Knee Dislocation Research Articles

THE MANCHESTER PATTERN KNEE-SPANNING EXTERNAL FIXATOR: A MECHANICAL COMPARISON WITH TRADITIONAL EXTERNAL FIXATOR CONSTRUCTS

IntroductionKnee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs.Materials & MethodsHoffman III (Stryker, USA) external fixation constructs were applied to articulated models of the lower limb, spanning the knee with a diamond pattern and a Manchester pattern. The stiffness was loaded both statically and cyclically with a Bose 3510 Electroforce mechanical testing jig (TA Instruments). A ramp to load test was performed initially and cyclical loading for measurement of stiffness over the test period. The results were analysed with a paired t-test and ANOVA.ResultsThe mean stiffness with the diamond pattern fixator was significantly less stiff than the Manchester pattern fixator – by a factor of 3 (40N/mm vs 115N/mm). Displacement increased in all patterns over simulated loading equating to six weeks. The diamond pattern demonstrated a 50%% increase in displacement over time. The Manchester pattern demonstrated only 20% increase in displacement over time. These are all statistically significant (p<0.01)ConclusionsThe aim of an external fixator in knee dislocations and vascular injuries is to provide stability, prevent displacement and protect repairs. Vascular injuries often require fixation for several weeks to protect a repair. The Manchester pattern, applying the principles of external fixation, provides a stiffer construct and also confers greater stability over the time a fixator may be required. We commend this more informed design for the management of knee dislocations and vascular injuries.

Frailty is a predictor of immediate postoperative complications following surgical management of knee dislocations.

To assess the utility of frailty in predicting outcomes following surgical intervention for KDs. The NIS database was queried for non-congenital knee dislocations from 2015 to 2019 that underwent ligament repair or surgical reduction. Patients were assigned frailty scores using the mFI-11, and outcomes were compared. Multivariate regression and ROC curve analysis were used to assess the independent association of obesity, frailty, VI, and age with adverse outcomes. A total of 3797 patients who underwent surgical management were included. Frailty was associated with extended LOS (OR 1.353, 95% CI 1.212-1.510, p < 0.001), adverse discharge (OR 1.716, 95% CI 1.515-1.946, p < 0.001), and complications (OR 1.449, 95% CI 1.352-1.553, p < 0.001). Severely frailty was associated with extended LOS (OR 1.838, 95% CI 1.611-2.097, p < 0.001), adverse discharge (OR 2.756, 95% CI 2.394-3.171, p < 0.001), and complications (OR 1.603, 95% CI 1.453-1.768, p < 0.001). Additionally, VI was a risk factor for extended LOS (OR 7.647 (6.442-9.076) p < 0.001), complications (OR 2.065 (1.810-2.341) p < 0.001), and adverse discharge (OR 1.825 (1.606-2.075), p < 0.001). Obesity was a risk factor for extended LOS (OR 1.599 (1.470-1.739), p < 0.001) and complications (OR 1.235 (1.108-1.377), p < 0.001). AUC analysis showed that frailty was the most accurate predictor of all outcomes when compared to VI, obesity, and age. Frailty is superior to age and obesity, and comparable to VI, at predicting adverse outcomes following surgical management of KDs. These findings suggest that frailty assessment might play a role in risk stratification and preoperative planning for KD patients that require surgical intervention.

Congenital dislocation of the knee: A noninvasive treatment method

BACKGROUND: Congenital knee dislocation is a significant topic of interest in the possible application of new reduction techniques immediately after birth. This initiative aims to minimize the consequences of dislocation, ensuring the possibility of normal joint formation and functioning from the very first stages of life. This is not only a technical achievement but also an approach to providing optimal conditions for the health and development of children with congenital knee dislocation.&#x0D; AIM: This study aimed to evaluate the functional and long-term treatment outcomes of congenital knee dislocation using a new patented method.&#x0D; MATERIALS AND METHODS: A total of 120 patients (194 knees) with congenital knee dislocation were examined. The patients were divided into the main group (55 patients, 90 knee joints) and the control group (65 patients, 104 knee joints). The main group received the treatment developed by the authors using an Ergopower ER 7028 vibration massager. In the control group, the traditional method of orthopedic correction of congenital knee dislocation using a Von Rosen splint and circular plaster casts was employed. At the start of treatment, the age of the patients in the main group was Me 28 [Q1 28; Q3 30] hours and that of the control group was Me 30 [Q1 28; Q3 34.5] hours.&#x0D; RESULTS: A comparative analysis of the treatment outcomes of the main and control groups showed that the developed method for correcting congenital knee dislocation using a vibration massager and careful manipulations, in contrast to traditional technology, achieved the most accurate orthopedic correction in 95% of cases, ensured the restoration of the axial profile of the knee joint and its stability, and created conditions for the harmonious growth and development of the lower extremities in adulthood. In the main group, after conservative treatment of congenital knee dislocation using improved technology, indicators for assessing knee joint function (66.7%) and pain relief (98.2%) were excellent after 5 years of observation, which was confirmed by data from a clinical study and use of specialized questionnaires.&#x0D; CONCLUSIONS: The proposed innovative method of conservative orthopedic correction of congenital knee dislocation by vibrovascularization of the thigh muscles is a differentiated approach to conservative treatment, which improved the overall and long-term treatment outcomes.

