Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient's medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

[Interventional management of peripheral vascular injuries : From the exclusion indication to the procedure of first choice]

BACKGROUND

Approximately one third of all traumatic peripheral artery injuries affect the upper extremities, while two thirds involve the arteries of the lower extremities. Historically, these injuries were treated by open surgical repair. Nowadays, interventional treatment, such as embolization or stent grafting are increasingly used to treat peripheral artery injuries.

OBJECTIVE

Determination of the current state of interventional treatment options for injuries of peripheral arteries.

MATERIAL AND METHODS

Selective literature review on the current state of interventional management of peripheral artery injuries.

RESULTS

Although scarce, the available data confirm the efficacy of interventional techniques for managing peripheral artery injuries; however, despite improvements in treatment techniques and interventional devices, not all patients are equally well suited for endovascular or open surgical treatment. Consequently, a multidisciplinary decision on the best treatment has to be made on a case by case basis.

CONCLUSION

According to the promising clinical data, interventional treatment should be considered more often. Diagnostic algorithms need to be adapted accordingly.

Imaging primer for CT angiography in peripheral vascular trauma

The use of computed tomography angiography (CTA) for the evaluation of peripheral vascular trauma has become increasingly prevalent in the past decade with the development of multidetector CT (MDCT) and multiple studies subsequently demonstrating high sensitivity, specificity, and diagnostic accuracy when compared with conventional angiography. Additional benefits of MDCT include the ability to rapidly acquire the images, perform multiplanar and 3D reconstructions, and assess the adjacent soft tissues and bones. Rapid intravenous injection of iodinated contrast material is required for optimal arterial enhancement. CTA manifestations of an arterial injury may be direct, and include active contrast extravasation, pseudoaneurysm, arteriovenous fistula (AVF), intimal injury, dissection, or occlusion. There are also indirect signs which have a high association with vascular injury, and should raise suspicion, when present. Pitfalls related to image acquisition or patient factors can be mitigated with appropriate planning and post-processing techniques.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSION

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

Critical Evaluation of the Methodologic Quality of the Top 50 Cited Articles Relating to Knee Dislocation and Multiligamentous Knee Injury

Background:

Many studies have evaluated the management of knee dislocations (KDs) and multiligamentous knee injuries (MLKIs). However, no study to date has analyzed the quality of the most cited articles in this literature.

Hypothesis:

There is a positive correlation between the number of article citations in the KD and MLKI literature and their methodologic quality.

Study Design:

Systematic review.

Methods:

The Web of Science online database was searched to identify the top 50 cited articles in KD and MLKI care. Demographic data were recorded for each study. The Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS) were used to analyze the methodological quality of each article. Spearman correlation coefficients (r_s) were then calculated.

Results:

The articles identified were published between 1958 and 2015 in a wide variety of peer-reviewed journals (n = 16). The majority of study level of evidence (LOE) was of low quality (level 5, 16%; level 4, 54%; level 3, 16%; level 2, 14%). There were no studies of level 1 evidence. The mean MCMS and MINORS scores were 29.0 (SD, 19.1; range, 3-72) and 6.1 (SD, 3.7; range, 0-14), respectively. No significant correlation was identified between the number of citations and the publication year, LOE, MCMS, or MINORS (r_s = 0.123 [P = .396]; r_s = 0.125 [P = .389]; r_s = 0.182 [P = .204]; and r_s = 0.175 [P = .224], respectively). Positive correlations were observed between improved MCMS and MINORS scores and more recent year of publication (r_s = 0.43 [P = .002]; r_s = 0.32 [P = .022]) as well as improved study LOE (r_s = 0.65 [P < .001]; r_s = 0.67 [P < .001]).

Conclusion:

The top 50 cited articles on KD and MLKI care consisted of low LOE and methodological quality, with no existing level 1 articles. There was no significant correlation between the number of citations and publication year, LOE, or study methodological quality. Positive correlations were observed between later publication date and improved methodological quality.

