Complete dislocation of the knee — the long-term results of ligamentous reconstruction

doi:10.1016/S0968-0160(98)00015-5

The Knee

Volume 5, Issue 4, 1 October 1998, Pages 255-260

https://doi.org/10.1016/S0968-0160(98)00015-5 Get rights and content

Abstract

Thirty-eight knee dislocations in 36 patients were studied to evaluate the outcome of ligamentous reconstruction. Twenty-two patients had an early ligamentous reconstruction and 16 patients had the ligamentous injury managed non-operatively. Long-term functional follow-up was obtained in 29 patients with 31 knee dislocations. Knee function was better in patients who had been received early ligament reconstruction. The Lysholm score was 85 in reconstructed knees compared to 69 in those knees treated non-operatively (P<0.02). However, a significant degree of degenerative change was observed in both groups on follow-up radiographs. Early ligamentous reconstruction provides better knee function following complete dislocation. Radiographic evidence of degenerative arthritis occurs in a high proportion of patients irrespective of early treatment.

Introduction

Most studies published to date dealing with complete knee dislocation have concentrated on the incidence and management of the associated vascular injury 1, 2, 3, 4. Little is known regarding the long-term implications of the ligamentous disruption that invariably accompanies the dislocation. There have been only a few studies that have addressed the treatment of the ligament injury 5, 6, 7, 8. Interpretation of the results in the literature has been hindered by small numbers of patients and a heterogeneous approach to treatment. Although recent studies have recommended operative treatment it is still uncertain whether ligamentous repair or reconstruction is worthwhile.

The present study is a follow-up of operatively and non-operatively managed ligament disruption following complete knee dislocation. The aim of the study was to evaluate the outcome of the ligamentous injury. In particular we wished to assess whether immediate operative reconstruction of knee ligaments had any advantage over conservative treatment.

Section snippets

Methods

To be eligible for inclusion in the study, patients had to have a radiologically documented knee dislocation or a definite clinical history of a dislocated knee requiring reduction. Using these criteria we identified 36 patients with 38 knee dislocations treated between January 1983 and December 1992. There were 28 males and eight females with a mean age of 32 years (range, 17–85 years). The mechanism of injury was a motor vehicle accident in 25 cases, sporting injuries in four cases,

Clinical assessment

All vascular repairs were successful and there were no amputations. Clinical assessment of anterior laxity between the two groups revealed a tendency towards greater laxity in the unreconstructed group. In the reconstructed group the Lachman was considered grade I in four knees (22%), grade II in 12 knees (66%) and grade III in two knees (11%). In the non-operative group only one knee (18%) was grade I, nine were grade II and three (23%) were grade III (P<0.03; Mann–Whitney test). A pivot shift

Discussion

The rarity of knee dislocation has made study of the condition difficult. Few orthopaedic surgeons have the opportunity of encountering more than the occasional case. Formal prospective studies have therefore not been conducted comparing operative and non-operative treatment methods. Many of the studies concentrate on the early complications and particularly the vascular injury 1, 2, 3, 4, 11, 12. The detection and management of a vascular injury associated with a knee dislocation is clearly

Conclusion

The present study suggests that operative reconstruction of the ligaments has an advantage over conservative methods, with improved medium-term functional outcome. The high rate of degenerative change in both non-operative and operatively managed groups suggest that many of these knees will progress to symptomatic arthritis. Operative reconstruction or repair of the cruciate and collateral ligaments is recommended in knee dislocation.

References (14)

NW Hoover
Injuries of the popliteal artery associated with fractures and dislocations
Surg Clin North Am
(1961)
NE Green et al.
Vascular injuries associated with dislocation of the knee
J Bone Joint Surg
(1977)
RE Jones et al.
Vascular and orthopaedic complications of knee dislocation
Surg Gynecol Obstet
(1979)
GF McCoy et al.
Vascular injury associated with low-velocity dislocations of the knee
J Bone Joint Surg
(1987)
MH Meyers et al.
Traumatic dislocation of the knee joint: a study of eighteen cases
J Bone Joint Surg
(1971)
MH Meyers et al.
Follow-up notes on articles previously published in the Journal. Traumatic dislocation of the knee joint
J Bone Joint Surg
(1975)
DJ Sisto et al.
Complete dislocation: a follow-up study of operative treatment
Clin Orthop
(1985)

There are more references available in the full text version of this article.

