How I Manage the Multiple Ligament Injured Dislocated Knee

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28 B A Levy and M J Stuart, Figure 1 A An angiogram showing complete popliteal artery occlusion in a patient with palpable pedal pulse B An. angiogram of the same patient showing collateral flow. ease of use The systolic blood pressure of the involved lower The use of ultrasound for arterial examination has shown. extremity at the level of the ankle is compared with the sys excellent sensitivity and specificity however it is technician. tolic blood pressure of the ipsilateral upper extremity Fig 2 dependent and not all centers or emergency rooms have the. If the difference or the ratio is greater or equal to 0 9 then the use of a 24 hour 7 day a week ultrasonographers and. risk of having a major arterial occlusion is almost negligible 4 therefore the use of ultrasound is not always readily avail. An ABI less than or equal to 0 8 should warrant the need for able Despite these limitations ultrasound is recognized as an. further diagnostic imaging with duplex ultrasound CTA or excellent noninvasive screening modality 3. conventional angiography Conventional angiography has long been considered the. gold standard for the assessment of a vascular injury 5 How. ever the risks associated with conventional angiography are. not benign including renal toxicity and pseudoaneurysm 6. Conventional angiography has excellent sensitivity and spec. ificity in the detection of significant arterial injury in addition. to less significant arterial injury like intimal tears 5 7. More recently CTA has become available Several authors. have shown excellent sensitivity and specificity using the. technique 3 8 The advantage of CTA over conventional an. giography is that the arteriogram portion is performed. through the antecubital fossa as opposed to the groin and. there is one fourth the radiation exposure,Open Knee Dislocation. If the patient sustains an open knee dislocation emergent. treatment is required for aggressive debridement and irriga. tion With a severe open medial or lateral side injury the. surgeon may elect to repair whatever tissues are obviously. torn using suture anchors or drill holes The open knee dis. location that requires multiple trips to the operating room. and those that sustain vascular injury benefit from the appli. cation of a joint spanning external fixator We use a magnetic. Figure 2 ABI resonance imaging MRI compatible spanning fixator Al. The multiple ligament injured knee 29, though the MRI quality in this setting is not nearly as good If there is a large medial sided tibial plateau fracture then we. because of associated metal artifact the images are adequate often elect to perform an open reduction and internal fixation. and give the surgeon the amount of information needed to of the medial plateau followed by a second staged ligament. plan for further surgical intervention reconstruction We typically proceed with fracture surgery in. Fixator placement can be achieved in numerous ways We the setting of a closed knee dislocation at approximately 5 to. prefer biplanar fixation with 2 half pins in the anteromedial 14 days after injury provided that the soft tissue appearance. tibia 30 off the coronal plane and 2 half pins on the antero is satisfactory. lateral femur 30 off the coronal plane This creates a Z shape In a polytrauma patient the multiple extremity injuries. configuration and offers a very stable construct Fixator pin dictate the timing of multiknee ligament reconstruction For. placement is important The distal femoral pin must not be in example if the patient has an ipsilateral Pilon fracture an. the joint or communicate with the joint space If the pin is ipsilateral tibial plateau fracture or an ipsilateral tibial shaft. placed at least 1 handbreadth proximal to the proximal pole femoral shaft fracture floating knee we would typically. of the patella with the knee in full extension it will be prox recommend fixing all the fractures first restoring bony. imal to the suprapatellar pouch and outside the joint The height length and width and then perform the multiliga. most proximal tibial pin should be distal to the planned ment knee reconstruction once all the fractures have healed. anterior cruciate ligament ACL and posterior cruciate liga In addition we often remove the fracture fixation hardware. ment PCL reconstruction incision sites before the ligament reconstruction On occasion the associ. We typically remove the fixator at approximately 3 to 4 ated polytrauma precludes the ability to perform a multiliga. weeks postinjury perform a gentle manipulation of the knee ment knee reconstruction because of the inability for the. and proceed with multiligament reconstruction if the soft patient to sustain a postoperative rehabilitation program. tissues allow or delay the reconstruction if the soft tissues are. not amenable to surgical intervention 9 We also recommend. obtaining a Duplex ultrasound US within 48 hours of fix Question 3 What Is the. ator removal to rule out a deep venous