Treatment Of Knee Dislocations Research Articles

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.

POSTERIOR CRUCIATE LIGAMENT INJURIES MANAGED WITH INTERNAL BRACING

Poor availability of allografts in South Africa has led to an increased use of synthetic augmentation to stabilize knee joints in the treatment of knee dislocations. This study aims to evaluate multiligament knee injuries treated with a posterior cruciate ligament internal brace.The study included patients with knee dislocations who were treated with a PCL internal brace. The internal brace involved the insertion of a synthetic suture tape, which was drilled into the femoral and tibial footprint. Chronic injuries were excluded. Patient-reported outcome scores (PROMs), range of motion, stress X-Rays, and MRI scans were reviewed to assess outcomes. Acceptable outcomes were defined as a Lysholm score of 84 or more, with grade II laxity in no more than one ligament and a range of motion from full extension to 90° or more.The study included eight patients, with a median age of 42, of which five were female. None of the patients had knee flexion less than 90° or an extension deficit of more than 20°. PROMs indicated acceptable outcomes (EQ5D, Tegner Lysholm). Stress radiographs showed less than 7mm (Grade I) of posterior translation laxity in all patients. Four patients underwent MRI scans 1–2 years after the initial surgery, which revealed healing of the PCL in all patients. However, increased signal in a continuous ligament suggested only partial healing in two patients. Tunnel widening of 200% and 250% was noted around the tibial and femoral PCL footprints, respectively.All patients demonstrated stable knees and acceptable PROMs. Tunnel widening was observed in all patients who had MRI scans. Factors such as suspensory fixation, anisometric tunnel position, and the absence of PCL tear repair may have contributed to the tunnel widening.

Long-Term Clinical Efficacy of Arthroscopy with Limited Incision in the Treatment of Knee Dislocation with Multiple Ligament Injuries

This study retrospectively analyzes the long-term clinical efficacy of single-stage arthroscopy-assisted surgery with limited incision in the treatment of knee dislocation (KD) with multiple ligament injuries (MLI). A total of 19 patients diagnosed with MLI at the First Affiliated Hospital of Guangxi Medical University and the 923th Hospital of the Joint Logistics Support Force of the People’s Liberation Army of China from March 2013 to May 2015 were included in this study. The functional levels were assessed using the Lysholm Knee Scoring Scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Tegner Activity Score, and range of knee motion preoperatively. Non-parametric and Friedman tests were employed to analyze the surgical outcomes. The Lysholm scores increased from a preoperative value of 43.00 (95% confidence interval: 31.00, 50.00) to 88.00 (82.00, 95.00) at the post-operative follow-up of 10–36 months, and further improved to 90.00 (78.00, 98.00) after 8-year follow-up period. The IKDC scores increased from a preoperative value of 32.20 (28.70, 35.60) to 80.50 (60.90, 86.20) at 10–36 months post-operatively and further improved to 86.90 (69.00, 93.10) after 8-year follow-up period. The Tegner scores showed improvement from a preoperative value of 0.00 (0.00, 1.00) to 5.00 (3.00, 5.00) at 10–36 months postoperatively and to 4.0 (3.00, 5.00) after 8-year follow-up period. The ranges of active knee motion increased from preoperative 35.00 (30.00, 40.00) to 130.00 (120.00, 135.00) at 10–36 months and 8 years postoperative follow-up. In conclusion, it is recommended to adopt arthroscopy with limited incision for restoring knee joint stability and motor function.

Anatomical repair and ligament bracing of Schenck III and IV knee joint dislocations leads to acceptable subjective and kinematic outcomes

PurposeThe aim of this study was to analyze the outcomes of anatomical repair and ligament bracing for Schenck III and IV knee dislocation (KD).MethodsThe results of 27 patients (15 and 12 cases of Schenck III and IV KD, respectively) after a mean follow-up of 18.1 ± 12.1 months (range 6–45 months) were retrospectively reviewed. Twenty-two patients suffered high-kinetic-energy accidents, whereas five patients suffered ultralow-velocity (ULV) trauma due to obesity. The outcome measures were the Lysholm score, Hospital for Special Surgery (HSS) knee score, Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Short Form 36 (SF-36) score. A kinematic 3D gait analysis with five walking trials was performed to compare the patients and healthy controls.ResultsThe mean KSS, HSS score, Lysholm score, and KOOS were 77.4 ± 14.4, 84.6 ± 11.2, 81.5 ± 10.4, and 67.3 ± 16.8, respectively. No intra- or postoperative complications occurred. The mean range of motion deficiency compared to the healthy side was 24.4 ± 18.5°. Ten patients had first-degree residual laxity of the anterior cruciate ligament; 12 and 2 patients had first- and second-degree residual laxity of the collateral ligament, respectively. Five patients underwent additional arthroscopic arthrolysis due to arthrofibrosis at an average of 6.2 ± 1.9 months (range 4–9 months) after the initial surgery. The 3D gait analysis showed no major differences in joint stability or movement between the patients and healthy controls. Only the ULV trauma patients had significantly lower outcome scores and showed larger kinematic deviations in joint movement during the gait analysis.ConclusionAnatomical repair with ligament bracing is a suitable surgical procedure in the treatment of KD and provides evidence in clinical practice with the benefit of early, definitive repair and preservation of the native ligaments. Patients reach acceptable subjective and objective functional outcomes, including mainly normalized gait patterns during short-term follow-up, with only minor changes in kinematics and spatial–temporal characteristics. Obese patients who suffered ULV trauma showed significantly inferior outcomes with larger deviations in joint kinematics.Level of evidenceLevel III.