Cited by (42)

Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment
2022, Arthroscopy, Sports Medicine, and Rehabilitation
Citation Excerpt :
Single-stage multi-ligament reconstruction was associated with lower overall cost, fewer surgical complications, and lower reoperation rates when compared with 2-stage reconstruction. Prior studies comparing outcomes of single-stage versus 2-stage approaches reported varying results regarding both objective measures and patient-reported outcomes.6,9,18-21 Because of the rarity of these injuries, sample size has been a consistent limiting factor in comparing these protocols.6,9,18-21
To compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.
The MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ² tests, and Fisher exact tests were used with an α level of .05 set as significant.
We identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group.
Single-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.
Level III, retrospective cohort study.
Multiple ligament injuries of the knee
2013, Orthopaedics and Trauma
Citation Excerpt :
The long-term result is usually dependent on the presence or absence of significant chondral damage. The literature related to long-term osteoarthritis development is limited, but it seems that it is likely to occur in a significant number of cases9,25 In chronic cases, unfortunately most patients will have accumulated some chondral damage from the excess laxity in the ligament complexes. However even in acute cases, chondral injury mitigates against a good result.
Multi-ligament injuries of the knee are complex. A high index of suspicion for knee dislocation having occurred at the time of injury is necessary, as many dislocations spontaneously reduce and are therefore occult. Significant vascular and neurological injuries often occur at the time of injury and need to be diagnosed and managed. Consequently, there should be a low threshold for angiography. MR imaging is a useful aid but careful clinical examination is essential. Non-surgical management is, in general, not advocated but has a role for structures that have a high chance of healing such as the medial collateral ligament. Good results from surgery can be obtained, especially when surgery occurs within 2–3 weeks post-injury, but this is only possible in uncomplicated cases. An osteotomy may be necessary in chronic cases, especially if the posterolateral corner is affected. The patient should be warned of prolonged rehabilitation, which may take up to 2 years before the full result is achieved. With appropriate treatment a majority of patients can return to pre-injury levels of work and daily activity. Higher level function is much less certain.
Knee dislocation: Descriptive study of injuries
2013, Revista Brasileira de Ortopedia
Descrever as lesões ligamentares e associadas ocorridas nas luxações traumáticas do joelho, relacioná-las aos mecanismos de trauma e identificar padrões de lesões.
Foram descritas 23 luxações do joelho entre março de 2010 e março de 2011. Após o diagnóstico das lesões, foi procedida a redução e fixação externa transarticular das luxações. Num segundo tempo, os pacientes foram avaliados sob anestesia e a exploração cirúrgica das lesões periféricas foi feita pelos membros do grupo de cirurgia do joelho da instituição. Os dados dos pacientes, junto com as descrições das lesões encontradas, foram registrados.
65% dos pacientes eram do sexo masculino, a média de idade foi de 35 anos, o mecanismo de trauma mais comum foi o acidente com motocicleta (60%). A lesão do ligamento cruzado anterior (LCA) ocorreu em 75% dos casos, a lesão do ligamento cruzado posterior (LCP) em 95%. A lesão periférica medial aconteceu em 65% das luxações e as lesões laterais em 40%. As luxações mais comuns foram as classificadas como KDI (25%) e KDIIIm (25%). A lesão arterial esteve presente em 15% dos casos e a lesão nervosa foi registrada em um paciente (5%). Na avaliação radiográfica inicial, 45% das luxações apresentavam-se reduzidas.
As luxações do joelho descritas apresentaram grande variabilidade, demonstrando que é preciso a avaliação individualizada de cada caso, sendo que o ortopedista precisa estar apto para o reconhecimento e tratamento específicos dessas diversas lesões.
Describe the ligamentous and associated injuries that occur in the traumatic knee dislocation, relating them to the mechanisms of trauma and to identify patterns of injuries.
Twenty three knee dislocations were described in the period between March 2010 and March 2011. After the diagnosis of the lesions, the reduction and transarticular external fixation of the dislocated knees were done. At the second moment, the patients were evaluated with physical examination under anesthesia and the surgical exploration of peripheral lesions was perfomed by a surgeon of the knee surgery group of this institution. The patients data with the description of the injuries were found and registered.
65% of patients were male, the average age was 35 years and the most common mechanism of trauma was the motorcycle accident (60%). The lesion of the anterior cruciate ligament (ACL) occurred in 75% of the cases, and the lesion of posterior cruciate ligament (PCL) in 95%. The medial peripheral injuries happened in 65% of the dislocations, and the lateral lesions in 40%. The most common dislocations were classified as KDI (25%) and as KDIIIm (25%). The arterial injury was present in 15% of the cases, and the nervous injury where registered in one patient (5%). At the initial radiographic evaluation, 45% of the dislocations presented reduced.