Over-utilization of computed tomography angiography in extremity trauma

Objectives:

Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center.

Methods:

We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied.

Results:

A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001).

Conclusion:

CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients’ treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.

Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm

Traumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation.

Vascular Injury in Orthopedic Trauma

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

Can Vascular Injury be Appropriately Assessed With Physical Examination After Knee Dislocation?

BACKGROUND

Knee dislocations are rare injuries with potentially devastating vascular complications. An expeditious and accurate diagnosis is necessary, as failing to diagnose vascular injury can result in amputation; however, the best diagnostic approach remains controversial.

QUESTIONS/PURPOSES

We asked: (1) What patient factors are predictors of vascular injury after knee dislocation? (2) What are the diagnostic utilities of palpable dorsalis pedis or posterior tibial pulses, and the presence of an ankle-brachial index (ABI) of 0.9 or greater?

METHODS

A database at a Level I trauma center was queried for patients with evidence of knee dislocation, demographic information (age at the time of injury, sex, Injury Severity Score, BMI, mechanism of injury), and the presence of open injury were recorded. One-hundred forty-one patients underwent screening at initial presentation, of whom 26 (24%) underwent early vascular exploration based on an abnormal physical examination. One-hundred five (91%) of the remaining 115 patients were available at a minimum followup of 6 months (mean, 19 ± 10 months). In total, 31 unique patients were excluded, including 10 patients (7%) who were lost to followup before 6 months. Among the 110 patients who met inclusion criteria, the mean age and SD was 37 ± 13 years, and the Injury Severity Score was 15 ± 9. There were 71 males (65%). Logistic regression was used to determine independent correlates of vascular injury. The vascular examination was reviewed for the presence of a palpable pulse in the dorsalis pedis artery, the presence of a palpable pulse in the posterior tibial artery, and whether the ABI in the dorsalis pedis was 0.9 or greater. Contingency tables were generated to assess the sensitivity, specificity, and accuracy of physical examination maneuvers. The physical examination was collectively regarded as "normal" when both pulses were palpable and the ABI was 0.9 or greater. The initial physical examination as just described was considered the diagnostic test being evaluated in this study; "positive" tests were evaluated by and confirmed at vascular surgery, and 6 months clinical followup without symptoms or progressive signs of vascular injury confirmed the absence of injury in the remainder of the patients. Contingency tables were generated again to assess the sensitivity, specificity, and accuracy of the combined physical examination.

RESULTS

Increased BMI (odds ratio [OR], 1.077; 95% CI, 1.008-1.155; p = 0.033) and open injuries (OR, 3.366; 95% CI, 1.008-11.420; p = 0.048) were associated with vascular injury. No single physical examination maneuver had a 100% sensitivity for ruling out vascular injury. A normal physical examination (palpable pulses and ABI ≥ 0.9) had 100% sensitivity for ruling out vascular injury.

CONCLUSIONS

Increased BMI and the presence of open dislocation are associated with a greater risk for vascular injury after knee dislocation. The combination of a palpable dorsalis pedis and posterior tibial pulse combined with an ABI of 0.9 or greater was 100% sensitive for the detection of vascular injury based on clinical followup at 6 months.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Pediatric Knee Dislocations and Physeal Fractures About the Knee

Given the high incidence of vascular and neurologic injury associated with pediatric knee dislocations and displaced physeal injuries about the knee, a thorough understanding of the clinical and radiographic signs associated with these injuries, relevant anatomy, workup, reduction techniques, and surgical management is crucial. A higher incidence of these injuries in children is anticipated because of increased participation in high-energy activities that result in contact or collision during sports or recreation. Complications, such as vascular and nerve injuries and compartment syndrome, can be diagnosed early in the workup to prevent catastrophic outcomes. The clinical examination should include evaluation of the motor and sensory status of the limb, palpation of pulses, and measurement of ankle brachial indices. Radiographic examination should include plain radiography and supplemental advanced imaging, if indicated. Vascular imaging or expert consultation should be considered when the pulse or ankle brachial index is abnormal on clinical examination. Selection of nonsurgical or surgical treatment depends on the fracture pattern and stability.

