Document Sample
05 Powered By Docstoc

                                                                                                  Volume 59, (2):120-125, 2008

                                           Knee dislocation
                                        A report on 9 patients

 A' Orthopaedic Clinic - General Hospital of Kilkis, 2B' Orthopaedic Clinic - General Hospital of Kilkis, 3Orthopaedic Clinic - General
Hospital of Agrinio

ABSTRACT                                                             INTRODUCTION
   The aim of our work is to present our relatively limited             The first description of knee dislocation was made by Sir
experience from the treatment of 9 patients with knee                Astley Gooper in 1824. It is so rare that many orthopaedic
dislocation, an extremely serious although, fortunately,             surgeons end their careers having seen one, two or even no
rare injury. In the period of 1980-2005, 9 patients with             knee dislocations at all . They concern 0.02% of all injuries,
knee dislocation were treated, 8 of whom were male and               though perhaps their occurrence is higher than reported,
1 female. The causes were: car accidents in the cases of             since they are either reduced automatically or immediately
6 patients (one with multiple injuries), a fall in another           in the emergency room, therefore not being reported .
patient and injuries during sports activities in another             Shields reports 26 knee dislocations in 28 years, while Mayers
two patients. The age of the patients ranged between                 53 knee dislocations in a period of 10 years . It seems that
18 and 47 years old, with an average of 31 years. Of the             knee dislocation occurrence has risen, due to an increase
above, 8 dislocations were closed and one open with an               in car accidents, participation in sports activities as well as
accompanying fracture of the medial femoral condyle. No              its better diagnosis - report.
neurovascular damage was identified in any patient. At the
time of their hospital admission to the emergency room, 3
knee dislocations had been automatically reduced, 4 were             MATERIAL AND METHOD
reduced closed with gentle manipulation under general                    In the period of 1980-2005, 9 patients with equal in num-
anaesthesia, while the remaining two open, one due to a              ber knee dislocations were treated, 8 of whom were male
failed closed reduction attempt and one because it was               and 1 female. The age of the patients ranged between 18
open. Following the reduction, all patients were subjected           and 47 years old, with an average of 31 years. The causes
to a new neurovascular evaluation, radiological examina-             were: car accidents in 6 patients (one with multiple fractures
tion, as well as immobilization with brace to 8 patients and         injuries), a fall in one patient and an injury due to partici-
external fixation to the patient with the open fracture. The         pation in sports activities in two patients. Only one out of
knee instability treatment was effected immediately to 1             the 9 knee dislocations was open, with an accompanying
patient, in 3 weeks from the injury to 4 patients, within 2          fracture of the medial femoral condyle (figure 1). The clinical
months to 2 patients and within 5 months to 2 patients               examination identified knee edemas due to hemathrosis in
(multiple injuries, open dislocation). The outcome was               all patients, knee instability in all 9 patients, as well as knee
judged as satisfactory in all 3 patients.                            deformity in 6 patients, since in the remaining 3 there was
                                                                     an automatic reduction. No neurovascular damage was
Key-words: knee dislocation, neurovascular damage,                   identified in any patient. Out of 9 dislocations, 3 had been
knee instability, treatment.                                         automatically reduced at the time of the patients’ admis-
                                                                     sion to the emergency room, 4 were reduced closed with
                                                                     gentle manipulation under general anaesthesia and 2 open
Mailing Address                                                      under general anaesthesia: the first after a failed attempt
Stamatios Parashou
                                                                     of a closed reduction due to medial femoral condyle intus-
A' Orthopaedic Department, G.H. of Kilkis
9E Em. Papa Str., Retziki 57010 Thessaloniki                         susception in the medial capsule, and the second because it
Tel.: 6946524411, e-mail: polfle@yahoo.com                           was an open dislocation. Following the reduction, all patients
S. PARASHOU et al. KNEE dISlOCATION. A REPORT ON 9 PATIENTS                                                                              121

                                                                 Table 1. PATIENTS TABLE

Sex              Mechanism/Type                               Injuries        Diagnosis           Treatment          Outcome
                 of dislocation
      M          Car accident-Closed-                         AC+PC+MC        R+MRI               Ar 5/12            P
                 Multiple injuries
      M          Car accident-Open                            AC+PC+MC        R+d+MRI             Ar 5/12            M
      M          Car accident-Closed                          AC+PC+MC        R+MRI               O immediately      VG
      M          Car accident-Closed                          AC+PC+MC        R+MRI               Ar 2/12            G
      M          Car accident-Closed                          AC+PC+MC        R+MRI               Ar 2/12            M
      M          Car accident-Closed                          AC+PC+MC        R+MRI               O 3/52             VG
      M          Fall-Closed                                  AC+PlC          R+MRI               O 3/52             G
      M          Football-Closed                              AC+PlC          R+MRI               O 3/52             G
      F          Ski-Closed                                   AC+PlC          R+MRI               O 3/52             G

