotic knee. This technique is designed to allow the surgeon to systematically address the numerous causes of motion loss of the knee.
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Affiliation(s)
- David H Kim
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Flowers A, Copley LAB. High-energy knee dislocation without anterior cruciate ligament disruption in a skeletally immature adolescent. Arthroscopy 2003; 19:782-6. [PMID: 12966388 DOI: 10.1016/s0749-8063(03)00388-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Knee dislocations are rare injuries in any age group, but even more unusual in skeletally immature individuals. Such injuries often occur from high-energy mechanisms and are commonly associated with disruption of both anterior and posterior cruciate ligaments. Although there are several previous reports of knee dislocation without disruption of the posterior cruciate ligament, there is only one report citing 3 cases of knee dislocation with the anterior cruciate ligament remaining intact, each occurring in skeletally mature individuals. We present a high-energy knee dislocation in a skeletally immature girl without anterior cruciate ligament disruption. We also discuss the evaluation, management, and outcome. Treatment of this condition with arthroscopically assisted posterior cruciate ligament reconstruction using tibialis anterior allograft 2 weeks after the acute injury resulted in complete functional recovery.
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Affiliation(s)
- Adam Flowers
- Department of Orthopaedic Surgery, University of Missouri, Kansas City, Missouri, USA
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