Penetrating nontorso trauma: the extremities

Similar to penetrating torso trauma, nontorso injuries have undergone a fascinating oscillation between invasive and noninvasive approaches. This article discusses an organized approach to the evaluation and initial treatment of penetrating extremity injuries based on regional anatomy and clinical examination. The approach is reliable, efficient and minimizes both delays in diagnosis and missed injuries. Outpatient follow- up is particularly important for patients with extremity injuries who are discharged home from the emergency department.

Vascular and nerve injury after knee dislocation: a systematic review

BACKGROUND

Vascular injury is a devastating complication of acute knee dislocation. However, there are wide discrepancies in the reported frequency of vascular injury after knee dislocations, as well as important differences among approaches for diagnosis of this potentially limb-threatening problem.

QUESTIONS/PURPOSES

We determined (1) the frequency of vascular and neurologic injury after knee dislocation and whether it varied by the type of knee dislocation, (2) the frequency with which surgical intervention was performed for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury.

METHODS

We searched the MEDLINE(®) literature database for studies in English that examined the clinical sequelae and diagnostic evaluation after knee dislocation. Vascular and nerve injury incidence after knee dislocation, surgical repair rate within vascular injury, and amputation rate after vascular injury were used to perform a meta-analysis. Other measures such as diagnostic modality used and the vessel injured after knee dislocation were also evaluated.

RESULTS

We identified 862 patients with knee dislocations, of whom 171 sustained vascular injury, yielding a weighted frequency of 18%. The frequency of nerve injuries after knee dislocation was 25% (75 of 272). We found that 80% (134 of 160) of vascular injuries underwent repair, and 12% (22 of 134) of vascular injuries resulted in amputation. The Schenck and Kennedy knee dislocation classifications with the highest vascular injury prevalence were observed in knees that involved the ACL, PCL, and medial collateral liagment (KDIIIL) (32%) and posterior dislocation (25%), respectively. Selective angiography was the most frequently used diagnostic modality (61%, 14 of 23), followed by nonselective angiography and duplex ultrasonography (22%, five of 23), ankle-brachial index (17%, four of 23), and MR angiography (9%, two of 23).

CONCLUSIONS

This review enhances our understanding of the frequency of vascular injury and repair, amputation, and nerve injuries after knee dislocation. It also illustrates the lack of consensus among practitioners regarding the diagnostic and treatment algorithm for vascular injury. After pooling existing data on this topic, no outcomes-driven conclusions could be drawn regarding the ideal diagnostic modality or indications for surgical repair. In light of these findings and the morbidity associated with a missed diagnosis, clinicians should err on the side of caution in ruling out arterial injury.

Current concepts in acute knee dislocation: the missed diagnosis?

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.

Open reduction of irreducible posterolateral rotary knee dislocation without sectioning of incarcerated vastus medialis: a case report with video illustration

Traumatic knee joint dislocations are relatively rare. Most of knee dislocations are reduced by closed manipulation. However occasionally, especially in the case of soft tissue incarceration, closed reduction may not be possible and open reduction is mandatory. This report introduces a case of irreducible posterolateral rotary knee dislocation with interposition of vastus medialis treated through two-staged operations. In this report, we included preoperative magnetic resonance images (MRI), detailed intraoperative descriptions with photographs and video illustration that show the status of an injured knee joint and the effectiveness of the treatment.

Death after closed adolescent knee injury and popliteal artery occlusion: a case report and clinical review

A healthy adolescent male soccer player sustained a radiograph-negative, effusion-negative physeal injury of the proximal tibia from a ground-level fall with traumatic occlusion of the popliteal artery. Orthopaedic evaluation and arteriography were delayed for 72 hours after the injury. He arrived at a tertiary referral center in multisystem organ failure secondary to lower extremity ischemic necrosis, septic pulmonary thromboembolism, and systemic shock. Emergent medical evaluation, a high index of suspicion, and a careful neurovascular examination are imperative after every closed knee injury in the young athlete.

Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges

The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.

[Vascular injuries associated with dislocation of the knee: diagnosis protocol]

INTRODUCTION

Knee dislocation is an unusual condition, and can have catastrophic consequences, such as vascular and neurological complications, in addition to the ligament injuries.

OBJECTIVE

The aim of this study is to analyse the effectiveness of a protocol of early diagnosis of vascular injuries associated with knee dislocations.

MATERIALS AND METHODS

A retrospective study was conducted which included acute knee dislocations treated in our institution, with a minimum of 12 months follow-up, between 1999-2010. A diagnostic protocol based on physical examination and ankle-brachial index was used in order to detect vascular injuries.

RESULTS

Ten dislocations, 30% with popliteal artery injury, were diagnosed early and received emergency treatment within 8 hours. There were associated neurological injuries in two patients. There were no amputations.

CONCLUSIONS

The systematic use of this protocol has avoided consequences of late diagnosis and has drastically reduced the abusive use of invasive tests, such as arteriography.

Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee

Traumatic knee dislocations are uncommon yet serious injuries that historically have had variable prognosis. The evaluation and management of traumatic knee dislocations remains controversial. Appropriate early management has been shown to have a significant impact on long term functional outcome. A comprehensive review of the recent literature is presented alongside our current approach to management. The dislocated knee is an under diagnosed injury which relies on a high index of clinical suspicion on presentation of any knee injury. There is now a degree of consensus regarding need for surgery, timing of surgery, vascular investigations, surgical techniques and rehabilitation protocols. Vigilant monitoring for neurovascular complications, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament surgeries is the key to successful management of these difficult injuries.

Vascular injury associated with extremity trauma: initial diagnosis and management

Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.

Vascular lesions associated with bicruciate and knee dislocation ligamentous injury

INTRODUCTION

The incidence of associated vascular lesions in biligamentous cruciate injuries of the knee ranges from 16 to 64%, with a mean rate of 30%. Treatment of ischemic vascular lesions associated with ligaments injury is well established, comprising emergency arterial vascular repair, most of the times combined to external fixation. In the absence of clinical symptoms of vascular lesion, some authors recommend systematically performing arteriography, while others advocate selectively prescribing this examination in doubtful clinical situations. The present study analyzed data extracted from the prospective series of the 2008 SOFCOT Symposium (dedicated to management of bicruciate knee lesions) and from an analysis of the literature, with emphasis on developing a diagnostic strategy for vascular lesions associated with bicruciate lesions.

MATERIAL AND METHODS

This multicenter prospective study included all patients treated in the reference centers for dislocation or bicruciate lesion of the knee between January 2007 and January 2008. All patients underwent early objective vascular imaging.

RESULTS

Sixty-seven patients were included. Mean dislocation reduction time was 2 hrs 45 min (max, 21 hrs). There were nine vascular lesions (12%). Absence of vascular lesion could be confirmed in 58 of the 59 patients exhibiting presence of peripheral pulses at initial examination. In one case, a vascular lesion was found on early imaging, but with no clinical consequence. In all eight cases with associated clinical pulse abnormality, complementary vascular check-up confirmed the presence of a vascular lesion. Angioscan induced no error of vascular assessment in this series, with no false positives or false negatives. One patient underwent amputation for critical ischemia. Three patients had vascular surgical treatment, two not undergoing secondary ligament surgery. Four of the five patients whose vascular lesion was conservatively managed by simple observation were able to undergo the scheduled treatment for their ligament lesions.