No effect of dislocation status at arrival in emergency department on outcome of knee joint dislocations.

Knee dislocation is a rare but severe injury of the lower extremities. The aim of this study was to report on the epidemiology, diagnostics and treatment of such injuries and to identify negative predictors of clinical outcomes. This retrospective analysis included all knee dislocations treated at a Level I Trauma Centre in Germany between 2009 and 2021. Medical records were categorised, collected and analysed in a standardised manner. A follow-up visit 1 year after the injury focused on limitations in knee mobility. A total of 120 knee dislocations were included in the study. 29.3% of patients presented to the emergency department with a dislocated joint, and 17.5% (n = 21) had a neurovascular lesion. At follow-up 12 months after the injury, 65.8% of the patients reported limitations in the range of motion, and 11.7% (n = 14) reported severe limitations in daily activities. Site infections due to surgery occurred in 3.3% of patients. Increased body weight (r = 0.294; p < 0.001 and r = 0.259; p = 0.004), an increased body mass index above 25 kg/m2 (body mass index, r = 0.296; p < 0.001 and r = 0.264; p = 0.004) and deficits in peripheral perfusion as well as sensory and motor function (r = 0.231;p = 0.040 and r = -0.192; p = 0.036) were found to be negative predictive factors for clinical outcome. For posttraumatic neurovascular injury, lack of peripheral perfusion, insufficient sensory and motor function (r = -0.683; p < 0.0001), as well as a higher Schenck grade (r = 0.320; p = 0.037),were identified as independent risk factors. The status of dislocation at the site of the accident and on arrival at the emergency department had no impact on the outcome or neurovascular injury. Knee dislocation is a rare injury with a high rate of severe complications such as neurovascular lesions. In particular, the initial status of neurovascular structures and injury classification showed a relevant negative correlation with the posttraumatic status of nerves and vessels. In particular, patients with these characteristics need close monitoring to prevent negative long-term consequences. Level III.

Congenital Dislocation of the Knee in the Delivery Room.

BACKGROUND Congenital dislocation of the knee (CDK) is rare and can cause significant distress in the delivery room to parents and to healthcare providers, especially if the latter are unaware of this condition. It may not be detected by prenatal ultrasound and can be either an isolated finding or associated with other anomalies such as developmental hip dysplasia and genetic syndromes such as Larsen syndrome. Because of the risk of development of contractures, immediate referral to a specialized provider is needed. Poor prognostic factors include an association with a genetic syndrome, limited knee flexion related to severe quadriceps retraction, and absence of anterior skin grooves. A satisfactory outcome can be anticipated in isolated cases with easy reducibility of the knee. CASE REPORT A term baby presented unexpectedly with left knee dislocation after delivery. The providers, unaware of the condition, immediately consulted the orthopedic service, who assisted in the diagnosis, and appropriate management was initiated. The baby had serial casting of the leg, which was applied for almost 3 months, with excellent results on the clinical examination. CONCLUSIONS CDK is a rare finding. The diagnosis is primarily clinical and radiographs are used to confirm and assess the degree of the dislocation. The degree of dislocation is important for management and prognosis. Interventions ranging from serial casting to surgery are required as soon as possible. As the CDK can be associated with genetic syndromes or other dysplasias such as developmental dysplasia of the hip and talipes equinovarus, further evaluation for these conditions is warranted.

Magnetic Resonance Imaging-Based Morphometric Analyses of the Bicruciate Injury of the Knee: Is There a Clue in the Distal Femur?