The Effect of Irreducible Dislocation on Functional Outcomes in Knees With Multiligament Injuries: A Matched-Cohort Analysis.

Background:Most cases of bicruciate knee dislocation (KD) with associated posteromedial disruption (KD-IIIM) are reducible, but some cannot be reduced by closed reduction because of soft tissue incarceration.Purpose:To compare the clinical characteristics and functional outcomes of KD-IIIM injuries in patients with or without incarceration of soft tissue requiring open or arthroscopic reduction.Study Design:Cohort study; Level of evidence, 3.Methods:This retrospective cohort study of patients with KD was conducted between January 2013 and December 2017 at a single large institution. We applied a 1:2 matching ratio between patients with irreducible KD-IIIM injuries (irreducible group; n = 14) and those with reducible KD-IIIM injuries (control group; n = 28). There were 13 patients in the irreducible group and 25 in the control group who completed follow-up (≥2 years) and were included in our analysis. The efficacy of treatment in patients with KD was evaluated based on range of motion, the Tegner score, the Lysholm score, and the International Knee Documentation Committee (IKDC) score.Results:At the end of follow-up, the mean Tegner score was 4.5 (range, 4-6), the mean Lysholm score was 79.2 (range, 60-95), and the mean IKDC score was 78.6 (range, 60.9-95.4) in the irreducible group. The respective results in the control group were 4.6 (range, 3-8), 83.1 (range, 39-100), and 80.6 (range, 42.5-96.6). These scores did not differ significantly between the 2 groups. Similarly, mean range of motion was similar between groups (irreducible, 118.1°; control, 124.8°). In the irreducible group, the acute subgroup showed significantly higher Lysholm and IKDC scores than the chronic subgroup, while the acute and chronic subgroups in the control group showed no significant differences in these respective outcome scores.Conclusion:In the present study, the treatment of irreducible KD led to similar functional outcomes compared with reducible KD. However, the treatment of chronic irreducible KD led to worse outcomes compared with acute irreducible KD, and therefore, urgent reduction is recommended in these patients.

Knee Dislocation and Multiple Ligament Injuries of the Knee.

The purpose of this paper is to present an overview of the progress in treatment of knee dislocations and posterior cruciate ligament (PCL)-based multiple ligament knee injuries over the past 25 years. The perspectives of where we were 25 years ago, where we are today, and where we will be in the future will be explored.

Initial Treatment of Knee Dislocation at Yopougon Teaching Hospital/Abidjan, Ivory Coast

Knee dislocation is a serious and rare injury. Its rarity and the variety of injuries that result from it mean that there is no adequate management that is universally accepted. The aim of this study was to evaluate our emergency care strategy for these injuries. Materials and methodology: This was a retrospective study conducted from January 1992 to December 2004 on nine cases of knee dislocation. It consisted of six men and three women. The average age of these subjects was 35, ranging from 15 to 50 years. The causes for these injuries included: public road accidents (n = 4), household accidents (n = 3), a sporting accident and a dislocation that occurred following a fight. The dislocations were anteromedial (n = 4), posterolateral (n = 2), posterior (n = 2) and anterior (n = 1). Associated injuries were sore joint (n = 2), contusion of the common peroneal nerve (n = 1) and vascular injury (n = 1). An angiography was performed on one patient for a vascular injury and an Elecmyography (EMG) for a common peroneal nerve injury. Closed reduction was used for eight patients and open reduction for one patient. Results: Five knees were stable with normal range of motion and some residual pain. Four patients had knee instability; two anterior, one anteroposterior and one lateral. In three of these patients, the CT arthrography/arthro-scan confirmed central pivot damage, with meniscal damage in two of them. The four patients were referred to a knee surgeon in a private practice. The post-operational effects were minimal in vascular injury. The EMG performed for the common peroneal nerve detected a nerve contusion. Conclusion: Our emergency care strategy remains closed reduction. This therapeutic management is consistent, at least in the first 15 days, with the literature.

