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PubMed1987

Vascular injury associated with low-velocity dislocations of the knee.

Complete dislocation of the knee is a relatively rare condition. When it occurs as a result of high-velocity injury, such as in a road traffic accident, associated vascular injury is generally suspected. In low-velocity injuries, however, distal pulses are often maintained throughout, and the possibility of vascular injury may erroneously be discounted. We report four cases of low-velocity dislocation of the knee, only one of which had an overt vascular disruption, but three of which had arterial damage. On the basis of our experiences, we recommend arteriography in all cases of complete dislocation of the knee.

Accidental Falls↗
PubMed1986

[Vascular and capsule-band reconstruction following knee joint dislocation].

This is a report about bilateral dislocations of the knee joints in one patient with arterial and venous stop because of endothelial lesions and thrombosis of the popliteal vessels on both sides. After reconstruction of circulation by means of vena saphena, the disrupted knee ligaments were also sutured. Large ventral exposure of the knee joint is recommended for both reconstruction of vessels and ligaments.

Adolescent↗
PubMed1984

Traumatic dislocation of the knee.

Traumatic dislocation of the knee is an uncommon orthopedic injury affecting primarily young males who have been subjected to major trauma. The presentation may be subtle and the diagnosis is frequently overlooked. The high frequency of associated limb-threatening vascular injury mandates careful search for and aggressive treatment of this entity, as misdiagnosis of the knee injury or failure to pursue evaluation of the vascular status of the limb will result in a large number of potentially avoidable amputations.

Emergencies↗
PubMed1985

Congenital dislocation of the knee.

Congenital dislocation of the knee is a very rare condition, the incidence in Scandinavia hitherto not being known with certainty. Thirteen patients treated during the years 1960 to 1983 with 19 affected knees were reviewed and followed up. Findings of muscular imbalances in nine of these cases and of spinal abnormalities in four cases strongly indicate neuromuscular imbalance as an aetiological factor. The minimum incidence was estimated to be 0.017 per mille or approximately 1 per cent of the incidence of congenital dislocation of the hip. Recommendations for treatment are that manipulation should be carried out gently, and if not successful within 2-3 months and in all cases of Grade III, an operation is indicated. Too many newborn children in this series had manipulation fractures or slipped epiphyses. However, signs of fracture had disappeared at follow-up in most cases.

Abnormalities, Multiple↗
PubMedDate not supplied

Congenital dislocation of the knee.

Congenital dislocations of the knee (CDK) are rare, occurring 40-80 times more rarely than congenital dislocation of the hip (CDH). In a multicentric study of the European Paediatric Orthopaedic Society, 56 cases of CDK were found in 46 babies. Many other malformations associated with CDK were noticed, and muscular abnormality was always found at the knee. According to the classification of Leveuf, three grades have to be considered: grade 3, or complete dislocation, was the most frequent. At birth, treatment consisted of physiotherapy with rigid splint. Twenty-four patients with CDK have been treated only by the conservative technique. Operations were performed according to the abnormalities of the extensor apparatus: a progressive release and lengthening of the quadricipital tendon was necessary in all cases. In all forms of treatment, the range of the knee flexion was 120 degrees. Only two children had a bad result because of unstable knees. Results were always better with conservative treatment.

Female↗
PubMed1995

Open dislocation of the knee.

Traumatic open dislocation of the knee is an infrequent, severe injury associated with extensive ligamentous damage and a high incidence of vascular and neurologic involvement. Eighteen patients with 19 open knee dislocations were treated at the affiliated hospitals of the University of Pennsylvania and Louisiana State University Medical Center during an 18-year period. Final results included three above-knee amputations, one knee fusion, and one total knee arthroplasty. The 14 knees salvaged had only fair to poor function according to the Hospital for Special Surgery Knee Injury Score at an average follow-up of 36 months after the injury (average score = 29, range - 17 to 37). Nine patients (47%) had concomitant neurologic or vascular injury, and eight patients (42%) had wound healing difficulties. Five complete disruptions of the popliteal artery or posterior tibial artery underwent emergent revascularization, successful in three of the extremities, with the remaining two extremities requiring above-knee amputations. These massive injuries are often limb-threatening despite prompt surgical intervention and early antibiotic therapy. There is a very high incidence of infection and neurologic injury with a guarded prognosis for limb survival and satisfactory function.

Adolescent↗
PubMed1990

Congenital dislocation of the knee.

Congenital dislocation of the knee (CDK), first described in 1922, is a rare condition sometimes associated with other congenital malformations. There is a total anterior dislocation with recurvatum and upward displacement of the proximal tibia. This review covers our ten year experience at the hospital San Juan de Dios, in Caracas, Venezuela, a children's hospital with three orthopaedic services. We have seen 22 affected knees in 14 patients. Newborn patients were treated on traction until reduction was achieved, followed by serial plaster of Paris casts until, optimally, 90 degrees of flexion was gained. Surgical treatment was used if conservative treatment had failed after six months, or if the patient first presented after the age of 12 months. All our patients were eventually able to walk, three with the assistance of calipers. Some limitation of knee flexion was commonly seen. The best results were achieved when treatment was started early.