DISCUSSION

At initial examination, it is essential to look for the peripheral pulse. In case of ischemic syndrome, the priority is a revascularization procedure associated to intraoperative arteriography. In case of abnormal pulse without obvious ischemia, emergency imaging (usually arteriogram or angioscan) is essential. Where there is no initial clinical vascular abnormality, good practice is less clearly cut. Initially, present pulses are found in a mean 30% (17-55%) of cases of popliteal artery lesion, according to the series. Different authors draw diverging conclusions from this fact. For some, the absence of frank abnormality on clinical examination is sufficient to exclude not any possible anatomic vascular lesion but any vascular lesion requiring surgery. However, even without pulse abnormality, we consider systematic imaging to be justified, partly by the difficulty of ensuring strict monitoring, and partly by the decompensation risk of clinically asymptomatic intimal lesions during the ligament surgery under consideration in most cases. Although many authors cling to the dogma of late emergency arteriography, recent reports argue against this attitude. Angio-MRI has good diagnostic value, but in practice is difficult to obtain in emergency. We would rather advocate angioscanning, which is easily available in emergency and does not incur the risk of local complication associated with arteriography.

Controversies in the treatment of knee dislocations and multiligament reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

Multiple ligament knee reconstruction clinical follow-up and gait analysis

Multiple ligament knee injuries are serious and rare injures that have not been studied using advanced gait analysis techniques. The purpose of this study was to perform clinical follow-up and gait analysis on patients with multiple knee ligament reconstruction. Twenty-four patients who underwent a multi-ligament knee reconstruction by a single surgeon volunteered to participate in this study. We performed complete clinical exam including instrumented ACL exam (KT-1000), and radiological exam including weight-bearing and PCL stress radiographs (TELOS) at minimum 2 years post index surgery. In addition, we performed complete three-dimensional gait analysis on 18 patients. We used a 10-camera, high speed (120 Hz) motion analysis system in conjunction with a multi-axis strain-gage force plate which calculated knee joint kinetics and kinematics while subjects performed flat-ground walking and stair-descent tasks. Kinematic and kinetic variables were compared between reconstructed and contralateral knees and unmatched, healthy control knees. All knee joint moments were normalized to subjects' weight. Clinical: Average knee joint flexion/extension 123.6 +/- 15.5/1.7 +/- 3.5, respectively. Average KT-1000 side-to-side difference was 1.2 +/- 2.0 mm, TELOS side-to-side difference on stress radiographs was 4.0 +/- 3.1 mm. Median IKDC score was 67 (range 13-94). Fifty-three percent of patients exhibited radiographic evidence of osteoarthritis (OA) on the operative side; one patient on the contralateral knee. During gait analysis, patients exhibited significantly reduced total knee joint range of motion, and external knee flexion moment in the reconstructed knee compared to the contralateral knee and healthy control knees. The magnitude of these differences was greater while descending a step. Finally, patients who had radiographic evidence of knee joint OA had significantly lower magnitude external knee flexion moment compared to those who did not have OA at the time of follow-up. Greater than 2 years after reconstruction, patients with multi-ligament knee injuries are able to return to daily activities. Gait analysis data suggests that patients may be experiencing higher magnitude changes in sagittal plane kinematics and kinetics during demanding functional tasks (stair decent). Changes in walking gait biomechanics may help explain why this group is experiencing unilateral knee joint degeneration.

Management of the acute knee dislocation: the Pittsburgh experience

Traumatic dislocation of the knee is among the most severe form of ligament injury to the lower extremity. While the incidence of knee dislocations is low, this injury is associated with a high rate of complications including amputation. There is potential for a traumatic knee dislocation to present to the emergency department after spontaneous or in-field reduction. This requires a vigilant, comprehensive, and systematic approach to the injured knee and extremity to avoid limb-threatening oversights. At the University of Pittsburgh a comprehensive algorithm has been developed to facilitate accurate and efficient diagnosis and treatment of complex traumatic knee injuries. The following manuscript includes a detailed review of the literature and explains our specific approach to this diagnostic dilemma.

[Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 14 cases]

PURPOSE OF THE STUDY

Complex femorotibial dislocation of the knee joint generally results from high-energy trauma caused by a traffic or a contact sport accident. Besides disruption of the cruciate ligaments, in 10-25% of patients present concomitant palsy of the common peroneal nerve and more rarely disruption of the popliteal artery. The purpose of this work was to assess outcome in a monocentric consecutive series of knee dislocations with ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.

MATERIAL AND METHODS

This retrospective series included eleven men and three women, aged 18 to 74 years (mean 47 years). The right knee was injured in five and the left knee in six. Trauma resulted from a farm accident in six patients, fall from a high level in two, a traffic accident in three and a skiing accident (fall) in one. Two other patients with morbid obesity were fall victims. Nine patients had a single injury, two presented an associated serious head injury, one a severe chest injury, and one multiple trauma with coma, chest contusion, and abdominal lesions. One patient had a fracture of the distal femur with associated ischemia. Five knee dislocations were open with a popliteal wound for three and a posteromedial wound for two. Four patients presented total sciatic nerve palsy and nine palsy of the common peroneal nerve. The dislocation was documented in ten cases: lateral (n=1), anterior (n=4), posterior (n=5). For four patients, the dislocation had been reduced during pre-hospital care. Preoperative arteriography was available for eight patients and confirmed the disruption of the popliteal artery; the diagnosis was obvious in six other patients who were directed immediately to the operative theatre without pre-operative imaging. Revascularization was achieved with a upper popliteal-lower popliteal bypass using an inverted saphenous graft. The graft was harvested from the homolateral greater saphenous vein in eight patients and the contralateral vein in six. On average, limb revascularization was achieved after 10.07 hours ischemia. Intravenous heparin was instituted for 810 days followed by low-molecular-weight heparin. The dislocation was stabilized by a femorotibial fixator in nine patients and a cruropedious cast in five. An incision was made in the anterolateral and posterior leg compartments in twelve patients. A revision procedure was necessary on day one in one patient because of recurrent ischemia; a second bypass using an autologous venous graft was successful. One other 75-year-old patient also presented recurrent ischemia on day five; the bypass was reconstructed but the patient died from multiple injuries. Seven thin skin grafts were used to cover the aponeurotomy surfaces. Mean duration of the external fixator was 3.4 months. The five patients treated with a plaster case were immobilized for 2.7 months on average. Ligament repair was performed in three patients (one lateral reconstruction and one double reconstruction of the central pivot for the two others). A total prosthesis with a rotating hinge was implanted in two patients aged 67 and 74 years after removal of the external fixator at six and seven months. Failure of the ligament repair also led to arthroplasty in a third patient.

RESULTS

Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in 13 patients. Transient acute renal failure required dialysis in one patient. Four patients developed pin track discharges and there was one case of septic arthritis of the knee joint which was cured after arthrotomy for wash-out and adapted antibiotics. Outcome was assessed a minimum 18 months follow-up (average 22 months) for the 13 survivors. The three sciatic palsies recovered partially at five and six months in the tibial territory but with persistent paralysis in the territory of the common peroneal nerve. The nine cases of common peroneal nerve palsy noted initially regressed completely or nearly completely in three patients, partially in three and remained unchanged in three. The results were assessed as a function of the final knee procedure: outcome was satisfactory for the patients with a total knee arthroplasty. Outcome of the three ligamentoplasties was good in one, fair in one, and a failure in one (revision arthroplasty). Patients treated by immobilization without a second surgical procedure complained of joint instability with a variable clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.