The morphology of the distal femur's intercondylar notch has been implicated in the susceptibility to and severity of cruciate ligament injuries. While previous research has primarily focused on isolated anteriorcruciate ligament (ACL) or posterior cruciate ligament (PCL) injuries, the relationship between notch morphology and combined cruciate injuries remains less understood. This study aimed to explore the association between femoral notch morphology and the severity of combined cruciate ligament injuries in adult males. In this retrospective cohort study, MRI scans from 118 adult male participants with and without knee dislocations (60 cases with Schenk classification Type II or higher knee dislocations and 58 controls) were analyzed. The study period ranged from 2015 to 2023. Femoral notch width, notch width index (NWI), and notch shape (U shape, A shape) were assessed using a Philips Multiva 1.5 Tesla system (Philips, Amsterdam, Netherlands). The statistical significance of differences in measurements between cases and controls was evaluated using independent sample t-tests performed with IBM SPSS Statistics, version 26 (IBM Corp., Armonk, NY). The case group exhibited a significantly smaller mean femoral notch width (15.88 mm ± 2.7 mm) and NWI (0.238 ± 0.58) compared to the control group (notch width 18.29 mm ± 3.4 mm, NWI 0.25 ± 0.31), with p-values of 0.004 for both measurements. The notch shape was predominantly A-shaped in the case group (n = 49) as opposed to U-shaped in the control group (n = 41). The study identifies a significant association between reduced femoral notch dimensions and the severity of complex cruciate ligament injuries. These findings support the notion that specific femoral notch morphologies may predispose individuals to more severe ligamentous injuries.

The anteromedial retinaculum in ACL-injured knees: An overlooked injury?

The purpose of this study was to retrospectively analyse the pattern of injury to the medial knee structures in anterior cruciate ligament (ACL) injured patients. It was hypothesised that anteromedial injuries would be more common than posteromedial lesions. One hundred and twenty subjects aged 18-25 years with a primary ACL injury were included. Patients were excluded if the time between injury and magnetic resonance imaging (MRI) was more than 28 days or if a knee dislocation or fracture was present. The MRIs were analysed with particular emphasis on injuries to the medial knee structures, menisci and bone bruise patterns. Injuries to the ligaments and anteromedial retinaculum (AMR) were graded according to severity, ranging from periligamentous oedema (grade I), partial fibre disruption of less or more than 50% (grade IIa or IIb) to complete tears (grade III). AMR injury was seen in 87 subjects (72.5%) on the coronal plane and in 88 (73.3%) on the axial plane, with grade III lesions observed in 27 (22.5%) and 29 knees (24.2%). Injuries to the superficial medial collateral ligament (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL) were detected in 60 patients (50%), 93 patients (77.5%)and 38 patients (31.6%). However, grade III injuries to the POL were observed in only seven knees (5.8%). Medial meniscus injuries were associated with lesions of the sMCL and AMR (p < 0.05), while lateral meniscus injuries were significantly more common in patients with dMCL rupture (p < 0.05). Data from this study suggest that injuries to the AMR are much more common than posteromedial lesions in subjects with ACL injuries. Level IV.

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Background: Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes. Indications: Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery. Technique Description: The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work. The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL. Results: Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction. Discussion: Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up

Background: Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. Purpose: To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. Results: A total of 42 patients (25 male, 17 female) were assessed at a mean 6.5-year follow-up (range, 2.1-10.7 years). Twenty patients (47.6%) were found to have a documented KD; they reported significantly lower IKDC (49.9 vs 63.0; P = .043), Lysholm (59.8 vs 74.5; P = .023), and Tegner activity level (2.9 vs 4.7; P = .027) scores than the patients without documented dislocation. VAS pain was not significantly different between groups (36.4 vs 33.5; P = .269). The incidence of neurovascular injury was greater among those with documented dislocation (45.0% vs 13.6%; P = .040). Subgroup analysis found that patients with KD3-L injuries experienced a greater deficit in Tegner activity level than patients with KD3-M injuries (Δ: –3.4 vs −1.2; P = .006) and had an increased incidence of neurovascular injury (41.7% vs 11.1%; P = .042). Documented dislocation status was predictive of poorer IKDC (β = −2.15; P = .038) and Lysholm (β = −2.85; P = .007) scores. Conclusion: Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.