Abnormalities, Multiple↗
PubMed2004

Knee dislocations-a retrospective study comparing operative versus closed immobilization treatment outcomes.

Controversies over operative versus closed immobilization of traumatic complex multiple ligamentous knee injury are still debated. The aim of our study is to evaluate the outcome of reconstructive vs non-reconstructive (closed immobilization) treatment outcomes. This is a retrospective review of cases seen at our institution. All cases admitted with a diagnosis of knee dislocation, defined as patients with multidirectional knee instability in the setting of trauma, were reviewed. Twenty-nine consecutive patients from January of 1996 to June of 2002 were reviewed. Twenty-six patients (89.7%) were successfully recalled and their functional outcome analyzed. Comparing the operated group (n=15, 57.7%) with closed immobilized patients (n=11, 42.3%), there was no statistical difference in the range of motion (mean difference 8.55 degrees , p=0.202). While the operated group had more flexion contracture (mean difference 3.9 degrees , p=0.002), they had better stability and better overall knee function as measured by the International Knee Documentation Committee (IKDC) score (the mean difference of IKDC score was 12.13, p=0.005). In the operated group of 15 patients, we compared partial repair (n=7) with complete repair of all torn ligaments (n=8). Superior results were noted in the group with complete repair of all structures, with comparable range of motion (mean difference 0.6 degrees , p=0.861) and flexion contractures (mean difference 1.0 degrees , p=0.795) but better stability and IKDC score (mean difference of IKDC score 13.6, p=0.003). Our conclusion is that operative treatment with complete repair of all torn structures produces the best overall knee function with better knee stability and patient satisfaction.

Adolescent↗
PubMed2003

Above-knee amputation after recurrent dislocations of total knee arthroplasty.

Amputation after total knee arthroplasty (TKA) is an extremely rare but disastrous complication. Most of the reported cases resulted from refractory deep joint sepsis or perioperative vascular complications. We present a case of above-knee amputation resulting from vascular complications after recurrent dislocations of a TKA in a patient with underlying end-stage renal disease. The possible association between certain metabolic diseases and instability of TKA is discussed. In contrast to the high incidence of vascular complications after traumatic knee dislocation, popliteal artery injury after TKA dislocation is seldom encountered. The importance of careful evaluation and serial physical examinations to exclude the possibility cannot be overemphasized, however. When compromise of the circulation was recognized, emergent exploration of the popliteal fossa for repair of the vascular injury presented the best chance to save the limb.

Amputation, Surgical↗
PubMed1997

Blunt popliteal artery injury: is physical examination alone enough for evaluation?

Failure to recognize popliteal artery injury and restore vessel continuity of flow after blunt trauma is a major cause of lower-extremity amputation and morbidity. A high index of suspicion and early recognition of the injury are paramount for limb salvage, especially with posterior knee dislocation. Traditionally, arteriography has been the test most widely used to ensure an expedient diagnosis and institution of appropriate treatment. More recently, some authors have tried to move away from routine arteriography and rely on physical examination alone without arterial evaluation to guide them on their course of treatment. Based on our experience, the presence of arterial pulses after blunt trauma and dislocation of the knee is not an absolutely reliable indicator to exclude an arterial injury. The high morbidity of a missed popliteal artery injury mandates arterial evaluation of the popliteal artery either by arteriography or ultrasonography. A patient is presented with multiple injuries including a posterior knee dislocation. He had completely normal lower-extremity pulses on initial examination and at the time of discharge, but was required to have emergency reoperation with a ruptured popliteal artery pseudoaneurysm 5 weeks later.

Adult↗
PubMed1993

Complete dislocation of the knee without disruption of both cruciate ligaments.

Complete dislocation of the knee is recognized to be an extremely severe injury, representing one of the few true orthopedic emergencies. There is major trauma to the ligaments, capsule, and tendons, with a high incidence of associated damage to the popliteal artery and peroneal nerve. Resulting disability can be great, reflected by pain, stiffness, or instability of the knee; neurologic deficits in the foot and ankle; and even amputation if the vascular injury is not addressed promptly. Most accounts of knee dislocations in the literature have suggested that disruption of both cruciate ligaments is necessary for a complete dislocation to occur. This consensus is based on clinical observations and some laboratory investigations of ligament failure patterns. This report presents four cases of complete tibiofemoral knee dislocation without disruption of both cruciate ligaments. We also review the literature on knee dislocations with an emphasis on the biomechanics of soft tissue restraints about the knee and analyze how sufficient laxity can occur, with one cruciate ligament remaining intact, to allow for complete knee dislocation.

