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PubMed1997

Knee dislocation: initial assessment and implications for treatment.

OBJECTIVE: To evaluate bicruciate knee injuries and determine whether they should be treated as knee dislocations, especially with regard to vascular injuries. DESIGN: Retrospective. SETTING: University hospital, level 1 trauma center. PATIENTS: Fifty patients admitted between 1987 and 1994 who had sustained knee dislocations or bicruciate ligament injuries. MAIN OUTCOME MEASURES: Mechanism of injury, direction of dislocation, knee ligament injury pattern, presence or absence of periarticular fracture, presence of vascular and nerve injuries, and location of associated trauma were measured. RESULTS: Twenty-two knees had classic knee dislocations. Twenty-eight knees presented as "reduced" bicruciate ligament injuries. Vascular injury occurred just as frequently in bicruciate ligament injuries as in knee dislocations. The direction of the knee dislocation did not predict ligament injury pattern or the presence of arterial injury. CONCLUSION: Bicruciate ligament injuries are equivalent to knee dislocations with regard to mechanism of injury, severity of ligamentous injury, and frequency of major arterial injuries.

Adolescent↗
PubMed2005

Surgical management of knee dislocations. Surgical technique.

BACKGROUND: The evaluation and management of knee dislocations remain variable and controversial. The purpose of this study was to describe our method of surgical treatment of knee dislocations with use of a standardized protocol and to report the clinical results. METHODS: Forty-seven consecutive patients presented with an occult (reduced) or grossly dislocated knee. Fourteen of these patients were not included in this series because of confounding variables: four had an open knee dislocation, five had vascular injury requiring repair, three were treated with external fixation, and two had associated injury. The remaining thirty-three patients underwent surgical treatment for the knee dislocation with our standard approach. Anatomical repair and/or replacement was performed with fresh-frozen allograft tissue. Thirty-one of the thirty-three patients returned for subjective and objective evaluation with use of four different knee-rating scales at a minimum of twenty-four months after the operation. RESULTS: Nineteen of the thirty-one patients were treated acutely (less than three weeks after the injury) and twelve, chronically. The mean Lysholm score was 91 points for the acutely reconstructed knees and 80 points for the chronically reconstructed knees. The Knee Outcome Survey Activities of Daily Living scores averaged 91 points for the acutely reconstructed knees and 84 points for the chronically reconstructed knees. The Knee Outcome Survey Sports Activity scores averaged 89 points for the acutely reconstructed knees and 69 points for the chronically reconstructed knees. According to the Meyers ratings, twenty-three patients had an excellent or good score and eight had a fair or poor score. Sixteen of the nineteen acutely reconstructed knees and seven of the twelve chronically reconstructed knees were given an excellent or good Meyers score. The average loss of extension was 1 degrees , and the average loss of flexion was 12 degrees . There was no difference in the range of motion between the acutely and chronically treated patients. Four acutely reconstructed knees required manipulation because of loss of flexion. Laxity tests demonstrated consistently improved stability in all patients, with more predictable results in the acutely treated patients. CONCLUSIONS: Surgical treatment of the knee dislocations in our series provided satisfactory subjective and objective outcomes at two to six years postoperatively. The patients who were treated acutely had higher subjective scores and better objective restoration of knee stability than did patients treated three weeks or more after the injury. Nearly all patients were able to perform daily activities with few problems. However, the ability of patients to return to high-demand sports and strenuous manual labor was less predictable.

Acute Disease↗
PubMed1994

Delayed presentation: dislocation of the proximal tibiofibular joint after knee dislocation.

Attention is brought to a unique case of an anterior dislocation of the proximal tibiofibular joint detected 1 month following closed reduction of a posterior knee dislocation. Open reduction and internal fixation were necessary to achieve a stable proximal tibiofibular joint. Additional attention should be paid to the proximal tibiofibular joint when evaluating acute or chronic knee dislocation.

Accidents, Traffic↗
PubMed2001

Irreducible knee dislocations secondary to interposed menisci.

Dislocations of the knee are accompanied by a highly variable pattern of osseous and soft tissue injury. While much attention has been directed toward the various combinations of ligament involvement observed in these injuries, the patterns of associated meniscal injury are described less frequently. We report two cases of patients in whom displaced medial meniscal tears prevented closed reduction following knee dislocation. Displaced bucket-handle meniscal tears necessitated open reduction in these patients and should be considered when evaluating patients with knee dislocations.

Accidents, Traffic↗
PubMed2004

[Irreducible knee dislocation by medial capsulo-ligament incarceration].

PURPOSE OF THE STUDY: Irreducible dislocation of the knee is exceptional. Incarceration of the capsulo-ligamentary elements in the inter-condylar notch is a particular causal mechanism. We report four new cases and review the literature to describe the diagnostic and therapeutic approach. MATERIAL AND METHODS: Between January 2001 and January 2002, four patients underwent surgery after trauma (wind surf, ski accidents) producing an irreducible knee dislocation. Mean patient age was 53 years and mean follow-up was 16 months. The IKDC classification was used to assess outcome. RESULTS: Physical examination revealed characteristic signs: a groove facing the medial joint line with signs of cutaneous suffering just above and a fold line behind the medial condyle. Orthopedic reduction failed. Surgery was performed in all cases and revealed incarceration of the entire capsulo-ligamentary structure in the intercondylar notch with the medial condyle in an extra-articular position. After surgical reduction, healing was achieved in all cases without cutaneous necrosis. The mean subjective IKDC score was 53.9. DISCUSSION: Orthopedic reduction is impossible in about 4% of all cases of knee dislocation. Clinical signs are characteristic when the medial capsulo-ligamentary structures are incarcerated in the intercondylar notch; the anatomic injury is almost always the same. Vasculonervous complications are exceptional but an emergency arteriography should be obtained to rule out an infra-clinical intimal lesion. Cutaneous necrosis is a specific complication of irreducible dislocation. Early and complete reduction is required to prevent necrosis. Arthroscopic management raises the risk of compartment syndrome since peripheral lesions are not healed. Satisfactory functional recovery requires associated repair of the cruciate ligaments. CONCLUSION: This type of irreducible dislocation of the knee is a specific clinical entity. It usually results from postero-lateral rotation but may exceptionally occur after lateral dislocation. A groove associated with a fold line indicates the need for rapid surgical reduction to avoid the risk of cutaneous necrosis.

Adult↗
PubMed1994

Immediate vascular and ligamentous repair in a closed knee dislocation: case report.

Traumatic dislocation of the knee is a significant injury, and concomitant neurovascular injury generally occurs in greater than one in three cases reported. This paper describes a patient with multiple injuries who sustained a traumatic knee dislocation with vascular compromise. Initial treatment included a vein graft of the arterial injury and reconstruction and reattachment of injured ligaments at the same time as joint stabilization with a Steinmann pin. If arterial injury is present it must be repaired first.

Adult↗
PubMed1990

Obesity. A risk factor for knee dislocation.

Complete dislocation of the knee joint is a severe injury that is commonly the result of high-velocity injuries and often associated with disruption of the popliteal artery. We report two cases in which obesity appeared to be the principal cause of knee dislocation with vascular compromise. Preventive measures in extremely obese patients are recommended.

Adult↗
PubMed1996

Delayed reduction of traumatic knee dislocation. A case report and literature review.

Knee dislocation after high energy trauma poses a major challenge to patients and treating physicians. The case presented documents the history and treatment of an unreduced posterior knee dislocation discovered 24 weeks after injury. Delayed surgical reduction was achieved, and satisfactory results were obtained with 22 months of followup of the patient. A detailed review of the literature found no comparable examples of longstanding traumatic dislocations of the knee but shed light on the probable cause for this unusual case. Close clinical followup, even after appropriate initial treatment of knee dislocations, is needed to eliminate similar occurrences.

Adolescent↗
PubMedDate not supplied

Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations.

BACKGROUND: Studies of traumatic knee dislocations have failed to provide a consensus regarding the best method of treatment. PURPOSE: Our purpose was to evaluate the results after surgical repair or reconstruction versus nonsurgical treatment and to compare the influence of prognostic factors. STUDY DESIGN: Retrospective study. METHODS: Eighty-nine patients were treated for traumatic knee dislocation. Surgical repair or reconstruction of the cruciate ligaments was performed in 63 patients (repair, 49; reconstruction, 14). In 26 patients, nonsurgical treatment was undertaken. RESULTS: At an average follow-up of 8.2 years, the mean Lysholm and Tegner scores were 75 and 3.7, respectively. The outcome in the surgical group was better than in the nonsurgical group. The scores were higher in patients who were 40 years of age or younger, who had sports injuries rather than motor vehicle accident injuries, and who had undergone functional rehabilitation rather than immobilization. CONCLUSIONS: Surgical repair or reconstruction of the cruciate ligaments was superior to nonsurgical treatment. Functional rehabilitation was the most important positive prognostic factor. Surgical repair or reconstruction of the cruciate ligaments is mandatory to achieve sufficient stability for functional rehabilitation. In cases of cruciate ligament avulsion, repair with transosseous fixation is a reasonable alternative to reconstruction, provided that it is performed within 2 weeks of trauma.

Adolescent↗
PubMedDate not supplied

Use of a hinged external knee fixator after surgery for knee dislocation.

PURPOSE: This study documents short-term clinical outcomes in patients with knee dislocations after blunt trauma and evaluates the compass knee hinge (CKH) external fixator for their treatment. TYPE OF STUDY: Nonrandomized prospective functional outcome study. METHODS: Forty patients with 43 knee dislocations were evaluated. Twelve knees underwent ligament reconstruction followed by placement of a CKH; this was group A. Group B included 27 knees that underwent the same treatment and rehabilitation protocol except that an external brace was used rather than a CKH. RESULTS: Thirty-six patients with 39 knee dislocations underwent follow-up ranging from 14 to 41 months (mean, 24). Four patients with 4 knee dislocations were lost to follow-up (1 group A, 3 group B). Group A underwent 27 knee ligament procedures with 2 (7%) failures based on clinical examination. Group B underwent 102 ligament procedures with 30 (29%) failures (P <.05). Anterior cruciate ligament (ACL) reconstruction revealed that 7 group A patients experienced 1 (14%) failure and 25 Group B patients experienced 7 (28%) failures. Posterior cruciate ligament (PCL) reconstruction in 7 group A patients included no failures, and 20 PCL reconstructions in group B included 1 failure. Reconstruction of the posterolateral corner (PLC) yielded no failures in 2 group A patients and 5 (25%) of 20 in group B. Repair of 8 PLCs in group A yielded 1 (12.5%) failure and 26 PLC repairs in group B had 14 (54%; P =.05). SF-36 data revealed low mean values with no significant differences between groups with current enrollment. CONCLUSIONS: Knee dislocation after blunt trauma requires aggressive surgical treatment and physical therapy. In the short-term evaluation, the CKH allows aggressive physical therapy without placing repaired or reconstructed ligaments under high stresses that can result in failure.

Accidents, Traffic↗
PubMed2004

Knee dislocations: management of the multiligament-injured knee.

Knee dislocations can occur in low-energy athletic injuries and in high-velocity motor vehicle trauma. These injuries require urgent recognition for evaluation for neurovascular injury. Advances in surgical reconstruction of multiligament-injured knees have led to more predictable return of function. This article reviews the diagnosis, initial treatment, and definitive management of multiligament-injured knees.

Anterior Cruciate Ligament Injuries↗
PubMed1992

Knee dislocations with intact PCL.

Complete knee dislocations are infrequent but serious injuries resulting from a wide spectrum of traumatic events. Significant soft tissue and ligamentous damage usually result. Previous experience and several reports in the literature had led us to believe that complete dislocations were associated with both ACL and PCL rupture. Three cases of documented complete knee dislocation in which the PCL is preserved intact are presented.

Adolescent↗
PubMed2001

Muscular buttonholing: An unusual cause of irreducible knee dislocation.

In cases of irreducible knee dislocation, all the medial joint structures have been reported to be the obstructing tissue. The case presented, the first in the English-language literature, is buttonholing of the femoral condyle through the vastus medialis muscle. Entrapment of the muscle bundle was diagnosed preoperatively using magnetic resonance imaging scans. The joint could be reduced easily, following sectioning of the muscle bundle.

Achilles Tendon↗
PubMed2002

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

BACKGROUND: Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. METHODS: All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. RESULTS: There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. CONCLUSION: This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Angiography↗
PubMedDate not supplied

A review of knee dislocations.

OBJECTIVE: To inform health care professionals about the various mechanisms of this little-known injury, as well as its potentially limb-threatening complications. In addition, keys to immediate recognition and the importance of a thorough rehabilitation program are stressed. DATA SOURCES: I searched MEDLINE (1966-2000) using the key words knee dislocation, knee injury, and tibiofemoral dislocation. DATA SYNTHESIS: Knee dislocations are uncommon but very serious injuries. Because the joint may spontaneously reduce before the examiner reaches the patient, the examiner must be aware of the potential complications and rule out any neurovascular damage immediately. CONCLUSIONS/RECOMMENDATIONS: Prompt recognition of this injury and proper care combined with an extensive rehabilitation program can greatly improve the prognosis for the patient. Neurovascular integrity should be assessed routinely for several days after the injury to ensure that complications do not develop.

Journal Article↗
PubMed2004

The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.

BACKGROUND: The risk of arterial injury with knee dislocation is well known. The most effective method for rapidly and accurately diagnosing arterial injury in this setting remains a topic of debate. Both physical examination and arteriography have been advocated, although each of these methods has its critics. The authors propose that the ankle-brachial index (ABI) can accurately predict whether patients with knee dislocations have sustained vascular injury. METHODS: A prospective study enrolled 38 patients with knee dislocation to evaluate for potential arterial injury using clinical pulse examination and ABI. Patients with an ABI lower than 0.90 underwent arteriography. Those with an ABI of 0.90 or higher were immobilized and admitted for serial examination and delayed arterial duplex evaluation. RESULTS: Of the 38 patients, 11 (29%) had an ABI lower than 0.90. All 11 had arterial injury requiring surgical treatment. The remaining 27 patients had an ABI of 0.90 or higher. None had vascular injury detectable by serial clinical examination or duplex ultrasonography. The sensitivity, specificity, and positive predictive value of an ABI lower than 0.90 were 100%. The negative predictive value of an ABI that reached 0.90 or higher was 100%. CONCLUSIONS: The ABI is a rapid, reliable, noninvasive tool for diagnosing vascular injury associated with knee dislocation. Routine arteriography for all patients with knee dislocation is not supported.

Adolescent↗
PubMed2000

High-velocity knee dislocation with vascular injury. Treatment principles.

A high-velocity knee dislocation is a true orthopedic emergency. A high index of suspicion is necessary to identify reduced knee dislocations in multiple trauma patients. Coexisting injuries are common in patients with high-velocity knee dislocations. After an initial assessment, the knee joint should be reduced immediately and splinted. Popliteal artery injury is common in high-velocity dislocations. Arteriograms can be helpful but should not delay operative treatment of obvious arterial injuries. Early restoration of flow to the ischemic limb will avoid amputation in most patients. The orthopedic surgeon must consider a variety of approaches when treating a patient with this type of injury. A spanning external fixator is a useful method for temporary immobilization in knee dislocation patients who have open dislocations, arterial repairs, or closed head injuries. Early surgery to improve the functional stability of the knee must be balanced against the risk of major surgery in patients with severe lower extremity and systemic injuries. The long-term risk of knee stiffness versus instability must be considered. Selective, subacute, aggressive collateral ligament repair and bicruciate reconstruction with allografts offer the best chance for optimal outcome.

Angiography↗