Good Short-Term Survivorship of Constrained Condylar Revision Knee Implants With Medial Pivot Kinematics: A Level IV Retrospective Study

BackgroundThe need for revision total knee arthroplasty surgery is increasing worldwide, and, in many cases, a constrained implant is required to provide joint stability. The purpose of this study was to examine the early loosening and functional outcome of a novel constrained condylar (CCK) revision total knee system designed to have medial pivot (MP) kinematics. MethodsA retrospective cohort study was performed, collecting clinical data from all patients who underwent revision total knee arthroplasty using a novel MP CCK system with a minimum four-year clinical follow-up. Patient demographics, survivorship, complications, and Forgotten Joint Score were analyzed based upon chart review. ResultsThere were 49 patients available for follow-up, who had a 100% survivorship free of aseptic loosening. All-cause revision survivorship was 92%. There were 4 patients who subsequently underwent rerevision. The causes for rerevision included periprosthetic joint infection in 2 patients, coronal plane instability in one patient, and a traumatic knee dislocation in one patient. There were 45 patients who completed the Forgotten Joint Score, who had an average of 49.8 (± 32.8, range 6.25 to 100). ConclusionsAt 4 years, mid-term follow-up, this novel CCK revision total knee system designed to have MP kinematics had good patient-reported outcomes with no revision for aseptic loosening. Future studies should evaluate the mid- and long-term survivorship of this innovative implant.

Traumatic knee dislocation

I would like to share my opinions on the article “Traumatic knee dislocation”. First of all, I would like to thank the authors for contributions to the science of a subject that is of great concern to physicians interested in the musculoskeletal system and whose treatment and rehabilitation is very difficult. I will try to contribute to such an important issue as a physical medicine and rehabilitation physician.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center.

To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI). Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction. MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment. We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

Two-stage ligament reconstruction with remnant preservation as treatment of knee dislocation

ObjectiveThe purpose of this study was to evaluate the clinical outcomes of two-stage reconstruction (peripheral reconstruction in phase I and central anterior cruciate ligament (ACL) / posterior cruciate ligament (PCL) reconstruction in phase II) with remnant preservation for patients with knee dislocation.MethodsA total of 70 patients (10 IIIM, 17 IIIL, and 43 IV) with knee dislocation were randomly divided into the remnant-preserved group and the simple reconstruction group. Patients underwent two-stage reconstruction, including the reconstruction of collateral ligament in phase I and the reconstruction of ACL/PCL in phase II (12 weeks after phase I). Grafts were harvested from the semitendinosus and gracilis tendons from both lower limbs. After the surgery, the joint flexion and extension, bone tunnel and ligament healing, and joint stability were evaluated.ResultsAfter the surgery, the lateral stability recovered in all patients, and X-ray revealed a good position of bone tunnel. Follow-up was performed at 12 months postoperatively and ranged from 24 to 91 months. At the final follow-up, knee flexion angle, IKDC, Lysholm, and Tegner scores were all higher in both groups compared to the preoperative period. Notably, the remnant-preserved group showed superior results in these parameters compared to the simple reconstruction group. There was statistical significance between the two groups in terms of the Lachman test.ConclusionThe knee function was well recovered after two-stage ligament reconstruction with remnant preservation.

Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up

BackgroundMulti-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old. MethodsThis study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores. ResultsOf 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40–72]) were assessed at a mean follow-up of 59.1 months (range 24–133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40–50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012). ConclusionsPatients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports. Level of evidenceIV, Case series.

Open injuries and obesity as emerging risk factors for vascular injury in knee dislocations: A retrospective study