Knee Dislocations

Background:Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.Purpose:To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee.Study Design:Review and case reports.Methods:Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form–36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability.Results:The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject’s IKDC score to “C.”Conclusion:Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

Hinged External Fixation in the Treatment of Knee Dislocations

Our hypothesis was that patients treated with hinged external fixators as an adjunct to multiple-ligament reconstruction would have fewer reconstruction failures than patients treated without external fixation. In this prospective randomized study, patients with a knee dislocation either underwent ligament reconstruction with placement of an external hinged knee brace following surgery (Group A) or underwent ligament reconstruction with placement of a hinged external fixator (Compass Knee Hinge) for six weeks instead of the brace (Group B). The patients were followed clinically and were evaluated with physical examination, Lysholm and International Knee Documentation Committee knee scores, visual analog scale pain scores, and status regarding return to work and activities. One hundred patients with 103 knee dislocations were enrolled. Seventy-seven patients with seventy-nine dislocations (thirty-two in Group A and forty-seven in Group B), with a minimum follow-up interval of twelve months, were available for evaluation. The mean duration of follow-up was thirty-nine months (range, twelve to eighty-six months). Nine patients (29%) in Group A had failed reconstructions compared with seven (15%) in Group B (p = 0.15). Group-A patients had twenty-two (21%) of 105 reconstructed individual ligaments fail compared with eleven (7%) of 157 reconstructed ligaments in Group B. The difference in ligament failure was significant (p < 0.001; power > 0.8), with more favorable results for the patients managed with the external fixation. Hinged external fixation as a supplement to reconstruction following knee dislocation was associated with fewer failed ligament reconstructions compared with external bracing. Patients presenting with highly unstable knee dislocations should be considered for hinged external fixation to supplement initial reconstructive procedures.

Paper 191: Operative versus Non-Operative Treatment of Knee Dislocation: Long-term Functional Results, Associated Injuries, and Failures

Paper 191: Operative versus Non-Operative Treatment of Knee Dislocation: Long-term Functional Results, Associated Injuries, and Failures

Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

OUTCOMES OF THE OPERATIVELY TREATED KNEE DISLOCATION

Despite being a serious injury with early complications associated with a high degree of morbidity, the outcomes of knee dislocations have improved dramatically since the days of Sir Astley Cooper. Currently, most authors favor early surgical reconstruction of the injured ligamentous structures. With modern surgical techniques and rehabilitation protocols, most patients are able to achieve functional range of motion and stability necessary for everyday life. Despite improvements in treatment, stiffness and pain, rather than instability, can be a problem. Patients continue to have difficulty returning to pre-injury levels of athletic competition and manual labor, although a significant number of patients have achieved these goals. As physicians, we must be knowledgeable in the current surgical techniques and rehabilitation protocols used in the treatment of knee dislocations, and the typical prognosis of the injury. By informing our patients of hurdles that they will be forced to overcome, in their path to recovery, before initiating treatment, patients will better understand the seriousness of the injury, which, it is hoped, will lead to compliance with their rehabilitation and thus better outcomes.

A Paradigm for the Age-Related Treatment of Knee Dislocations in Larsen's Syndrome

Three cases of Larsen's syndrome in siblings are presented to illustrate a paradigm for the age-related treatment of deformity. Each child presented at a different age, with differing degrees of deformity and growth disturbance. Both growth and remodeling potential influenced the choice of treatment and outcome. The surgeon who undertakes the correction or prevention of these deformities must face the problem of and, it is hoped, use, growth potential from open physes and the progressive loss of remodeling capacity with advancing age.

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.

LENGTHENING FOR CONGENITAL SHORT FEMUR. RESULTS OF DIFFERENT METHODS

We have reviewed the results in 37 patients with unilateral congenital short femur (Pappas classes III to IX), treated by different lengthening procedures. The increase in the length of the femur varied from 15.6% to 142%, excellent or good results being obtained in 32 patients (86%). There was an average of 1.9 complications per case, most being seen earlier in the series when the Wagner technique was used. With the Orthofix and the Ilizarov techniques, we used callus distraction in all cases. We found that the proximal diaphysis of the congenitally abnormal femur healed less well, and we now prefer to perform corticotomy and callus distraction of the distal metaphysis. The Ilizarov method gave the best results, offering the possibilities of the simultaneous use of a Hoffmann fixator across the hip and the treatment of knee dislocation and instability.

Lengthening for congenital short femur. Results of different methods.

We have reviewed the results in 37 patients with unilateral congenital short femur (Pappas classes III to IX), treated by different lengthening procedures. The increase in the length of the femur varied from 15.6% to 142%, excellent or good results being obtained in 32 patients (86%). There was an average of 1.9 complications per case, most being seen earlier in the series when the Wagner technique was used. With the Orthofix and the Ilizarov techniques, we used callus distraction in all cases. We found that the proximal diaphysis of the congenitally abnormal femur healed less well, and we now prefer to perform corticotomy and callus distraction of the distal metaphysis. The Ilizarov method gave the best results, offering the possibilities of the simultaneous use of a Hoffmann fixator across the hip and the treatment of knee dislocation and instability.