thrombosis 10 If the Status of the Soft Tissues. US is positive then we avoid aggressive knee manipulation. The third question that we ask is the status of the soft tissues. avoid the use of a tourniquet and have an inferior vena cava. The soft tissues may actually dictate when the surgeon feels it. filter placed preoperatively 11, is safe for multiligament knee reconstruction For example. in the case of a closed knee dislocation with central pivot. Compartment Syndrome medial and lateral sided disruption the soft tissues may or. Compartment syndrome requires emergent 4 compartment may not be amenable to an arthroscopic central pivot and an. fasciotomies This takes precedence over just about any clin open medial and lateral sided reconstructions within a few. ical situation We recommend classic 2 incision 15 cm weeks form the injury Although several authors have shown. 4 compartment fasciotomies when indicated 12 that early reconstruction leads to improved outcomes over. delayed reconstruction the soft tissues take precedence We. Irreducible Knee Dislocation recommend waiting until the soft tissues are amenable for. At times knee dislocations present with the inability to be surgical repair This occurs once the bruising has resolved. reduced in the emergency room The so called irreducible the skin wrinkles and is not under tension and all blisters. knee dislocation often is a posterolateral dislocation have completely healed 11. whereby the medial femoral condyle gets trapped or button. holed through the medial capsular structures A dimpling of. the medial skin is often the clue In these rare cases emergent Question 4 Is There. reduction of the knee either via arthroscopic means or formal a Peroneal Nerve Injury. open arthrotomy is necessary 13, Peroneal nerve injuries occur in approximately 25 of dis.
located knees 14 Most of these injuries are axonal traction. Question 2 Does the Patient injuries neuropraxias but some are complete transections. These nerve injuries are typically associated with lateral side. Have Any Associated Injuries injuries to the knee The treatment of peroneal nerve palsy. The next question that we ask is whether or not there are when the nerve is believed to be intact is usually observation. associated injuries For example is this a polytrauma patient a serial electromyography and if no recovery is found tibial. with multiple extremity fractures or is there an associated tendon transfer to restore active dorsiflexion 15 More re. knee fracture along with the knee dislocation Often times a cently partial nerve transfers from a healthy motor branch of. periarticular fracture such as a fibular head fracture may the tibial nerve to a healthy motor branch of the distal per. dictate a staged procedure as opposed to a single surgical oneal nerve distal to the area of injury has been described 16. intervention For a fibular head avulsion we would often In a study of 11 patients performed at our institution almost. recommend open reduction and internal fixation of the frac 50 showed some form of nerve recovery although this took. ture rehabilitating the knee while allowing the fracture to several years in most patients Although the evidence is lack. heal and then a delayed multiligament knee reconstruction ing the patients who had improved outcomes had their neu. 30 B A Levy and M J Stuart, rosurgical intervention within a 3 month period from the. time of injury Currently at our institution if a patient pres. ents after a knee dislocation with a complete peroneal nerve. palsy with no evidence of nerve recovery or documentation. of a complete transection then we perform a partial nerve. transfer as early as possible once the soft tissues are amenable. and then perform a multiligament knee reconstruction as a. second stage If however the patient has had a delayed. course of treatment which has not allowed multiligament. knee reconstruction and the peroneal nerve has been out for. over a year then we typically would do the multiligament. knee reconstruction and consider a tibial tendon transfer at a. later date,Question 5 What Ligamentous,Structures Are Disrupted. Radiographic Examination, Routine anteroposterior and lateral radiographs often hold. clues to ligament disruption Because most knee dislocations. spontaneously reduce the radiographs often look normal. However subtle signs of joint space asymmetry or posterior. tibiofemoral subluxation may be present Therefore careful. scrutiny is warranted and at times stress radiographs may. show and confirm ligament disruption, Figure 4 An intraoperative photograph of MCL repair back to the. MRI is the imaging modality of choice for the evaluation of. the dislocated knee because no other imaging modality offers. get optimal imaging When it is not feasible to get an MRI. more detail of the ligament and associated cartilage and me. then a clinical stress examination or examination under an. niscal injuries If a spanning fixator is in place as we men. esthesia using fluoroscopy is often very helpful, tioned earlier we still recommend MRI assuming that the.
