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Traumatic Knee Dislocations

Introduction
Rare injury Incidence might be higher, but goes

unrecognised probably because dislocation would have reduced at the scene of injury itself. True orthopaedic emergency- extensive ligamentous damage and potential for vascular complications associated with these injuries.

Basic stabilisers of knee


Medial collateral ligament,
semimembranosus, tendons of pes anserinus, and oblique popliteal ligament medial stabilisers ITB, LCL, popliteal tendon, biceps femoris lateral stabilisers. Crutiates anterior and posterior and rotatory stabilisers.

Mechanism of injury
High energy trauma: motor vehicle
accidents Pedestrian versus motor vehicle accidents. Athletic events like football injury Low energy injury is less frequent but do occur: in obese patients fall while getting downstairs these are challenging to treat.

Mechanism of injury
Exaggerated hyperextension of knee produce

knee dislocation. ACL tore first followed by PCL followed by posterior capsule at 30* of hyperextension popliteal artery tear at 50* of hyperextension. A varus/ valgus force combined with hyperextension causes variable degree of collateral ligament injury too.

Associated injuries
Vascular Neurological injury Osteochondral fractures Menisci injuries

Vascular injury
Vascular structures are securely fixed
proximally at the adductor hiatus and distally at the soleus arch hence exaggerated tibiofemoral displacement causes vascular rupture. Incidence 7 15% Surgical emergency

Neurological injury
Peroneal nerve commonest nerve to get
injured Incidence: 14 to 35% Poor prognosis Tibial nerve if injured even less favourable prognosis.

Classifications kennedy classification


Based on displacement of tibia over femur Anterior Posterior Medial Lateral Rotatory: anteromedial/anterolateral/
posteromedial/ posterolateral.

Position

Characteristics

Anterior

Most common type, Arterial injury [traction] Hyperextension most common cause Arterial injury [complete tear] High association with extensor mech rupture Irreducible MFC buttonholes through medial capsule High incidence of peroneal nerve palsy Transverse skin furrow medially

Posterior

Posterolateral

Adv / dis adv of position classification


Adv: Guides the surgeon the reduction maneuver Alerts the associated complications. Dis adv: Due to spontaneous reduction difficult to classify Doesnt specify the anatomic structures that are torn which in turn guides the surgical decision making.

Anatomic classification by schenck


Based on clinical examination and MRI Based on the anatomic sturctures that are torn Assigns numbers based on which ligaments are

torn. Higher the number higher is the level of injury. System considers four ligament groups: ACL, PCL, PMC and PLC.

Classification

Injury pattern

KD1
KD2 KD3M

KD3L
KD4 KD5

Knee dislocation with one crutiate lig intact Bicrutiate knee dislocation Bicrutiate lig tear, + PMC torn. PLC intact -do- but PMC intact
Bicrutiate and both corners torn Fracture dislocation

KD3 most common pattern KD3L prognosis bad compared to KD3M


w.r.t arthrofibrosis, instability, and disability. KD4 high energy injury associated with arterial injury.

Clinical features


History : of high enery trauma, dash board injury. pain On/e: irreducible knee dislocation Knee swelling [ if extensive capsular tear, swelling might not be prominent] Occasionally subtle signs like abrasions, minimal swelling. Examination under GA shows gross ligamentous laxity. Associated fractures : femur shaft, acetabulum, and tibial plateau #s. Note: Acurate diagnosis in a polytrauma case requires high index of suspicion.

Clinical assessment
Look for distal pedal pulses at admission,
after 4-6 hours, and at 24 hours following admission. Colour and temp of distal limb.

Investigations
Plain X ray of knee:

Possible findings includeAvulsion fragments Asymmetry between lateral and medial joint spaces

MRI
Helpful to assess the structures that are
torn when clinical evaluation is difficult due to associated fractures. Also helpful in assessing the ligamentous damage in a spontaneously reduced knee. Note: MRI to be done before the stabilisation of fractures to avoid metal artifacts.

Vascular assessment.
Routine arteriography not necessary for all
cases. Only those injuries where in a vascular insult is suspected during clinical assessment can be subjected to arteriography. Also, doppler USG can be an easy initial screening inv to rule out a vascular injury.