DISCUSSION

An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma. The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation is between 4 and 20%. The rate is closely related to that of injury to nerves and soft tissue. Ischemia should be immediately suspected in all cases of knee dislocation. The pedious and tibial pulses must be carefully noted before and after reduction of the dislocation to determine whether or not there is an organic arterial lesion. If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction. Otherwise, arteriography should be performed. Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture. Repair requires a bypass between the upper popliteal artery and the tibioperoneal trunk using an inverted saphenous graft because the walls are torn over several centimeters. The traumatology and vascular surgical teams must work in concert from the beginning of the surgical work-up in order to establish a coherent operative strategy founded on primary reduction of the dislocation, installation of a fixator and then vascular repair and aponeurotomy incisions. It would be preferable to wait until the bypass is proven patent and wound healing is complete before proposing ligament repair. This should be done after a precise anatomic work-up to assess each ligament lesion. Bony avulsion or simple disinsertion can however be repaired in the emergency setting at the time of the bypass as well as any ligament rupture which is obvious and-or situated on the medial collateral approach. Secondarily, elements of the central pivot can be repaired in young patients with an important functional demand. Arthroplasty is not warranted except in the elderly patient. Dissection of the popliteal fossa or debridement of the wound enables a careful anatomic assessment of the nerve trunks. In the event of a peroneal nerve disruption, it is advisable to fix the nerve ends to avoid retraction. Beyond three months without clinical or electromyography recovery, surgical exploration is indicated. In the event more than 15 cm is lost, there is no hope for a successful graft. Complete knee dislocation is extremely rare. It can be caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy. Compression, contusion or disruption of the popliteal artery is very rarely caused by the displacement of the femur or the tibia. Limb survival may be compromised. Mandatory emergency restoration of blood supply will modify immediate and subsequent surgical strategies. There has not however been any study exclusively devoted to double joint and vascular involvement. Our objective was to present a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

[Dislocation and fractures around the knee with popliteal artery injury: A retrospective analysis of 54 cases]

A retrospective multicentric series of 54 cases of knee trauma with acute ischemia by popliteal artery injury were analyzed. These high-energy traumas involved 25 dislocations and 29 fractures, 11 involving distal femur, 15 the proximal tibia and 3 a floating knee. There were 45 men and 7 women, mean age 42 years. Thirty-three patients suffered multiple injuries. The knee injury was open in 25 cases and associated with sciatic paralysis in 32. Vascular repair was almost always achieved with bypass surgery. An external fixator was used in 39 patients. Vascular repair was unsuccessful in three cases requiring amputation, all three cases involving fractures. There were also six secondary amputations due to muscle necrosis or septic nonunion. The rate of complete recovery of the sciatic was 25%. The rate of nonunion was 37%, half due to infection. Outcome assessed at at least one year follow-up was moderate with frequent functional sequelae. The analysis of these results and data reported in the literature provided indications for diagnostic and therapeutic propositions.

The Belfast approach to managing complex lower limb vascular injuries

INTRODUCTION

Complex lower limb vascular injuries (CLVIs) in high-energy penetrating or blunt trauma are associated with an unacceptably high incidence of complications including amputation. Traumatic ischaemia and ischaemia-reperfusion injury (IRI) of skeletal muscle often lead to limb loss, the systemic inflammatory response syndrome (SIRS) which affects remote organs and even the potentially fatal multiple organ dysfunction syndrome (MODS). Surgical care of CLVIs everywhere, including Northern Ireland until 1978, was governed by an anxiety to restore arterial flow quickly often using expedient and flawed repair techniques while a damaged major vein was frequently ligated.

MATERIALS AND METHODS

A new policy centred on early intraluminal shunting of both artery and vein, restoring arterial inflow and venous outflow, respectively, was introduced at the Regional Vascular Surgery Unit of The Royal Victoria Hospital, Belfast in 1979. It imposed a disciplined one-stage comprehensive approach to treatment involving a sequence of operative manoeuvres in which all damaged anatomical elements receive meticulous and optimal attention unshackled by time constraints.

RESULTS

Comparisons drawn between the pre-shunt period of unplanned treatment (1969-1978) and the post-shunt period centred on the use of shunts (1979-2000) showed that early shunting of both artery and vein in both penetrating (P) and blunt (B) injuries significantly reduced the necessity for fasciotomy (P: p=0.016, B: p=0.02) and caused a significant fall in the incidence of contracture (P: p=0.018, B: p=0.02) and of amputation (P: p=0.009, P: p=0.012).

