Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis

[Treatment of acute knee dislocations]

A knee dislocation is a serious injury involving at least two of the four major ligamentous stabilizers of the knee. This injury results in multidirectional knee instability. In dislocation of the knee the popliteal artery and the peroneal nerve can also be damaged. Dislocations with vascular involvement are potentially threatening injuries of the lower extremities. The diagnosis of knee dislocation can be difficult due to a high rate of spontaneous reduction at the initial examination. Knee dislocations are rare and mainly occur in young men. They are mostly caused by high-energy trauma; however, they can also be caused by low-energy injuries. Obesity increases the risk of knee dislocations. The classification of a knee dislocation is based on the anatomical structures involved and the direction of dislocation. The acute treatment includes reduction and stabilization measures. Associated injuries, such as vascular, nerve, extensor mechanism and cartilage injuries as well as fractures and meniscal injuries can influence the treatment approach and the outcome. The definitive surgical treatment depends on the severity of the injury and can include ligament reconstruction or repair with bracing. The aftercare should be individually adapted with the aim to restore knee joint stability and function. Complications such as arthrofibrosis, peroneal nerve palsy, compartment syndrome, postoperative infection and recurrent instability can occur. In the long term, patients have an increased risk for the development of symptomatic osteoarthritis.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury

PURPOSE

To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors.

METHODS

From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared.

RESULTS

A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients.

CONCLUSIONS

Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications

Introduction

Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications.

Methods

A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury.

Results

Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome - all successfully treated and three contracted deep infections - one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital.

Conclusion

Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications.

How to cite this article

Barnard L, Karimian S, Foster P, et al. Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications. Strategies Trauma Limb Reconstr 2023;18(2):87-93.

Team Approach: Treatment of Traumatic Dislocations of the Knee

»

Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee.

»

Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category.

»

Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review

OBJECTIVE

To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs).

DESIGN

Scoping review.

DATA SOURCES

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary.

RESULTS

Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups.

CONCLUSIONS

There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.

Mid-Term Results following Traumatic Knee Joint Dislocation

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.

Predictors of Mid- to Long-Term Outcomes in Patients Experiencing a Knee Dislocation: A Systematic Review of Clinical Studies

Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m² are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m², concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.

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.

Comparison of computed tomography angiography and physical exam in the evaluation of arterial injury in extremity trauma

BACKGROUND

CT angiography (CTA) is increasingly used in the evaluation of arterial injury in extremity trauma. While it may provide additional objective data, it comes with inherent risks and expense. The purpose of this study was to compare CTA to physical exam in the evaluation of arterial injury in extremity trauma.

METHODS

We performed a retrospective review of patients who underwent CTA for evaluation of upper or lower extremity trauma at a Level 1 trauma center over a 10 month period. Patients were classified based on initial vascular exam (normal, soft signs, hard signs), and arterial injury on CTA was classified as major (named arteries) or minor (un-named arteries). We evaluated rates of vascular intervention in each group and compared the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for physical exam and CTA in identifying arterial injury requiring intervention.

RESULTS

A total of 135 CTA studies were included. On initial vascular exam, 71% of patients had a normal exam, 22% had soft signs, and 6% had hard signs. The NPVs for arterial injury requiring intervention of a normal physical exam and negative CTA were both 100%. The PPVs for arterial injury requiring intervention of major injury on CTA and hard signs on physical exam were 35% and 50%, respectively.

CONCLUSION

A normal physical exam can likely rule out the need for vascular intervention and eliminate the need for CTA. Additionally, the presence of hard signs on physical exam is potentially superior to CTA in predicting the need for vascular intervention.

[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.

Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

Purpose

Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF).

Methods

Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined.

Results

Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication.

Conclusion

Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01632-0.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Management of multiligament knee injuries

Up to 18% of multiligament knee injuries (MLKI) have an associated vascular injury.All MLKI should be assessed using the ankle brachial pressure index (ABPI) with selective arteriography if ABPI is < 0.9.An ischaemic limb following knee dislocation must be taken to the operating theatre immediately for stabilization and re-vascularization.Partial common peroneal nerve (CPN) injury following MLKI has better recovery than complete palsy.Posterior tibial tendon transfer is offered to patients with complete CPN palsy if there is no recovery at six months.Operative treatment with acute or staged reconstructions provides the best outcome in MLKI.Effective repair can only be performed within three weeks of injury.There is no difference between repair and reconstruction of medial collateral ligament and posteromedial corner.Posterolateral corner reconstruction has a lower failure rate than repair.Early mobilization following MLKI surgery results in fewer range-of-motion deficits. Cite this article: EFORT Open Rev 2020;5:145-155. DOI: 10.1302/2058-5241.5.190012.

