The Knee Dislocation 20 Years Later: What I Have Learned,

I Get It Stable, But Do I Solve The Arthritis Problem

Practical Manage of the Multiple Ligament Injured (Dislocated) Knee

Gregory C. Fanelli, M.D.

115 Woodbine Lane
Danville, PA 17822-5212
570-271-6700
gregorycfanelli@gmail.com
GC Fanelli

Disclosure
Royalties:
Springer
PCL Textbooks
Multiple Ligament Injured Knee Textbooks

Stock options: None

Consultant:
Biomet Sports Medicine
PCL ACL Instrumentation System
Speaker

Conmed
Speaker

Research support: None

Educational support: None
Other support: None
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1. Vascular Assessment Acute MLIK

Incidence 1.6 to 50% (Whalen, Green, Welling)

Bicruciate tears = TF Dislocation (Wascher)
Beware post traumatic DVT
Hyperextension
Anterior
Popliteal artery stretch
Arterial rupture

Dashboard knee
Posterior
Arterial contusion (intimal damage)

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1. Vascular Assessment Acute MLIK

What to do:
Physical exam + ankle brachial index
Abnormal pulses or ABI < 0.9
Arteriography, MRA, CTA
Mills, J Trauma, 2004

Non flow limiting intimal tear

Observe
No tourniquet during surgery
Vascular surgery available
ABI = doppler systolic arterial pressure in injured limb (ankle) /
doppler systolic arterial pressure in uninjured limb (brachial)
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Popliteal Artery Variations

Keser, Arthroscopy, 2006; 22 (6):656-659
PA lateral to central axis 94.3%
PA on central axis 5.7%

Kim, Ann Surg, 1989, 210 (6):776-781

Normal PA branching 92.2%
PA variants 7.8%
High origin of anterior tibial artery 72% of the 7.8%

Butt, J Arthroplasty, 2010, 25 (8):1311-1318

Anterior tibial artery anterior to popliteus muscle 2.1%

Mavili, Diagnostic and Interventional Radiology, 2011;

17:80-83
Normal PA branching 88.1%

12% of popliteal arteries may have abnormal branching

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Butt, J Arthroplasty, 2010, 25 (8):1311-1318

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Kim, Ann Surg, 1989, 210 (6):776-781

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PCL ACL Lateral Medial PA tear

Vascular Repair Vein Graft
ORIF Tibial Plateau Fracture
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2. Peroneal Nerve Injury

Incidence as high as 50% KDs
Contributes to poor outcomes
Nerve repair:
Small gap, minimal tension, end to end repair

Nerve grafting:
Graft length main predictor of outcome
Successful functional recovery (Kim, Neurosurgery, 2004)
< 6 cm, 75%
6 to 12 cm, 38%
13 to 24 cm, 16%

Our preferred treatment :

Peroneal nerve neurolysis
Serial EMGs after 1 month
Posterior tibial tendon transfer
Predictable functional recovery (Cush, SMAR, 2011)
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3. Correct Diagnosis
Exam under anesthesia assisted with
flouroscopy
Anterior posterior translation
Hyperextension
Varus and valgus laxity
Determine stable hinge
Beware axial rotation
Diagnostic arthroscopy

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4. External Fixation

Indications (Stuart, Op Tech Sports Med, 2001)

Open dislocations
Vascular repair
Inability to maintain reduction

External fixator vs. brace (Khanna, Levy, AANA, 2008)

Preoperative spanning external fixation

Post op, no SSD, IKDC, Lysholm, manipulation
ROM external fixator: 102` flexion
ROM brace: 129` flexion
P = 0.02
External fixation group more complex cases

Post operative external fixation (Compass Knee Hinge )

Stannard, JBJS, 2014
Recurrent instability

Brace 27%
CKH 4%
P < 0.05

Take home message

Control the knee in a brace, use the brace
Cannot control the knee in a brace, use external fixation

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Ultra Low Energy Injury

34 year old female
54, 460 pounds
Slipped on a wet floor in
her kitchen
Twisting injury to the right
knee
Acute tibial femoral
posterior dislocation
Arteriogram negative
Nerve function intact
ACL PCL Lateral Side
tears
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4. External Fixation

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5. Surgical Timing Acute MLIK

Vascular status
Medial and lateral side injury severity
Degree of instability
Reduction stability

Delayed or staged reconstruction 2-3 weeks-less

postoperative motion loss
Fanelli, Arthroscopy, 1996, 2002, 2005, JKS 2005, JBJS 92
A 2010
Wascher, Arthroscopy, 1999
Mook, Miller, JBJS 91 A, 2009

My preferred approach
Single stage procedure
Within 2 to 4 weeks of the initial injury
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5. Surgical Timing Acute KD

Vascular injuries
Irreducible dislocations
Open injury
Skin condition
Extensor mechanism disruption
Reduction stability

Modifiers-Considerations

Collateral ligament injury severity

Fractures and articular surface injuries

Other orthopaedic injuries
Multiple system injuries
Head trauma

Take home message:

Ideal surgical timing is not always
possible

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6. Repair or Reconstruct, Graft Source

PCL ACL reconstruction (allograft, autograft)

No SSD between allograft and autograft (Fanelli, Arthroscopy, 1996, 2002)
Bony/soft tissue avulsions (Beware interstitial ligament damage)

Posterolateral corner
Stannard, AJSM, 2005
Repair only, 37% failure
Repair + reconstruction, 9% failure

Levy, AJSM, 2010

Repair only, 45% failure

Posteromedial corner
Levy, AANA, 2008
Repair only, 29% failure

Stannsrd, AOSSM, 2009

Repair only, 20% failure
Autograft reconstruction, 3.7% failure
Allograft reconstruction, 4.8% failure

Take home message

Posterolateral and posteromedial primary repair with augmentation / reconstruction

provides better success than primary repair alone
Allograft and autograft are both successful
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7. Arthroscopic or Open PCL ACL Reconstruction?