fixator is an magnetic resonance compatible frame because. this will help delineate treatment When at all possible we Question 6 What Is. would delay obtaining the MRI until the fixator is removed to Our Treatment Plan. The next question we ask ourselves is the treatment plan. Once we understand any emergent issues associated inju. ries or fractures of the status of the soft tissues and MRI. stress examination under anesthesia findings we devise a. treatment plan This strategy may be a single stage 2 stage. Figure 5 An intraoperative photograph of MCL reconstruction using. Figure 3 An arthroscopic view of ACL and PCL grafts an Achilles tendon allograft. The multiple ligament injured knee 31, Figure 6 A A pictorial representation of posterolateral corner reconstruction B An intraoperative photograph of. posterolateral reconstruction, or even 3 stage procedure but always depends on the factors injury In the setting of an ACL PCL MCL posteromedial cor. mentioned earlier as well as the specific combination of liga ner injury when the MCL is torn from the femur we typically. ments injured Although many combinations of injury pat allow the patient to rehabilitate their knee to allow the MCL. terns exist here are a few examples to heal and then perform a delayed central pivot reconstruc. tion ACL PCL If the MCL is torn off the tibia has an asso. ACL PCL ciated fracture or is a so called MCL Stener lesion where it. In the setting of an ACL PCL injury with no collateral liga is trapped on top of the pes anserine tendons we favor either. ment damage our preference is to regain range of motion a single staged MCL repair Fig 4 and ACL PCL reconstruc. allow the soft tissues to heal and then perform ACL PCL tions If the soft tissues are not amenable to the combined. reconstructions once the soft tissues allow Fig 3 surgery we use MCL repair only with ACL and PCL recon. structions as a second stage In the chronic setting we favor. ACL PCL Medial Sided Injury MCL reconstruction with an Achilles tendon allograft Fig 5. We performed a systematic review of the literature which. failed to show an advantage for medial collateral ligament ACL PCL Lateral Sided Injury. MCL repair versus reconstruction 15 The decision to per The ACL PCL lateral sided injury is the most frequent and. form a repair or a reconstruction is dependent on the location sometimes can be the most complex We have shown a 40. of the tear the quality of the tissues and the chronicity of the failure rate with repair of lateral sided structures without. 32 B A Levy and M J Stuart, period Progressive knee range of motion is then allowed. predominantly prone in the setting of a PCL reconstruction. and partial weight bearing is initiated Other authors have. noted excellent results with more aggressive rehabilitation. protocols that allow immediate range of motion and weight. bearing 19 23,Conclusions, The orthopedic surgeon should have a high index of suspi. cion for a dislocated knee when faced with any multiligament. knee injury or periarticular fracture It is imperative to per. form a thorough neurovascular examination along with some. form of screening test such as ABI to avoid the dire conse. Figure 7 An intraoperative photograph compass joint spanning ex. ternal fixator quences of a missed vascular injury Although no single treat. ment algorithm can help guide management of the dislocated. How I Manage the Multiple Ligament Injured Dislocated Knee Bruce A Levy MD and Michael J Stuart MD The multiple ligament injured knee or the dislocated knee remains a challenge for any orthopedic surgeon because of the high risk of associated neurovascular injury and potential devastating consequences including loss of limb Although

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