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Knee Dislocation
Knee Dislocation
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.
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.
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
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
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
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.
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.
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.
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.
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
Sai Ram