Irreducible Posterolateral Fracture Dislocation of the Knee in an Elderly Patient Treated with Rotating Hinge Total Knee Replacement

Knee dislocation is one of the few real orthopaedic emergencies. It is a serious but relative uncommon injury, representing less than 0.02% of all orthopaedic injuries. Especially posterolateral knee dislocation is much rarer condition that is often missed or misdiagnosed. The main feature of this very rare condition is to be irreducible by closed reduction due to the interposition of soft tissues inside the enlarged medial joint space, such as the medial capsule and retinaculum, vastusmedialis, and medial meniscus. The pathognomonic sign of a posterolateral knee dislocation is the anteromedial distal thigh transverse "pucker" or "dimple sign." We report the case of an 87-year-old man who sustained an irreducible posterolateral fracture dislocation of the knee after being hit by car which has been treated with rotating hinge knee replacement with 1-year of follow-up.

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.

Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study

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.

[Neurovascular complications in fractures of the extremities, part 1 : Vascular lesions]

Neurovascular injuries in fractures threaten at least the function of extremities. The timely interaction between diagnosis and treatment of vascular injuries helps to avoid a poor outcome or even fatal complications. An important parameter is to "think about it" for injuries under strain. An ankle-brachial index (ABI) of <0.9 is an indicator. Massive bleeding, manifest and long-lasting peripheral ischemia and a rapidly expanding hematoma necessitate an immediate surgical intervention. Endovascular techniques are recommended on the extremities of stable patients with circumscribed vascular lesions. The debate about the sequence of repair (vascular vs. osseous) has to be decided on an individual basis; however, when in doubt vascular repair should be given priority. Vessel reconstructions should be performed without tension and must be covered by vital soft tissues, the indications for fasciotomy should be liberally interpreted. The prognosis with respect to preservation of the extremity and long-term functional outcome substantially depends on the quality of treatment of accompanying injuries.

Diagnostic workup and endovascular treatment of popliteal artery trauma

Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial 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.

Effect of Vascular Injury on Functional Outcome in Knees with Multi-Ligament Injury: A Matched-Cohort Analysis

BACKGROUND

Multi-ligament knee injury (MLKI) associated with knee dislocation can result in vascular injury. The purpose of this study was to compare knee function after MLKI between patients with a vascular injury requiring popliteal artery bypass grafting and patients without vascular involvement. Additionally, factors associated with poor knee function in patients who had MLKI with vascular injury were evaluated.

METHODS

This retrospective study identified patients with an MLKI between 1992 and 2014. Each patient who had a concomitant vascular injury requiring bypass grafting (vascular cohort, n = 16; mean age, 30.3 years) was matched to 2 patients without a vascular injury (control cohort, n = 32; mean age, 31.4 years) on the basis of age, knee dislocation (KD) grade, and peroneal nerve status. Fifteen patients in the vascular cohort and 26 patients in the control cohort had an isolated knee injury. Functional outcomes were assessed with physical examination of range of motion and ligamentous stability as well as patient-reported outcome scores.

RESULTS

The vascular cohort had a mean Lysholm score of 62.5 points (range, 16 to 100 points) and a mean International Knee Documentation Committee (IKDC) score of 59.7 points (range, 14.9 to 100 points) at a mean (and standard deviation) of 8.3 ± 5.0 years after surgery. The control cohort had a mean Lysholm score of 86.4 points (range, 51.0 to 100.0 points) and a mean IKDC score of 83.8 points (range, 35.6 to 100.0 points) at a mean of 6.0 ± 4.0 years. The vascular cohort had significantly lower Lysholm (p = 0.001) and IKDC (p = 0.002) scores than the control cohort. A body mass index (BMI) of >30 kg/m was predictive of lower IKDC (p = 0.0009) and Lysholm (p = 0.0008) scores.

CONCLUSIONS

Patients who sustain an MLKI with an associated popliteal artery injury requiring bypass grafting have significantly lower knee function scores than patients without vascular involvement. This information can be used to help counsel patients with combined multiple ligament and popliteal artery injuries.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.].

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.

[Ligament bracing--augmented cruciate ligament sutures: biomechanical studies of a new treatment concept]

BACKGROUND

In the context of acute knee dislocations, suture repair of ruptured cruciate ligaments leads to good clinical results in 80% of cases. Disadvantages are low primary stability and subsequently secondary elongation of the sutured ligaments. In the present study, we compared primary stability of suture repair, reinforced by different suture augments, to cruciate ligament reconstruction.