PurposeKnee dislocations (KDs) are rare in orthopaedic trauma but can have devastating effects. Failing to diagnose a concomitant vascular injury can lead to amputation. Different methods are used for the diagnosis of a vascular injury and the best approach is under debate.This study aims to examine the risk factor(s) of vascular injury in patients with KDs, examine variables that differ between obese patients and non-obese patients with KDs, and analyse the modalities used to identify vascular injuries in the KD population. MethodsThe electronic patient medical record system at a major trauma centre was retrospectively reviewed to identify knee dislocations from 2015 to 2022. These were stratified based on age, gender, BMI, mechanism of injury, vascular injury, non-vascular complications, and laterality. Co-variates were inputted into a univariable regression analysis, followed by a multivariable regression analysis to identify risk factors of vascular injury in patients with knee dislocations. Co-variates were also compared between obese and non-obese patients using two-tailed t-tests for continuous variables and chi-squared test for categorical variables. ResultsForty patients were identified with a KD, with twenty-eight males and twelve females. The average age was 42.9 years, seventeen patients had a BMI of thirty or over, and eleven patients (27.5%) had a vascular injury. Open injuries (OR: 2.21; 95% CI: 1.19–11.30; p = 0.038) and obesity (OR: 2.66; 95% CI: 1.45–18.69; p = 0.027) are risk factors for vascular injury in patients with knee dislocation. Compared to non-obese patients, obese patients had a higher rate of open injury (p = 0.028), vascular injury (p = 0.017), low-energy injuries (p = 0.014), non-vascular complications (p = 0.017), and amputation (p = 0.036). ConclusionOpen injuries and obesity are risk factors for vascular injury in patients with KD. Compared to non-obese patients, obese patients have low-energy injuries and an increased rate of non-vascular complications, meaning that clinicians could err on the side of caution when investigating vascular injury.Level of evidence: IV.

Delayed Presentation of Popliteal Artery Injury after Salter-Harris III Proximal Tibia Fracture

Introduction. Proximal tibia physeal fractures in children are not very common but can be dangerous because they can harm popliteal fossa structures, especially the popliteal artery. Popliteal artery injuries (PAI) are most commonly the result of trauma to the lower extremity, including blunt force, hyperextension injuries, complex fractures, and knee dislocations that can compromise popliteal neurovascular structures. Case Presentation. A 14-year-old boy presents to the emergency department after being transferred from an outside hospital 24 hours after a left lower extremity hyperextension injury. Radiographs demonstrated a Salter-Harris III proximal tibia fracture with posterior displacement. ABIs were deferred due to palpable distal pulses and no evidence of compartment syndrome. Closed reduction and percutaneous pinning were planned to correct the fracture. Intraoperatively, it was discovered that knee extension decreased lower extremity perfusion while knee flexion returned perfusion. An angiography revealed a popliteal artery occlusion with no distal flow. Based on this, an above-knee to below-knee popliteal bypass using the contralateral great saphenous vein was performed followed by closed reduction and percutaneous pinning of the proximal tibia. Conclusion. Proximal tibia physeal injuries, especially the Salter-Harris III and IV injuries, warrant a high index of suspicion of popliteal artery injuries. Palpable pulses and delayed presentation in the distal lower extremity do not rule out a PAI because collateral flow to the anterior and posterior tibial arteries may mask signs of an avascular limb, highlighting the need for a thorough history and physical exam. The authors present this case to reaffirm the importance of an ankle-brachial index when evaluating hyperextension injuries with proximal tibial epiphyseal fractures.

Case report of closed reduction of an irreducible postero-lateral knee dislocation and review of the literature

Case report of closed reduction of an irreducible postero-lateral knee dislocation and review of the literature

Prenatal diagnosis and postnatal outcome of fetal congenital knee dislocation: systematic review of literature.

Congenital knee dislocation (CKD) is a rare condition, affecting 1 in 100 000 newborns. Its prenatal diagnosis is challenging and not well described in the literature, especially when it appears isolated and not as part of a complex malformation or syndromic pattern. The purpose of this study was to provide a comprehensive review of the available literature on the prenatal diagnosis and postnatal outcome of CKD and to summarize the current evidence on this topic. A systematic review of the literature on the prenatal diagnosis of CKD was performed in PubMed, Scopus and EMBASE. A predefined combination of specific keywords was used, focusing on intrauterine manifestations, diagnostic methods, prenatal behavior, postnatal treatment and neonatal outcome as well as long-term outcome in terms of ambulation, motion and joint stability. The quality of studies was assessed using the National Institutes of Health tool for quality assessment of case series. A summary of results was carried out providing proportions and rates of diagnostic and prognostic features associated with this rare condition. In total, 20 cases were retrieved for analysis, of which 19 were obtained from the identified eligible studies (n = 16) and one was an unpublished case from our center. The median gestational age at prenatal diagnosis, which was made using ultrasound in most cases, was 20 weeks (range, 14-38 weeks). Bilaterality was observed in 11/20 (55%) cases. The condition was isolated in 7/20 (35%) cases and associated with other anomalies in 13/20 (65%) cases. An association was observed with oligohydramnios (4/20 (20%)), and an invasive procedure was performed in 13/20 (65%) cases, including 11 cases with an invasive procedure performed for diagnostic purposes. Genetic testing was normal in all isolated cases for which information was available (4/7), while a genetic syndrome was present in 10/13 (77%) non-isolated cases (Larsen, Noonan, Grebe, Desbuquois or Escobar syndrome). There were seven terminations of pregnancy, of which six were performed in cases with associated anomalies and one in an isolated case, 11 cases of postnatal survival, one case of intrauterine death and one of neonatal death. The fetal and neonatal deaths occurred in cases with associated anomalies or abnormal genetic findings. Postnatal treatment was mostly conservative, with only two reports (18% of the 11 surviving neonates) of surgical intervention, both in cases with associated anomalies. Postnatal follow-up was up to 1 year in most cases, and motor outlook appeared normal in all isolated cases. CKD is a rare fetal anomaly with a prenatal diagnosis achievable from the early second trimester, for which a favorable outcome can be expected when no associated anomalies are present. Prenatal diagnosis should include detailed ultrasound assessment and amniocentesis for extensive genetic studies, particularly in non-isolated cases. Early postnatal treatment achieves success in most cases without surgical intervention and leads to a normal motor outlook. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Indications for computed tomography angiography in limb trauma.

Computed tomography angiograms (CTAs) are useful in detecting vascular injury. There is a lack of consensus regarding the indications of CTAs in limb trauma, leading to overutilisation of CTAs in some centres and exposing patients to unnecessary harm. Thus, the aim of this study is to define the appropriate indications for CTAs in limb trauma. This is a retrospective cohort study of consecutive CTAs performed in a tertiary hospital from January to December 2022. Demographic and clinical factors were collected from the patients' charts including physical examination findings and arterial pressure index (API) measurements. Physical examination findings include hard signs (e.g. absent pulse) or soft signs (e.g. non-expanding haematoma). These data were analysed to detect correlation with vascular injury on the patient's CTA. Forty-nine CTAs were included, of which 10 (20.4%) found vascular injury. Hard signs (P < 0.001) and an API <0.9 (P = 0.02) were significantly correlated with vascular injury. Hard signs had a sensitivity of 90% and specificity of 82%, whereas APIs had a specificity and sensitivity of 100%. Soft signs were not correlated with vascular injury due to poor specificity but had a sensitivity of 100%. Knee dislocations were not associated with vascular injury (P = 0.5). This small study suggests that CTAs are indicated if there are hard signs of vascular compromise or an API <0.9, provided the patient is haemodynamically stable. The presence of soft signs can help identify which patients should receive an API measurement. CTAs may not be routinely indicated in knee dislocations.

Tibiofemoral Dislocation Management in a Rural High School Football Scenario: Development of a Popliteal Artery Injury Suspicion Index.

This study evaluated the knowledge and preparedness of athletic trainers (ATs) for diagnosing and managing an anterior tibiofemoral knee dislocation in a rural or limited-resource high school football setting scenario. The study hypothesis was that more experienced ATs would display greater preparedness than less experienced ATs. A secondary objective was to develop evidence-based guidelines to help the AT provide better emergency triage care. This prospective cross-sectional study distributed a rural high school football game scenario survey electronically to a random sample of 2000 certified ATs to determine their perceptions of readiness to diagnose and manage an anterior tibiofemoral knee dislocation with signs or symptoms of possible popliteal artery injury. A total of 249 surveys (12.5%) were completed. Years of athletic training experience were ≤5 years (n = 82, group 1) and ≥6 years (n = 167, group 2). Both groups perceived that they could not "rule out" an arterial injury and had similar "red flag" sign and symptom rankings. Group 2 perceived a more serious situation than group 1 (77.5 ± 15 vs 70.8 ± 14, P < 0.0001) and were more likely to activate the emergency action plan (74.5 ± 25 vs 64.4 ± 26, P = 0.005). Both groups were "neutral" about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that evidence-based guidance was needed. More experienced ATs perceived a more serious situation than less experienced ATs and were more likely to activate the emergency action plan. Both groups were neutral about their ability to diagnose the condition or manage the case, had poor ankle-brachial index test familiarity, and agreed that they would benefit from evidence-based guidance. Proposed guidelines provide the AT with a more measured, evidence-based index of suspicion for potential popliteal artery injury in anterior tibiofemoral dislocation cases. This will complement existing hospital emergency department-based management algorithms, decreasing the likelihood of this condition progressing to limb loss or death.