The characteristics of the knee dislocations described showed a great range of variability demonstrating that an individualized evaluation of each case is mandatory. The surgeon should be able to recognize and choose the correct treatment to these lesions.
Acute knee dislocation: An evidence based approach to the management of the multiligament injured knee
2011, Injury
Citation Excerpt :
Knee dislocations of 5–17% are reported to be open [27]. In 14–44% of patients, knee dislocation is reported to be a component of multiple trauma [3,22,37,67,70,72]. An anatomical classification was proposed by Kennedy in 1963, based on direction of tibial dislocation in relation to the femur [26]:
Traumatic knee dislocations are uncommon yet serious injuries that historically have had variable prognosis. The evaluation and management of traumatic knee dislocations remains controversial. Appropriate early management has been shown to have a significant impact on long term functional outcome. A comprehensive review of the recent literature is presented alongside our current approach to management.
The dislocated knee is an under diagnosed injury which relies on a high index of clinical suspicion on presentation of any knee injury. There is now a degree of consensus regarding need for surgery, timing of surgery, vascular investigations, surgical techniques and rehabilitation protocols.
Vigilant monitoring for neurovascular complications, appropriate investigations and early involvement of surgeons with a specialist interest in knee ligament surgeries is the key to successful management of these difficult injuries.
Multiligament Knee Injury: Should Surgical Reconstruction be Acute or Delayed?
2009, Evidence-Based Orthopaedics: The Best Answers to Clinical Questions
Multiple-ligament knee injuries: A systematic review of the timing of operative intervention and postoperative rehabilitation
2009, Journal of Bone and Joint Surgery
Traumatic knee dislocations that result in multiple-ligament knee injuries are unusual and are poorly studied. We are not aware of any prospective data regarding their treatment. Both the optimum timing of surgery for repair or reconstruction and the aggressiveness of rehabilitation are debated. The purpose of this systematic review was to compare the outcomes of early, delayed, and staged procedures as well as the subsequent rehabilitation protocols.
We surveyed the literature and retrieved twenty-four retrospective studies, involving 396 knees, dealing with the surgical treatment of the most severe multiple-ligament knee injuries (those involving both cruciate ligaments and either or both collateral ligaments). Data were extracted, and surgical timing was categorized as acute, chronic, or staged. Early postoperative mobility and immobilization were also compared.
We found that acute treatment was associated with residual anterior knee instability when compared with chronic treatment (odds ratio, 2.58; 95% confidence interval, 1.2 to 5.8; p = 0.018). Significantly more patients who were managed acutely were found to have more flexion deficits when compared with those who were managed chronically (odds ratio, 5.18; 95% confidence interval, 1.5 to 17.5; p = 0.004). Staged treatments yielded the highest percentage of excellent and good subjective outcomes (79%; 95% confidence interval, 62.2% to 89.3%). Additional treatment for joint stiffness was significantly more likely in association with acute treatment (17%; 95% confidence interval, 13.0% to 22.4%; p < 0.001) and staged treatment (15%; 95% confidence interval, 7.6% to 28.2%; p = 0.001) when each was compared with chronic treatment (0% [zero of seventy-one]; 95% confidence interval, 0.0% to 5.1%). Early mobility was not associated with increased joint instability in acutely managed patients. Early mobility yielded fewer range-of-motion deficits but did not reduce the rate of follow-up manipulation or arthrolysis.
This review of the available literature suggests that delayed reconstructions of severe multiple-ligament knee injuries could potentially yield equivalent outcomes in terms of stability when compared with acute surgery. However, in the acutely managed patient, early mobility is associated with better outcomes in comparison with immobilization. Acute surgery is highly associated with range-of-motion deficits. Staged procedures may produce better subjective outcomes and a lower number of range-of-motion deficits but are still likely to require additional treatment for joint stiffness. More aggressive rehabilitation may prevent this from occurring in multiple-ligament knee injuries that are treated acutely.
Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

View all citing articles on Scopus

View full text

Complete dislocation of the knee — the long-term results of ligamentous reconstruction

Abstract

Introduction

Section snippets

Methods

Clinical assessment

Discussion

Conclusion

Surg Clin North Am

Vascular injuries associated with dislocation of the knee

J Bone Joint Surg

Vascular and orthopaedic complications of knee dislocation

Surg Gynecol Obstet

Vascular injury associated with low-velocity dislocations of the knee

J Bone Joint Surg

Traumatic dislocation of the knee joint: a study of eighteen cases

J Bone Joint Surg

Follow-up notes on articles previously published in the Journal. Traumatic dislocation of the knee joint

J Bone Joint Surg

Complete dislocation: a follow-up study of operative treatment

Clin Orthop