OBJECTIVE

The concept of ligament bracing with transosseous suture repair of the cruciate ligaments and additional suture augmentation is biomechanically superior to cruciate ligament reconstruction.

MATERIAL AND METHODS

A total of 42 porcine knee joints divided into seven groups were examined. The stability of four different suture/augmentation combinations were compared to cruciate ligament reconstruction with human hamstring tendons. The investigational setup consisted of testing 1000 cycles with 20 N to 154 N load in a.-p. translation and 60° flexion. Elongation and load to failure were measured.

RESULTS

Neither reconstruction (3.13 ± 1.65 mm; 362 ± 51 N) nor augmented suture repair (1.89-2.5 mm; 464-624 N) achieved the primary stability of the intact cruciate ligament (0.63 ± 0.34 mm, 1012 ± 91 N). In comparison to ligament reconstruction, all four augmented suture repairs showed minor elongation in the cyclic test and a higher load to failure. The isolated suture repair showed poor results (6.79 ± 4.86 mm, 177 ± 73 N).

CONCLUSION

Augmented suture repair provides significantly higher stability compared with isolated suture repair and reconstruction with hamstring tendons. The concept of ligament bracing could be a promising future treatment option in acute knee dislocations. Clinical results remain to be seen.

[Ligament bracing--augmented primary suture repair in multiligamentous knee injuries]

OBJECTIVE

Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation.

INDICATIONS

Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury.

CONTRAINDICATIONS

Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance.

SURGICAL TECHNIQUE

Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70-90° flexion. Fixation of the ACL augmentation in 20-30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization.

POSTOPERATIVE MANAGEMENT

Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks.

RESULTS

In total, 20 patients have been treated using the principle of "ligament bracing". So far 8 patients (aged 18-60 years, median 33 years) have been assessed with a follow-up of 10-15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.

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.

Endovascular Therapy And Controversies In The Management Of Vascular Trauma

Aim:

To review the advent of endovascular treatment of vascular injuries and its controversies.

Methods:

Literature review over the past 13 years using the PubMed search engine.

Results:

The management of vascular trauma has changed dramatically over the last decade. This is mainly due to the advent of advanced endovascular techniques and technologies. There are, however, a limited number of publications with a correspondingly small number of patients and lack of long-term follow-up. In this article, we discuss the injuries to different vessel groups and their respective endovascular approaches. Of the literature available, the endovascular management of aortic injuries still holds the most experience and has shown favorable results.

Conclusion:

Endovascular management of vascular injuries is a new addition to the armamentarium of the surgeon. The fact that it is minimally invasive is a major advantage and the published data are encouraging. However, in order to determine which anatomical sites and circumstances are most appropriate for this method versus open surgery, more reports are necessary.

Acute knee dislocation

Traumatic knee dislocations are relatively rare yet serious injuries. They remain under diagnosed injuries in view of the frequency with which they can present having spontaneously reduced. Diagnosis requires a high index of clinical suspicion on presentation of all knee injuries. Careful, repeated and vigilant monitoring for neurovascular compromise following diagnosis, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament injury are important factors in managing these injuries. The prognosis has improved in recent years following establishment of some consensus on the evaluation, investigation, management and rehabilitation of these injuries and this article presents an evidence based review of these principles.

Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis

PURPOSE

Treatment of knee dislocation is still controversial. There is no evidence to favour ligament suture or reconstruction. Until now, no meta-analyses have examined suture versus reconstruction of cruciate ligaments in knee dislocations with respect to injury pattern and rupture classification.

METHODS

We searched Medline, the Cochrane Controlled Trial Database, and EMBASE for studies on surgical treatment for 'knee dislocation' and 'multiple ligament injured knee'. A meta-analysis was performed using individual patient data.

RESULTS

Nine studies including 195 patients (200 knees) with a mean age of 31.4 (±13) years fulfilled the study requirements. Thirteen cases of type II dislocations, 63 cases of type III medial, 84 cases of type III lateral, and 40 cases of type IV dislocations, according to Schenck's classification, were found. Poor or moderate results were found in 70 % of patients without surgical treatment of ACL or PCL (n = 27). Patients (n = 40) treated by sutures of the ACL and PCL demonstrated a significantly greater proportion of excellent or good results (40 and 37.5 %, respectively) (p < 0.001). Patients who underwent reconstruction of the ACL and PCL (n = 75) showed excellent or good results (28 and 45 %, respectively). No significant difference was found when comparing suture versus reconstruction of the ACL and PCL (n.s.). The outcome depends considerably on Schenck's injury pattern classification.