Treatment options
Rx

Operative

Non Operative

Non Operative options


Indications: Critically ill Patient unable to tolerate the surgical procedure Grossly contaminated wound In very elderly sedentary person. Available options: Long leg or cylinder cast Long leg knee brace locked in extension if wound care is needed repeatedly.

7 -8 weeks of immobilisation Followed by removal of cast Manipulation under GA Later rehabilitation primarily for achieving
maximum knee motion

Operative Treatment

Involves repair of all injured ligaments. Can be open repair or arthroscopic. Open injury open repair is preffered Bony avulsions of ligaments are generally treated best by open repair and soon after injury. General preference is arthroscopic repair of acl/pcl and open repair of posterolateral and posteromedial complex.

Timing of surgery
Very little data exists in literature regarding ideal timing for surgery. Usually has to be individualized based on: Open or closed injury Degree of contamination if open Degree of associated soft tissue injury if closed.

Timing of Surgery
Acute repair = repair done within 3 weeks Chronic repair = repair done > 4 weeks.
Adv of delayed repair: Better nutritional state after recovering from trauma Improved local soft tissue condition Thus a potentially decreased risk of infection and wound dehisence.

Adv of Acute repair: Decreased total trauma recovery time Improved healing of the injury to the capsule of knee by taking advantage of the inflammatory reaction associated with the initial injury.

Reconstruction vs non operative Rx


Studies show that surgically treated
patients had better motion, stability, and return to work and recreational activities.

Lateral/ posterolateral reconstruction


If no significant laxity can be treated
conservatively. If laxity present surgery is the main stay of Rx. Repair of all injured ligaments, posterolateral capsular advancement, and augmentation of posterolateral structures.

Posterolateral reconstruction
Local rotation of a strip of iliotibial band on a

distally based pedicle - to reconstruct the popliteus.- by muller Central slip of biceps tendon to augment popliteofibular ligament by muller. Achilles tendon / BPTB reconstruction noyes technique. Reconstruction with semitendinosus by larsen.

Posterolateral instability with varus knee


Pre op evaluate any varus alignment of knee. Soft tissue reconstruction alone will not be

sufficient in such knee as varus thrust will stretch out the reconstructed lateral complex. Hence high tibial valgus osteotomy will have to be done before or during posterolateral reconstruction of a varus knee.

Posteromedial reconstruction
Partial MCL tear heal well with non
operative Rx In type 1 and 3 injuries mcl reconstruction is performed Chronic mcl laxity needs repair. Involvement of posterior oblique ligament needs repair.

Posteromedial reconstruction
Tibialis anterior and tibialis posterior
allografts have been used for PMC reconstruction. MCL reconstruction done by routing a soft tissue graft between the attachment points of superficial MCL Later capsular reefing.

Arthroscopic ACL and PCL reconstruction


has to be done. Choice of the grafts depends on the structures injured. BPTB graft , hamstrings for ACL. Achilles tendon for PCL reconstruction.

Post op rehabilitation
Knee in full extension x 6 weeks NWBCA x 6 weeks Protected Knee range of motion can be

started at 3rd week. Brace is discontinued after 10th week. Return to sports after 9th post op month.

Order of reconstruction
PCL is reconstructed first Followed by ACL Followed by posterolateral complex And posteromedial complex.

Order of reconstruction and tensioning of graft


After PCL fixation tension the pcl with
knee in 90 * of flexion Later ACL fixation and tensioning of ACL done in full extension of knee Repair, augment and reconstruct the collaterals. Last radiographic confirmation of knee joint reduction.

Complications
Due to deficiencies in evaluation: Faliure to recognise vascular injury Associated ligamentous injury Lower extremity mal-alignment Due to surgical intervention: Vascular injury Nerve injury Compartment syndrome Wound healing problems Physeal injuries fractures

Long term complications


Chronic instability Arthrofibrosis Post traumatic arthritis Articular cartilage injury Chronic pain in the knee due to any of the
above problems.

Sai Ram