Adolescent↗
PubMed1996

[Complex trauma of the knee joint. Diagnosis--management--therapeutic principles].

The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by high-energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. This small but important group with severe injuries needs a detailed treatment algorithm, because despite the treating surgeon's skill, enthusiasm and wishful thinking, these injuries frequently lead to unsatisfactory results. The combination of distal femoral fractures and proximal tibial fractures was defined as complex knee injury type 1; the combination of distal femoral fractures or proximal tibial fractures with second or third degree open or closed soft-tissue injury was defined as complex knee injury type 2; knee dislocations were defined as complex knee injury type 3. A decision-making scheme is presented specifically addressing timing and treatment modalities. Out of 116 type 1 and 2 complex knee injuries, 8 had a deep infection, in 6 cases an amputation was carried out and in 4 cases a knee arthrodesis was performed. In 81 isolated distal femoral fractures, only 4 had a deep infection, none needed amputation, and in only 1 case did a knee arthrodesis have to be performed. The average Neer Score in 90 followed-up complex knee injuries, types 1 and 2, was 76.5 +/- 13.5 compared with 82.8 +/- 10 (out of 54 isolated distal femoral fractures). Out of 37 cases with knee dislocation, 22 (60%) had an poor result according to the Lysholm Score (average Lysholm Score 60.7 +/- 28).

External Fixators↗
PubMed2004

Ipsilateral dislocation of knee, foot and ankle.

We present a case of ipsilateral dislocation of the knee, ankle and midfoot. No previous report of this combination of injuries was found in a review of the literature. In spite of the type of injury, no neurovascular compromise or complications turned up. Closed reduction of the dislocations was possible and performed under general anaesthesia. At the last examination, 4 years after injury, the alignment of the joints was preserved, and the range of motion of the three joints resembled that of the opposite side. Without fractures, the closed reduction and temporary immobilisation of all the affected joints produced a remarkably good result.

Accidents, Traffic↗
PubMed1994

Popliteal artery injury in a lumberjack.

We discuss the case of a patient with knee dislocation and popliteal artery injury. A high index of suspicion for vascular injury must be maintained in cases of blunt knee injury because more than one third of patients with knee dislocation will have an associated popliteal artery injury. Patients with a grossly unstable knee after blunt trauma often have had a knee dislocation; such patients should receive aggressive evaluation for popliteal artery injury. Arteriography should be done for all trauma patients with a grossly unstable knee joint or knee dislocation and palpable pedal pulses. For patients with severe limb ischemia, arteriograms may be done in the operating room to expedite revascularization. Without rapid recognition and revascularization, blunt injury to the popliteal artery results in a rate of limb loss of more than 30%.

Accidents, Occupational↗
PubMed2002

Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography.

HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.

Adult↗
PubMed2000

Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures.

Injuries involving the anterior cruciate, posterior cruciate, and medial collateral ligaments represent one combination of injuries representing knee dislocation. Prompt reduction and neurovascular evaluation are necessary when treating these injuries. Operative management involving reconstruction and repair of the injured structures produces optimal results. This article outlines the principles involved in evaluating and managing these injuries, combined with specifics of the authors' treatment approach, and review of the literature.

Anterior Cruciate Ligament↗
PubMed1995

Do superoxide radicals in blood indicate anastomotic patency after microvascular tissue reperfusion?

Superoxide radicals were measured in the blood of six patients who underwent vascular reconstruction after ischemic injury in an attempt to predict prognosis following surgery. Three free-tissue transfers (two free latissimus dorsi flaps, one free vascularized fibular osteocutaneous graft) were performed on patients with skin or bone defects associated with open tibial fractures. Vascular reconstructions were performed on two patients with popliteal vascular injuries, in one case with an open femoral fracture and in another with an open knee dislocation. A third vascular reconstruction was performed on a patient with a subclavian artery injury associated with a clavicular fracture. Superoxide levels in the blood were quantified by a chemiluminescence method using a derivative of luciferin. Blood was obtained prior to reperfusion and periodically to 72 hr postoperatively. In patients who underwent successful reconstructions, superoxide levels increased after reperfusion. Vascular insufficiency was associated with acute drops in superoxide concentrations. Superoxide levels are a promising clinical marker which can predict insufficiency during reperfusion following tissue ischemia.

Adolescent↗
PubMed1996

Bilateral popliteal artery injury from bumper crush injury.

Blunt trauma to the knee of sufficient force to result in knee dislocation or fracture is commonly associated with popliteal artery injury. The challenging problem of bilateral popliteal artery injury has been rarely reported. We describe a case of bilateral popliteal artery injury after bumper crush injury between two automobiles that illustrates a successful method of management. Expeditious revascularization with minimum ischemia time was obtained by using the posterior approach, rather than the conventional medial approach, allowing two surgical teams to work simultaneously.

Accidents, Traffic↗