CONCLUSION

Conservative treatment after knee dislocation yields poor clinical results. Suture repair of cruciate ligaments can still serve as an alternative option for multiligament injuries of the knee and achieve good clinical results, which are comparable to those of ligament reconstruction. The data provided by this meta-analysis should be reinforced by a prospective study, in which suture repair and ligament reconstruction are compared.

LEVEL OF EVIDENCE

IV.

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.

ACR appropriateness criteria(®) acute trauma to the knee

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.

[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.

Diagnosis and management of knee dislocations

An acute knee dislocation is an uncommon injury, with a high rate of associated vascular and neurologic injuries as well as potentially limb-threatening complications. High-energy trauma is the most common cause of an acute knee dislocation, although lower-energy injuries, such as those sustained during athletic competition, are increasing in incidence. Injuries to the popliteal artery and common peroneal nerve are relatively common, requiring a high index of suspicion and complete neurovascular examination in a timely fashion. All cases of suspected knee dislocation should have an ankle-brachial index performed, reserving arteriography for those with an abnormal finding. Initial management consists of closed reduction, if possible, and application of a hinged brace or external fixator. Definitive management remains an area of controversy, although anatomic surgical repair or reconstruction is favored by most surgeons to help optimize knee function. Most patients treated for a knee dislocation can expect to return to their daily activities, but with less predictable returns to sporting activities.

Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized?

A concerning number of patients referred to our clinic with knee dislocations have not been thoroughly evaluated for popliteal injury. The objective of this study is to present our experience and attempt to identify possible causes for this trend. Thirty-one consecutive patients with knee dislocations referred over a 1-year period were evaluated. Patients were assigned to either of two groups: Group I included all patients initially evaluated with an evidence-based protocol for identifying clinically significant vascular injury associated with knee dislocation, and Group II included all patients who had not received an evidence-based evaluation. The main outcome measure was delay in the diagnosis of a limb threatening vascular injury (>8 h) within each group. Six out of the 31 patients referred, were evaluated for vascular injury without an evidence-based protocol. These patients were significantly more likely to have had a delay in the diagnosis of their vascular injury beyond 8 h (P = 0.032) and were less likely to have been evaluated at a level I trauma center (P < 0.001). As expected, evidence-based protocols are superior when compared to initial pedal pulse examination alone for identifying surgically significant vascular injury within 8 h. The consequences of a delay in diagnosis beyond 8 h can be catastrophic and one patient in this series required an above-knee amputation. This is not new information, however, a significant number of patients with knee dislocations continue to be evaluated solely by initial pedal pulse examination. Though effective protocols exist, orthopedic surgeons must work to facilitate the implementation of these protocols at their referring institutions.

Dislocation and bicruciate lesions of the knee: epidemiology and acute stage assessment in a prospective series

INTRODUCTION

Knee dislocation and bicruciate lesions are rare. Assessments of results from retrospective series carry an insufficient level of evidence. A prospective multicenter study was therefore set up, under the auspices of the French Society of Orthopedic Surgery.

MATERIAL AND METHODS

The inclusion period covered the whole of 2007. Clinical, imaging (dynamic X-ray and MRI) and vascular (angioscan and arteriography) assessment was performed systematically. In patients over the age of 60 years, ligament lesions were always managed non-surgically; in those under the age of 60 years, surgery was considered in the absence of associated vascular lesion or open dislocation and if there was frontal laxity exceeding 15 degrees or a posterior drawer test greater than 10mm. The posterior cruciate ligament (PCL) and peripheral ligament tears were repaired or reinforced under arthroscopy or by arthrotomy. The anterior cruciate ligament was never operated on. In all other cases, management was conservative.

RESULTS

Sixty-seven knees were included (55 male, 11 female; mean age: 37 years). Fifteen patients (25.4%) had bicruciate lesion, and 44 (74.6%) knee dislocation. Mean trauma-to-reduction interval was 3 hrs 50 min. Only one of the nine cases of popliteal artery lesion exhibited discernible distal pulse wave. Only three of these patients underwent vascular surgical repair. Twelve knees (five bicruciate lesions, seven dislocations) had isolated common peroneal nerve damage.

DISCUSSION

This prospective study detailed the epidemiology and treatment of the lesions encountered, with the option of PCL and peripheral ligament reconstruction. The results, however, still require long-term analysis.

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.