      M: male, F: female, AC: anterior cruciate ligament, PC: posterior cruciate ligament, MC: medial collateral ligament,
      PlC: posterior lateral corner, O: openly, Ar: arthroscopically, VG: very good, G: good, M:medium, P: poor, d: during

were subjected to a new neurovascular evaluation of the                       and a patella tendon autograft from the healthy crus in 5
crus, 8 patients to knee immobilization with brace and the                    patients. The average duration of follow-ups was 11 years.
open dislocation patient to external fixation. A new radio-                   All patients had quadriceps atrophy, flexion limitation by
logical examination with anteroposterior and lateral X-ray                    5-15 degrees, extension limitation by 4 degrees, as well as
radiographs followed to confirm the reduction. In order to                    a mild knee arthritis. The mean term in lynsholm score was
evaluate the ligament damages, 8 patients had a magnetic                      90 for those operated within the 3 first weeks and 79 for
tomography in the knee. Intraoperative rupture of the                         those operated later. The mean terms for every day activity
anterior cruciate ligament, the posterior cruciate ligament                   were 88 and 77, while the mean terms for sports activity
and the medial collateral ligament (figure 2) was identified                  were 85 and 66 correspondingly.
in the patient with the open reduction. As for the other
8 patients who were subjected to an MRI, we identified a
rupture of the anterior cruciate ligament in all of them, a
rupture of the posterior cruciate ligament in 5 patients, a                      The deformity observed in a knee dislocation usually makes
rupture in the medial collateral ligament in 5 and a rupture                  diagnosis easy. Many times, though, there is an automatic
of the posterior lateral corner in 3 patients. The magnetic                   dislocation reduction and the only indirect indication is
tomography was conducted within 3 weeks from the injury in                    knee instability, accompanied with damage to at least 3
6 of the patients, while in the remaining two (multiple-injury                knee ligament elements. Knee dislocations are classified as
and open-dislocation patients) it was conducted 5 months                      closed or open, reducible or irreducible and according to
after the injury, after the fracture union. The knee instability              the tibia deviation in relation to the femoral bone. A large
rehabilitation was immediate in one patient (open reduction                   series of studies monitoring 245 knee dislocations reported
due to failure of the closed one), open within 3 weeks from                   an anterior dislocation from hyperextension in a 40% occur-
the injury in 4 patients, arthroscopically within 2 months                    rence, posterior dislocation from the knee impact on the
from the injury in two patients and arthroscopically within 5                 car dashboard in a 33% occurrence, a lateral dislocation in
months from the injury in two patients (multiple-injury and                   18% and a medial dislocation in 4% from a violent impact
open-dislocation cases), (figure 3). For the rehabilitation of                with valgus or varus directions. The rotatory dislocation,
the posterior cruciate ligament, we used achilloallograft in                  a quite rare case, was reported in a 5% occurrence7. The
4 patients, as well as immediate stitching and anchorage                      irreducible dislocation is owed to the interposition of the
in 2 patients; for the rehabilitation of the anterior cruciate                medial femoral condyle in the medial articular capsule3,10,11.
ligament we used a patella tendon allograft in 4 patients                     The open knee dislocation occurrence is reported to be
122                                                                                                          E.E.X.O.T., Volume 59, Number 2, 2008

 A                                                     Β

 C                                                                                                  D

Figure 1. A. Open knee dislocation after a car accident, B. We can observe the accompanying fracture of the medial femoral condyle, C.
Immediate postoperative X-rays. We can observe the condyle fixation with 2 K-W as well as the knee stabilization with external fixation,
D. instability rehabilitation 5 months after the surgery.

20-25%. Rarely are there in the literature knee dislocation           an angiography should be made . If the crus is ischemic,
reports without an accompanying rupture of the anterior               there should be reduction with gentle manipulation under
cruciate ligament . There should always be a neurovascular            intravenous regional anaesthesia, immobilization in braces and
examination of the crus, both clinically and with doppler             new vascular check. If the flow is restored, radiographs and
system. The ankle-branchial index (ABI) is also useful. Any           an angiograph should be conducted, otherwise there should
rate lower than 0.90 is an indication for an angiography,             be immediate operation. The popliteal artery rehabilitation is
while higher than 0.90 suggests a normal flow in the ves-             effected with a venous graft from the contralateral saphen-
sels, though it should be accompanied with pulpation .                ous, with simultaneous stitching of the capsule-ligament
We should note that the existence of a pulse does not rule            system and immobilization with external fixation. Both the
out the possibility of vascular damage. If in suspicion of            instability check through a magnetic tomography and re-
vascular damage, an angiosurgeon should be consulted and              habilitation are effected in a second phase, usually after 12
S. PARASHOU et al. KNEE dISlOCATION. A REPORT ON 9 PATIENTS                                                                            123