Single v Two Stage

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Single Stage Open

7. Arthroscopic or Open PCL ACL Reconstruction?

Single Stage Open

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7. Arthroscopic or Open PCL ACL Reconstruction?

Single Stage Open

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7. Arthroscopic or Open PCL ACL Reconstruction?

Single v Two Stage

Stage 1

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Stage 2

Take home message:

Everyone of these cases is different
The central pivot disruption is relatively constant
The medial side, lateral side, extensor mechanism injury
severity determines the surgical approach

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Arthroscopic
Open
Single stage
Two stage

Patient Positioning \ Set Up

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8. Surgical Technique

PCL/ACL Reconstruction

Protect the neurovascular structures!

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8. Surgical Technique

PCL Reconstruction Transtibial Technique

Posteromedial Safety Incision

PCL Reconstruction

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8. Surgical Technique

8. Surgical Technique

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ACL Reconstruction

Tensioning and Fixation

Graft tensioning
Graft tensioning boot
MLIK set 0` (PCL and ACL)
Full Arc Dynamic Tensioning

Final fixation flexion angle

PCL DB and SB 70`- 90`
ACL 20 - 30`

Full ROM
Lateral and medial sides (30`)
Primary fixation
Resorbable interference screw
Aperture opening

Back-up fixation
Button
Spiked ligament washer
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8. Surgical Technique

8. Surgical Technique

Most of the Time

=/- Interference Screw

Hyperextension (+ Heel Lift Off)

Tibia Fibula Joint Injury
Revision PLR

Lateral Posterolateral Capsular Shift and/or Reattachment Always

Peroneal Nerve Decompression and Neurolysis Always
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8. Surgical Technique

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Medial Posteromedial Reconstruction

Screw and Washer

or
Adductor Magnus Loop

Posteromedial Capsular Shift

and/or
Reattachment
Always

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8. Surgical Technique

High Grade Acute Medial Side Tear

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8. Surgical Technique

9. Post Operative Rehabilitation Program

Full extension long leg brace
Crutch ambulation
NWB 3 to 5 weeks

Progressive ROM
POW # 3 or POW # 5

Progressive weight bearing

POW # 3 or POW # 5

Progressive ROM, strength, proprioceptive skills training

Sports / heavy work in 12 months
Strength, ROM, proprioceptive skills

Functional brace (may protect collateral ligament complex)

Must observe carefully and individualize
Get a feel for the personality of the knee
ROM under anesthesia
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Edson, Fanelli, Beck. Postoperative rehabilitation of the MLIK

Sports Medicine Arthroscopy Review, 2011, 19 (2)

10. Outcomes: What To Expect Long Term

Fanelli, Edson, Giannotti. AA combined ACL PCL reconstruction.
Arthroscopy, 1996
Fanelli, Edson. AA assisted combined ACL PCL reconstruction. 2-10
year results. Arthroscopy, 2002
No graft tensioning boot

Fanelli, Edson, et al. Treatment of combined ACL PCL MCL PLC

injuries of the knee. J Knee Surgery, 2005
Tensioning boot utilized

Fanelli, Beck, Edson. Single compared to double bundle PCL

reconstruction using allograft tissue. J Knee Surgery, 2012
Fanelli, Edson. Combined PCL ACL lateral and medial side (global
laxity) reconstruction. Technique and 2 to 18 year results. J Knee
Surgery , 2012
Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically
treated knee dislocations: stability restored, but arthritis is common.
CORR, 2014
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10. Outcomes: What To Expect Long Term

Autograft-allograft, acute-chronic
No statistically significant difference
KT 1000, stress x-ray, HSS, Lysholm, Tegner

Mechanical graft tensioning boot (Biomet)

Without boot 46% normal posterior drawer
With boot 87-92% normal posterior drawer
PLI and PMI corrected in both series

SB vs DB PCL Reconstruction
No statistically significant difference
Static stability (stress x-ray [2.56mm and 2.36 mm], KT 1000)
Return to pre-injury level of function (73 to 84%)

Long term results MLIK

60% return to pre-injury level of function (Tegner)
93% same or one Tegner grade lower level of activity

23 to 30% rate of degenerative joint disease

Static stability retained
Physical examination, KT 1000, stress x-ray
18 to 22 years post op

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10. Outcomes: What To Expect Long Term

Seven Years s/p Bilateral Knee Dislocations

Rom: R 0-112, L 0-105
KT 1000 (mm excursion)

PCL screen L=0, R=1, SSD=1

Corrected Posterior L=1, R=2, SSD=1
Corrected Anterior L=2, R=1, SSD=1
30 ADM 30# L=10, R=11, SSD=1

HSS L 92/100, R 87/100

Lysholm L90/100, R 95/100
Tegner 4, preinjury 4-5

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10. Outcomes: What To Expect Long Term

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22 Years Post Op PCL ACL PL PM Reconstruction

2013

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2015

Gregory C. Fanelli, M.D.

115 Woodbine Lane TYJ
Danville, PA 17822-5212
570-271-6700
gregorycfanelli@gmail.com