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![Vascular Injuries: Recommendations
[A] ischemic limb after reduction
immediate surgical exploration
injury and location predictable
arteriogram: only if additional associated proximal injury
[B] abnormal vascular status - viable limb
diminished pulses
decreased capillary refill
ABI < 0.9
“urgent” arteriogram](https://image.slidesharecdn.com/l06-kneedislocations-161225231936/75/L06-knee-dislocations-23-2048.jpg)
![Vascular Injuries: Recommendations
[C] normal vascular status and no ligament or
extremity surgery
normal PT/DP pulses and normal capillary refill
ABI > 0.90
careful observation with serial exams
vascular surgery and invasive radiology “available”
MRA/MRI
evaluate for non-occlusive (intimal) injury
sensitivity and specificity uncertain
arteriogram if abnormal](https://image.slidesharecdn.com/l06-kneedislocations-161225231936/75/L06-knee-dislocations-24-2048.jpg)
![Vascular Injuries: Recommendations
[D] normal vascular status - potential or
planned ligament or extremity surgery
normal PT/DP pulses and normal capillary refill
ABI > 0.90
careful observation with serial exams
vascular surgery and invasive radiology “available”
MRA/MRI as part of pre-operative evaluation
routine arteriogram within 24 - 48 hours
intimal injury
anticoagulation
no tourniquet
limited and delayed surgery (10-14 days)
no endoscopic PCL (tibial tunnel)](https://image.slidesharecdn.com/l06-kneedislocations-161225231936/75/L06-knee-dislocations-25-2048.jpg)
![Associated Injuries: Polytrauma
Mills WJ : Severe HO After High Energy Knee Dislocation: The
Predicitve Value of the Injury Severity Score; OTA 2001.
35 consecutive knee dislocations
Harborview Medical Center
associated injuries
23% popliteal artery
20% peroneal nerve
surgical treatment
29: open acute [< 4 weeks]
6: arthroscopic delayed [6 wk - 10 m]
CPM and early motion as wound permitted](https://image.slidesharecdn.com/l06-kneedislocations-161225231936/75/L06-knee-dislocations-33-2048.jpg)
![42 female
unrestrained front seat passenger MVA
multiple injuries
laparotomy
spleenectomy, hepatic packing
LC-1 pelvis
[R] knee dislocation
Case Example: KD-IIIL](https://image.slidesharecdn.com/l06-kneedislocations-161225231936/75/L06-knee-dislocations-70-2048.jpg)
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L06 knee dislocations
- 1. Knee Dislocation William R.Creevy, MS, MD Assistant Professor and Vice Chairman Department of Orthopaedic Surgery Boston University Medical Center Mark A. Neault, MD Brian D. Busconi, MD University of Massachusetts Medical School
- 2. Knee Dislocation “It isunlikely that any single physician personally cares for more than a few knee dislocations in a lifetime of practice” JBJS 1971
- 3. Epidemiology AUTHOR CENTER CASESREFERENCE Frassica 1992 Mayo Clinic 14 2 million admissions Wascher 1997 New Mexico 33 5 years Eastlack 1997 US Army 28 5 years Moore 1990 Denver 0.12 % of all trauma admissions
- 4. Epidemiology true incidence isprobably underreported 20% - 50% spontaneously reduced practice environment trauma center sports medicine practice general orthopaedics
- 5.
- 6. Anatomy popliteal artery adductor hiatus soleusarch tension injury hyperextension posterior
- 7. Anatomy peroneal nerve biceps femoris fibularneck tension varus direct injury
- 8. Pathomechanics mechanism of injury lowenergy - sports high energy - MVA position of knee direction of applied force degree of exagerrated motion hyperextension ± varus/valgus → anterior flexion + posterior force → posterior
- 9. Pathomechanics Kennedy, 1963 10 cadavericknee specimens hyperextension ACL PCL posterior capsule @ 30º popliteal artery @ 50º
- 10. Pathomechanics avulsion injuries ofcruciates clinical studies: Sisto (1985) & Frassica (1992) combined data 80% PCL avulsion (“femoral peel off”) 30% ACL avulsion Schenck (1999) cadaveric cruciate injury model hyperextension with variable strain (velocity) high (5400%/sec): stripping lesion femur low (100%/sec): mid-substance tear
- 11. Classification purpose determine prognosis (outcome) guidetreatment historical: Kennedy (1963) tibial position with respect to femur visual inspection radiograhs documented dislocation both cruciates torn
- 12. Positional Classification: Problems 20%- 50% reduced at presentation does not define exact status of ligaments collateral: MCL vs. LCL-PLC knee dislocation with intact PCL Myers (1975), Shelbourne (1992), Cooper (1992) ACL + collateral → “simple treatment” vascular injury less likely? knee dislocation with intact ACL Schenck (1992) fracture dislocation patterns: Moore (1981)
- 13. Classification: Structures Involved V C N IIIL ACL / PCL / LCL+PLC MCL intact IV ACL / PCL / MCL / LCL+PLC III M ACL / PCL / MCL LCL+PLC intact Schenck 1992 II arterial injury nerve injury fracture dislocation Anatomic Classification of Knee Dislocations I single cruciate + collateral ACL + collateral PCL + collateral ACL / PCL collaterals intact
- 14. Anatomic Classification combined seriesapplication Walker (1994): 13 patients Eastlack (1997): 28 patients type III most common III L poor outcome vs. III M duration of disability arthrofibrosis Sickness Impact Profile Lysholm and IKDC scales
- 15. Utility of AnatomicClassification requires surgeon to focus on what is torn directs treatment to what is injured accurate discussion of injuries among clinicians comparison of similar injuries within wide spectrum of knee dislocations
- 16. Associated Injuries: Vascular highincidence combined results of 11 published series average: 32% range: 8% to 64% pathology intimal tear arterial disruption direction of dislocation: no difference low velocity: decreased incidence?
- 17. Associated Injuries: Vascular Jones(1979) “significant” arterial injury 4 of 15 (27%) patients “normal” post-reduction pulses liberal arteriography Kendal (1993) surgical arterial injuries always present with change in vascularity: physical exam pulse deficit diminished capillary refill Lynch (1991) doppler pressure measurement ABI > 0.9 → no clinically important vascular injuries selective arteriography
- 18. Physical Examination Inspection ± Obviousdeformity Consider immediate reduction Hint: Coexistent varus/valgus instability in extension = ACL/PCL injury ± Hemarthrosis May be absent 2° to capsular disruption Popliteal ecchymosis Evaluate skin ↑ Hyperextension
- 19. Physical Examination Vascular Exam Dorsalispedis and posterior tibial arteries Pulse absent Consider immediate closed reduction – If still absent → O.R. for exploration – If pulse returns → consider angiogram vs. observation 8 hour ischemic time is MAXIMUM Pulse present A.B.I. > 0.9 → observe A.B.I < 0.9 → angiogram &/or exploration
- 20. Associated Injuries: Vascular DeBakey(1946) WWII 80% amputation rate popliteal artery injury not revascularized Green (1977) knee dislocation with popliteal artery injury 90% amputation if not revascularized within 8 hours WHAT IS THE ROLE OF ANGIOGRAPHY?
- 21. Vascular Injuries: Principles 1.Evaluate and document the vascular status (DP/PT pulses and capillary refill) in any patient with a proven or suspected knee dislocation. 2. Once the dislocation is reduced the circulation should be re-evaluated. 3. Revascularization should be performed within 8 hours. 4. Arteriography should not delay surgical reanastomosis.
- 22. Vascular Injuries: Principles 5.It is unacceptable to suggest spasm as a cause for decreased or absent pulses in an attempt to justify observation. 6. If arterial insufficiency or abnormality is present, there is a vascular injury. 7. Arterial injury is treated with excision of the damaged segment and reanastomosis with reverse saphenous vein graft. 8. An experienced vascular surgeon should be utilized to verify clinical findings and interpret studies.
- 23. Vascular Injuries: Recommendations [A]ischemic limb after reduction immediate surgical exploration injury and location predictable arteriogram: only if additional associated proximal injury [B] abnormal vascular status - viable limb diminished pulses decreased capillary refill ABI < 0.9 “urgent” arteriogram
- 24. Vascular Injuries: Recommendations [C]normal vascular status and no ligament or extremity surgery normal PT/DP pulses and normal capillary refill ABI > 0.90 careful observation with serial exams vascular surgery and invasive radiology “available” MRA/MRI evaluate for non-occlusive (intimal) injury sensitivity and specificity uncertain arteriogram if abnormal
- 25. Vascular Injuries: Recommendations [D]normal vascular status - potential or planned ligament or extremity surgery normal PT/DP pulses and normal capillary refill ABI > 0.90 careful observation with serial exams vascular surgery and invasive radiology “available” MRA/MRI as part of pre-operative evaluation routine arteriogram within 24 - 48 hours intimal injury anticoagulation no tourniquet limited and delayed surgery (10-14 days) no endoscopic PCL (tibial tunnel)
- 26.
- 27. Physical Examination Neurologic Exam PeronealNerve EHL &/or tibialis anterior strength Dorsal 1st web space sensation Tibial Nerve FHL &/or gastroc/soleus strength Lateral border & plantar surface of foot sensation
- 28. Associated Injuries: PeronealNerve incidence: 14% to 35% most common with Type III L (varus) traction injury disruption rare: nerve repair precluded usually axonotmesis observation poor prognosis (<25% functional return) 12-18 months role of delayed decompression?
- 29. Associated Injuries: PeronealNerve nerve injury has an important influence on surgical decision making absent peroneal never function impairs limb function and activity level limited ligament surgery LCL + PLC repair PCL avulsion
- 30. Physical Examination Isolated LigamentExam ACL Lachman @ 30° PCL Posterior drawer @ 90° LCL/PLC Varus stress @ 30° and full extension ↑ Tibial E.R. @ 30° ↑ Posterior tibial translation @ 30° MCL Valgus stress @ 30° Patellar tendon
- 31. Physical Examination Combined LigamentExam LCL/PLC & Cruciate ↑ Varus in full extension & 30° MCL & Cruciate (PCL) ↑ Valgus in full extension & 30° PLC & PCL ↑ Tibial E.R. @ 30° & 90° ↑ Posterior tibial translation @ 30° & 90° Stability in full extension Excludes significant PCL or capsular injury
- 32. Associated Injuries: Polytrauma kneedislocation is a spectrum of injuries simple low energy sports related isolated injury complex high energy vehicular trauma associated extremity and multi-system injuries important differences future functional activities ability to participated in rehabilitation program other systemic and/or physiologic factors?
- 33. Associated Injuries: Polytrauma MillsWJ : Severe HO After High Energy Knee Dislocation: The Predicitve Value of the Injury Severity Score; OTA 2001. 35 consecutive knee dislocations Harborview Medical Center associated injuries 23% popliteal artery 20% peroneal nerve surgical treatment 29: open acute [< 4 weeks] 6: arthroscopic delayed [6 wk - 10 m] CPM and early motion as wound permitted
- 34. Associated Injuries: Polytrauma MillsWJ : Severe HO After High Energy Knee Dislocation: The Predicitve Value of the Injury Severity Score; OTA 2001. heterotopic HO: 6 patients (17%) ISS = 26-50 GCS = 3T-15 no heterotopic HO: 29 patients (83%) ISS = 9-26 GCS = 10-15 (2 severe brain injury) 6 of 23 (26%) multiple injuries developed HO positive predicitve value ISS > 26 = 86%
- 35. Associated Injuries: Polytrauma MillsWJ : Severe HO After High Energy Knee Dislocation: The Predicitve Value of the Injury Severity Score; OTA 2001. HO occurred only in open acute cases (6/29 = 20%) 14% major wound complications bi-crucite surgery = 100% HO range of motion 4 ankylosis + 2 less than 10 º arc 3 open release and excision of HO - unsuccessful 6 delayed arthroscopic with ISS < 20: no HO range of motion flexion average: 129º 50% flexion contracture >5 º 2 manipulation / 1 open release
- 36. Associated Injuries: Polytrauma MillsWJ : Severe HO After High Energy Knee Dislocation: The Predicitve Value of the Injury Severity Score; OTA 2001. what is an ISS >26? ISS = sum 3 highest AIS² non-lethal single system injury of greatest magnitude: ISS = 25 two system injury needed to obtain ISS > 26 conclusion multisystem trauma and early open surgery increase risk for HO and loss of motion poor functional outcome - not correctable change in treatment protocol at Harborview limited early surgery brace or external fixation delayed surgery
- 37. Imaging the DislocatedKnee Plain X-ray MRI Arteriogram Venography CT Scan Bone Scan
- 38. Plain Radiographs Views AP &lateral 45° oblique Patellar sunrise Findings Obvious dislocation Irregular/asymmetric joint space Lateral capsular sign (Segond) Avulsions Osteochondral defects
- 39. MRI indications: all kneedislocations and equivalents valuable diagnostic tool pre-operative planning identify ligament avulsions: femoral PCL MCL: injury location → incision lateral structures: popliteus, LCL, biceps meniscal pathology displaced in notch → early surgery limited arthroscopy 2º extravasation articular cartilage lesions
- 40. Early Management of KneeDislocations Orthopedic Emergency!!! Assess Neurovascular Status Closed Reduction “Dimple sign” = irreducible (posterlateral dislocation) If No Pulse s/p Reduction Vascular exploration Knee Immobilizer vs. External Fixation
- 41. Technique of ClosedReduction Anterior Traction & elevation of distal femur Posterior Traction & extension of proximal tibia Lateral / Medial Traction & translation Rotational Traction & Derotation AVOID force applied against popliteal fossa
- 42. Irreducible Knee Dislocation Posterolateral “DimpleSign” Puckering of anteromedial skin Buttonhole Medial femoral condyle thru medial retinaculum / capsule Watch Skin Necrosis Open Reduction Required
- 43. Initial Stabilization of KneeDislocations Knee Immobilizer Offers stability External Fixation Better for grossly unstable knee Protects vascular repair Skin care for open injuries NO Casting
- 44. Treatment: General Considerations mostauthors recommend repair of the torn structures non-operative treatment: “poor results” period of immobilization shorter = improved motion + residual laxity longer = improved stability + limited motion recent clinical series have reported “better” results with operative treatment no prospective, controlled, randomized trials of comparable injuries
- 45. Treatment: General Considerations immobilizationafter operative treatment permanent stiffness flexion contracture (loss of extension) decreased flexion early ROM is absolutely essential stable ligament fixation cooperative reliable patient once stiffness occurs it is very difficult to treat A loose mobile knee is better than a stable stiff knee!!
- 46. Treatment: Recommendations view theinjury in the context of the whole patient individualized treatment multiple variables 4 “key issues” that influence decision making
- 47. Treatment: Recommendations KEY ISSUES 1.Associated injuries vascular injury nerve injury multi trauma head injury poor soft tissue envelope LIMITED SURGICAL INTERVENTION
- 48. Treatment: Recommendations KEY ISSUES 2.Presence of ligament avulsions “simplified” surgical treatment re-attachment EARLY OPEN SURGERY
- 49. Treatment: Recommendations KEY ISSUES 3.Complete posterolateral corner disruption is best treated with early open repair LATE RECONSTRUCTION DIFFICULT
- 50. Treatment:Recommendations KEY ISSUES 4. Reconstitutionof the PCL is important allows tibiofemoral positioning around which collateral and ACL surgery evolve ACL reconstruction prior to PCL is never indicated PCL IS THE CENTRAL PIVOT
- 51. Non-operative Treatment immobilization inextension for 6 weeks external fixation “unstable” or subluxation in brace obese multi-trauma head injury vascular repair fasciotomy or open wounds
- 52. Non-operative Treatment removal offixator under anesthesia arthroscopy manipulation for flexion assessment of residual laxity
- 53. Results of Ligament Reconstruction Shapiroand Freedman 1995 10 Knee Dislocations Tx: 7 Patients Early, Open Allograft Recon of ACL/PCL MCL/LCL/PLC 1° repaired at time of OR Average f/u 51 months Results: 6 patients good-excellent 4 of 7 needed manipulation Fanelli et al 1996 20 Knee Dislocations Tx - Scope assist recon ACL/PCL Allograft/autograft MCL tx non-op PLC tx w/biceps femoris Timing PLC → wait 2-3 weeks MCL → 6 weeks rehab Minimum f/u 2 years Results: ↑ knee scores, ↓ instability
- 54. Results of Ligament Reconstruction Noyes& Barber-Westin 1997 11 Knee Dislocations Tx - Scope assist Recon ACL/PCL Allograft/autograft Repair Medial/Lateral Average f/u 4.8 years Immediate Motion Post-Op Results 5 required manipulation 9 patients full ROM 3 patients good-excellent Wascher et al 1999 13 Knee Dislocations Tx Allograft, Scope ACL/PCL recon Repair medial/lateral Average f/u 38 months Results Mean arc of motion 130° 2 manipulations 1 knee “normal”, 6 → sports
- 55. Results of Ligament Reconstruction Yehet al 1999 25 Knee Dislocations Tx - Scope PCL recon / delay ACL 1° repair medial/lateral Timing ≈ 2 weeks Average f/u ≈ 2 years Results ROM 0 - 130° 3 required scope debride 21 returned to office work Cole and Harner 1999 25 Knee Dislocation Tx Scope ACL/PCL recon 6 PLC recon / 7 MCL repair Average f/u 3 years Results 5 lost 15° flexion 9 normal, 13 near normal KT-1000 = 0.1mm Timing w/in 3 wks preferred
- 56. Treatment of SpecificPatterns
- 57. Treatment: KD-I ACL +MCL MCL - predictable healing cylinder cast immobilization in extension for 2 weeks hinged brace → ROM delayed ACL reconstruction motion restored residual laxity and desired activity level
- 58. Treatment: KD-I ACL +LCL/PLC delayed surgery @ 14 capsular healing identification of lateral structures arthroscopic ACL - femoral fixation instruments and experience with open techniques femoral fixation tibial fixation / ACL tensioned after LCL/PLC open posterolateral repair / reconstruction
- 59. Treatment: KD-II ACL +PLC collateral ligaments intact hinged brace + early ROM extension stop at 0º arthroscopic reconstruction after 6 weeks PCL only in most cases ACL/PCL limited to high demand patient sedentary individuals = no surgery
- 60. Treatment:KD-IIIM ACL + PLC+ MCL immobilization in extension early surgery (2 weeks) EUA and limited diagnostic arthroscopy (MRI) single straight medial parapatellar incision open PCL reconstruction or repair MCL repair
- 61. Case Example: KD-IIIM 47year old female pedestrian MVA isolated injury examination diffuse swelling and ecchymosis ROM: 10/0/80 normal DP/PT pulses motor sensory normal ligament testing Lachman 3+ post drawer 3+ valgus 3+ 0º and 30º varus stable
- 62. Case Example: KD-IIIM closedreduction and brace arteriogram normal MRI mid-substance ACL and PCL midsubstance MCL EUA and stress radiographs
- 63. Case Example: KD-IIIM diagnosticarthroscopy
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- 65.
- 66.
- 67.
- 68. PCL Reconstruction: “DoubleBundle”
- 69. Treatment: KD-IIIL ACL +PLC + LCL/PLC immobilization in extension delayed surgery @ 14 days diagnostic arthroscopy arthroscopic or open PCL open LCL/PLC incisions are critical - avoid midline PCL = medial (open or arthroscopic) straight posterolateral
- 70. 42 female unrestrained frontseat passenger MVA multiple injuries laparotomy spleenectomy, hepatic packing LC-1 pelvis [R] knee dislocation Case Example: KD-IIIL
- 71. knee examination Lachman 3+ posteriordrawer 3+ valgus stable varus 3+ @ 0º and 30 º ER ↑ all degrees radiographs normal arteriogram normal immobilized in extension x 2 weeks Case Example: KD-IIIL
- 72.
- 73. lateral exposure anatomic repair ITB bicepsfemoris popliteus tibial fibular LCL posterior capsule meniscus Case Example: KD-IIIL
- 74.
- 75. Case Example: PCLFemoral “Peel-Off”
- 76. Case Example: KD-IIILC 25year old male motorcycle vs. telephone pole scene: deformity knee confused and combative intubated and sedated ground ambulance to local ER knee dislocation reduced abnormal vascular exam Medflight to BMC
- 77. Case Example: KD-IIILC examination3 hours after injury effusion: none? swelling: severe, diffuse, ecchymosis tenderness: sedated ROM: 15/0/120 neurovascular: absent DP/PT pulses cool pale foot motor / sensory NA
- 78. Case Example: KD-IIILC stabilityexamination after injury Lachman 3+ posterior drawer 3+ valgus stable varus 3+ @ 0º and 30 º ER ↑ all degrees isolated injury immediate treatment 4 compartment fasciotomy “on table” arteriogram in OR vascular reconstitution with RSV open lateral repair
- 79.
- 80.
- 81. Results of Ligament Reconstruction Noyes& Barber-Westin 1997 11 Knee Dislocations Tx - Scope assist Recon ACL/PCL Allograft/autograft Repair Medial/Lateral Average f/u 4.8 years Immediate Motion Post-Op Results 5 required manipulation 9 patients full ROM 3 patients good-excellent Wascher et al 1999 13 Knee Dislocations Tx Allograft, Scope ACL/PCL recon Repair medial/lateral Average f/u 38 months Results Mean arc of motion 130° 2 manipulations 1 knee “normal”, 6 → sports
- 82. Results of Ligament Reconstruction Yehet al 1999 25 Knee Dislocations Tx - Scope PCL recon / delay ACL 1° repair medial/lateral Timing ≈ 2 weeks Average f/u ≈ 2 years Results ROM 0 - 130° 3 required scope debride 21 returned to office work Cole and Harner 1999 25 Knee Dislocation Tx Scope ACL/PCL recon 6 PLC recon / 7 MCL repair Average f/u 3 years Results 5 lost 15° flexion 9 normal, 13 near normal KT-1000 = 0.1mm Timing w/in 3 wks preferred
- 83. Management of NerveInjury Exploration vs. Observation Early AFO Early Achilles Stretching Wait on Nerve Conduction Studies At least 6 weeks, possibly 3 months Dynamic Bracing i.e. articulating AFO Tendon Transfers PRN
- 84. Management of NerveInjury Surgical Exploration Intact BUT damaged Observation 1 year or more until return 50% never return Disruption Primary repair Cable grafting Results – No good studies to date
- 85. Knee Dislocation: Summary anatomicclassification selective use of angiography individualized surgical treatment associated injuries limited surgery → “corner repair” multi-trauma head injury vascular or nerve injury PCL + collateral LOOSE AND MOBILE IS BETTER THAN STIFF AND STABLE Return to Lower Extremity Index