                                                                                                       Figure 2. A. Knee dislocation
                                                                                                       after a fall, B. Failure in closed
                                                                                                       reduction, C. Open reduction
                                                                                                       with a simultaneous ligament
                                                                                                       rehabilitation (allograft for the
                                                                                                       anterior cruciate ligament,
                                                                                                       posterior cruciate ligament
                                                                                                       fixation on the tibia and medial
                                                                                                       collateral stitching on the femur,
                                                                                                       D. Immediate postoperative X-

 A                                     C

months, so that there has been vascular damage restoration            the simultaneous dislocation reduction and immobilization
and ischemic bandaging can be used                  . The peroneal    with braces or external fixation for 6 weeks. Instability reha-
nerve damage has an occurrence of approximately 25% and               bilitation is effected after the fracture union . If a closed
varies from complete neurotmesis to simple neuroapraxia.              reduction fails, the treatment involves either an open or an
The rate of full or partial rehabilitation reaches 40-50% .           arthroscopic reduction, though the latter is best avoided
In an open dislocation with a peroneal nerve damage, the              due to the high risk of compartment syndrome                   . The
recommended treatment involves examination, its immedi-               instability restoration is effected either immediately or in a
ate stitching with the simultaneous stitching of the capsule,         second phase. In the case of a successful closed reduction,
immobilization with external fixation and nerve monitoring. In        instability can be treated either conservatively or surgically.
a closed dislocation with peroneal nerve damage, the closed           Conservative treatment is recommended for eldery patients
reduction, immobilization for 6 weeks and monitoring the              with low survival expectancy and a bad general condition.
nerve function are favoured. If we have indications of nerve          Prolonged immobilization time leads to a stable but inflex-
function, we can proceed with the instability rehabilitation          ible knee, while short time leads to a flexible but unstable
after the total function of the nerve; if not, we proceed with        knee              . There is a dispute over the time of surgical
exploration and nerve rehabilitation with the use of a graft.         instability rehabilitation, the surgical technique to be used,
In the case of permanent damage, we proceed with tendon               the type of grafts and the rehabilitation program. The best
transfers or triple arthrodesis . For open knee dislocations,         results have been given by the open rehabilitation of the
the recommended course involves open reduction, stitching             ligaments within 3 weeks from the injury. If rehabilitation
the capsule system and stabilization with EX-F for 6 weeks,           delays for more than 3 weeks, then preferably it should be
while instability rehabilitation follows in a second phase. If        done arthroscopically in 6-12 weeks after we have full move-
there are accompanying fractures, they are treated with               ment of the knee and healing of the capsule. difficulties will
124                                                                                                                E.E.X.O.T., Volume 59, Number 2, 2008

                                               B                                                     C

                                              Picture 3. A. Anterior knee dislocation in a multiple-fracture patient, B. Magnetic tomography
                                              showing rupture of the anterior cruciate ligament, posterior cruciate ligament, medial collateral
 A                                            ligament and medial meniscus, C. Instability rehabilitation 6 months after surgery.