CONCLUSIONS

The policy of early shunting of artery and vein in CLVIs has proved to be of great benefit in terms of significantly improved outcomes, better operative discipline and harmonious collaboration among the specialists involved.

Physical examination of the knee

Even with the rapid advancement in technology and medical imaging, there is still no substitute for the history and physical examination that can be obtained from a patient. With a well-performed history and physical, the majority of pathology can be determined prior to any expensive imaging or surgical procedures. The knee is one of the most commonly injured joints, and its function is critical to basic ambulation and participation in sports, work, and activities of daily living. This article reviews the key concepts to a complete evaluation of the knee and highlights aspects of the physical examination and radiographic imaging that best aid in diagnosing knee pathology.

Screening for extermity arterial injury with the arterial injury with the arterial pressure index

Certain extremity injuries presenting to the ED or Trauma Unit warrant increased suspicion for underlying arterial trauma. Such injuries include knee dislocations, displaced medial tibial plateau fractures and other displaced bicondylar fractures around the knee, open or segmental distal femoral shaft fractures, floating joints, gunshot wounds in proximity to neurovascular structures, or mangled extremities. Once the diagnosis of arterial trauma is made, a multi-disciplinary approach is warranted. The diagnostic strategies for vascular injury have undergone an evolution over the past 2 decades. One and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular compromise [Bunt TJ, Malone JM, Moody M, et al. Am J Surg 1990;160(2):226-8; Reid JD, Weigelt JA, Thal ER, et al. Arch Surg 1988;123(8):942-6; Applebaum R, Yellin AE, Weaver FA, et al. Am J Surg 1990;160(2):221-4; discussion 224-5; Dennis JW, Frykberg ER, Veldenz HC, et al. J Trauma 1998;44(2):243-52; discussion 242-3]. An efficient and effective evidence-based approach to diagnosing vascular injury is necessary, as the difficulty in diagnosis, the multiplicity of diagnostic strategies, the limited time frame in which to initiate appropriate treatment, the limb threatening complications of a missed diagnosis, and the increased awareness of health care expenditures make this entity an intimidating diagnostic challenge [Johansen K, Lynch K, Paun M, et al. J Trauma 1991;31(4):515-9; discussion 519-22; Lynch K, Johansen K. Ann Surg 1991;214(6):737-41; Walker ML, Poindexter Jr JM, Stovall I. Surg Gynecol Obstet 1990;170(2):97-105; Kendall RW, Taylor DC, Salvian AJ, et al. J Trauma 1993;35(6):875-8]. The purpose of this article is to present an evidence-based algorithm for patients who present with either arterial injury or a high-risk of arterial injury. A diagnostic algorithm will be presented, and the rationale for diagnostic interventions will be discussed in the context of current medical literature.

Popliteal artery disease: diagnosis and treatment

The popliteal artery is a relatively short vascular segment but is affected by a unique set of pathologic conditions. These conditions, which may be common throughout the arterial system or exclusive to the popliteal artery, include atherosclerosis, popliteal artery aneurysm, arterial embolus, trauma, popliteal artery entrapment syndrome, and cystic adventitial disease. The clinical manifestations, imaging appearances, and treatment options associated with these pathologic conditions differ significantly. Consequently, the radiologist should be familiar with these conditions to direct imaging for accurate diagnosis and treatment and to prevent loss of limb.

Irreducible posterolateral knee dislocation resulting from a low-energy trauma

A small amount of knee dislocations is included in the irreducible knee dislocations group. In such instance, medial femoral condyle is buttonholed through the gap formed by medial retinacular and capsular structures and this prevents reduction. In this study, we present two cases in which there were irreducible posterolateral knee dislocations resulting from a low-energy trauma. In both cases, dimple sign produced by the invagination of the medial retinacular structures and capsule and ecchymosis medially were noted. Soft tissue invaginated between the trochlea and intercondylar notch was extracted by open reduction.