be encountered in stitching the medial collateral ligament                  tion of the Knee. J Bone Joint Surg. 1977; 59A:236-239.
and the posterior lateral corner due to scars . For the liga-            8. Nystrom M, Samini S, Ha Eri GB. Two Cases of Irreducible Knee.
mentoplasty of the posterior cruciate ligament the achilloal-               dislocation Occuring Simultaneously in Two Patiens and a Re-
lograft is preferable, while for the anterior cruciate ligament             view of the literature. Clin Orthop. 1992; 277:197-200.
the patella tendon allograft or autograft from the healthy               9. Samini S, Shahriaree H. Arthroscopic View of an Irreducible
crus are preferred. Quite often, knee function is not fully                 Knee dislocation. Arthroscopy 1991; 9:322-326.
restored, and osteoarthritis develops. Negative prognostic              10. dubberly J, Burnell C, longstaffe A, Macdonald Pb. Irreducible
factors are: an open dislocation, accompanying fractures,                   knee dislocation treated dy arthroscopic debridement. Arthros-
damage to the peroneal nerve, damage to the popliteal                       copy. 2001 Mar; 17(3):316-319.
artery and the delayed rehabilitation of instability.                   11. Kontakis GM, Christoforakis JJ, Katonis PG, Hadjipavlou AG. Ir-
                                                                            reducible knee dislocation due to interposition of the vastus
                                                                            medialis associated with neurovascular injuty. Orthopedics. 2003
REFERENCES                                                                  Jun; 26(6):645-6.
 1. Rockwood and Green’s fractures. Traumatic dislocations of           12. Flowers A, Copley lA. High-energy dislocation without anterior
    the Knee.                                                               cruciate ligament disruption in a skeletally immature adolescent.
 2. Kennedy JC. Complete dislocation of the Knee Joint. J Bone              Arthroscopy. 2003 Sep; 19(7):782-6.
    Joint Surg. 1963; 45A:889-904.                                      13. Mills WJ, Barei dP, McNair P. The value of the ankle-brachial index
 3. Shields l, Mitral M, Cane EF. Complete dislocation of the Knee:         for diagnosing arterial injury after dislocation: a prospective
    Experience at the Massachusetts General Hospital. J Trauma.             study.J Trauma. 2004 Jun; 56(6):1261-5.
    1969; 9:192-215.                                                    14. Stannard JP, Sheils TM, lopez-Ben RR, McGwin G Jr,Robinson
 4. Meyers M, Harvey JP. Traumatic dislocation of the Knee Joint.           JT, Volgas dA. Vascular injuries in knee dislocations: the role of
    J Bone Joint Surg. 1971; 53A:16.                                        physical examination in determing the need for arteriography.
 5. Campell’s Operative Orthopaedics. Volume Three. Acute dis-              J Bone Joint Surg Am. 2004 May; 86-A(5);910-5.
    locations. Knee. P. 1351-1353.                                      15. Rihn JA, Groff Y, Harner Cd, Cha PS. The acutely dislocated knee:
 6. Good l, Johnson RJ. The dislocated Knee. J Am Acad Orthop               evaluation and nagement. J Am Acad Orthop Surg. 2004 Sep-
    Surg. 1995 Oct; 3(5):284-292.                                           Oct; 12.
 7. Green Ne, Allen Bl. Vascular Injuries Associated With disloca-      16. Jones RE. Vascular and Orthopaedic Complications of Knee
S. PARASHOU et al. KNEE dISlOCATION. A REPORT ON 9 PATIENTS                                                                              125

    dislocation. Surg Gynecol Odstet. 1979; 149:554-8.                     tions. Istr. Course lect 1999; 48:515-22.
17. lefrak EA. Knee dislocation: An Elusive Cause of Critical of       24. dedmond BT, Almekinders lC. Operative versus nonoperative
    Critical Arterial Occlusion.Arch Surg. 1976; 111:1021.                 treatment of knee dislocations: a meta-analysis. Am J Knee
18. Welling RE,Kakkasseril J,Cranley JJ. Complete dislocation of the       Surg 2001; 14:33-8.
    Knee With Popliteal Vascular Injury. J Trauma. 1981; 21:450-       25. Richter M, Bosch U, Wippermann B, ofmann A, Krettek C.
    452.                                                                   Comparison of surgical repair or reconstrution of the cruci-
19. Wolma FJ. Arterial Injuries of the leg Associated With Fractures       ate ligaments versus nonsurgical treatment in patients with
    and dislocations. Am J Surg. 1980; 140:806.                            traumatic knee dislocations. Am J Sports Med. 2002 Sep-Oct;
20. Niall dM, Nutton RW, Keating JF. Palsyof the common peroneal           30(5):718-27.
    nerve after traumatic dislocation of the knee. J Bone Joint        26. Wong CH, Tan Jl, Chang HC, Khin lW, low CO. Knee dislocations-a
    Surg Br. 2005 May; 87(5):664-7.                                        retropective study comparing operative versus closed immo-
21. Garozzo d, Ferraresi S, Buffatti P. Surgical treatment of com-         bilization treatment outcomes. Knee Surg Sports Traumatol
    mon peroneal nerve injuries: indications and results. A series         Arthrosc. 2004 Now; 12(6):540-4. Epud 2004 Mar 4.
    of 62 cases. J Neurosurg Sci. 2004 Sep; 48(3):105-12.              27. Chhabra A, Cha PS, Rihn JA, Cole B, Bennet CH, Waltrip Rl, Harner
22. Giannoudis PV, Roberts CS, Parikh AR, Agarwal S, Hadjikouti-           Cd. Surgicalmanagement of knee dislocations. Surgical tech-
    dyer C, Macdonald dA. Knee dislocation with ipsilateral femo-          nique. J Bone Joint Surg Am. 2005 Marq87 Suppl 1(Pt1)Q1-21.
    ral shaft fracturea: a report of five cases. J Orthop Trauma.      28. Harner Cd, Waltrip Rl, Bennet CH, Francis KA, Cole B, Irrgang
    2005 Mar; 19(3):205-10.                                                JJ. Sugical management of knee dislocations. J Bone Joint Surg
23. Schenck RC Jr, Hunter RE, Ostrum RF, Perry CR. Knee disloca-           Am. 2004 Feb; 86-A(2):262-73.

Shared By: