{"id":147,"date":"2024-06-29T03:57:45","date_gmt":"2024-06-29T03:57:45","guid":{"rendered":"https:\/\/orthopaedicsone.com\/viewpoints\/orthopaedicsone-viewpoints-early-vs-late-treatment-of-knee-dislocation\/"},"modified":"2024-06-29T03:59:57","modified_gmt":"2024-06-29T03:59:57","slug":"orthopaedicsone-viewpoints-early-vs-late-treatment-of-knee-dislocation","status":"publish","type":"page","link":"https:\/\/www.orthopaedicsone.com\/viewpoints\/orthopaedicsone-viewpoints-early-vs-late-treatment-of-knee-dislocation\/","title":{"rendered":"Early vs. Late Treatment of Knee Dislocation"},"content":{"rendered":"

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Scroll down to respond to the OrthopaedicsOne Poll: For the best functional and clinical outcomes, early operative treatment of a multiligament-injured knee is essential<\/h3>\n

The debate over the best management for knee dislocation is presented below. Most of the available clinical information is based on retrospective clinical series, making the need for large randomized prospective multicentre trials necessary to better understand how to best manage these difficult injuries.<\/p>\n

Viewpoint 1: Bruce A. Levy, MD<\/h3>\n

Early Treatment of Knee Dislocations<\/h3>\n

The dislocated knee is a limb-threatening injury with a significant rate of neurovascular compromise. Optimal treatment strategies remain highly debated.<\/p>\n

First and foremost, it is important to recognize that a knee dislocation has occurred, as the vast majority of patients present after spontaneous reduction. For example, a patient may present to the emergency room with normal X-rays and a massively swollen knee with gross instability. This clinical scenario should alert the physician to the possibility of a knee dislocation.<\/p>\n

Thorough vascular assessment is probably the most important first step to the management of these injuries. Recently, several authors have demonstrated that serial physical examination alone is safe.1,2<\/sup> However, it is also recognized that normal and symmetric pulses may be present with a complete popliteal artery occlusion secondary to collateral flow. <\/p>\n

<\/span>Read more…<\/span><\/p>\n

At our institution, we perform ankle-brachial indices (ABIs) on every patient who presents to the emergency room with a diagnosis or presumption of a knee dislocation. The ABI is a non-invasive screening tool that is easy to perform in the acute setting.<\/sup><\/p>\n

ABI = Doppler systolic arterial pressure in injured limb (ankle) \/ Doppler systolic arterial pressure in uninjured limb (brachial)<\/strong><\/p>\n


\nFigure 1.<\/strong> Demonstrating Doppler probe measurement of the systolic pressure at the dorsalis pedis artery to determine the ankle-brachial index.<\/p>\n

\nIn a study of 38 patients, Mills et al showed that the risk of a significant vascular injury with an ABI greater than 0.9 is essentially 0%.<\/sup> If patients have an abnormal ABI, then we perform further vascular screening with arterial duplex ultrasound. If the ultrasound is equivocal or non-diagnostic, then we proceed with computerized tomography arteriography (CTA). The advantage of CTA compared to conventional arteriography is that the contrast is injected into the antecubital fossa as opposed to the groin and requires less than one quarter the radiation.<\/sup><\/p>\n

A thorough neurologic exam is also important as there is approximately a 25% risk of peroneal nerve injury.<\/sup> Chronic peroneal nerve palsy, even after a successful multiligament knee reconstruction, can cause significant functional impairment. Conventional treatment consists of neurolysis, nerve grafting, and tibial tendon transfers, all with moderate success. More recently at our institution, we have been performing direct nerve transfer from a healthy motor branch of the tibial nerve to the healthy distal portion of the injured peroneal nerve.<\/sup> Our preliminary results are encouraging, but our outcomes have yet to be published.<\/p>\n

Currently, there is a paucity of data in the literature to help guide treatment strategies with regard to ligament repair\/reconstruction. We recently performed an evidence-based systematic review, specifically addressing three areas: 1) surgical versus nonoperative treatment, 2) repair versus reconstruction of injured ligamentous structures, and 3) early versus late surgery of damaged ligaments. Our review demonstrated that early operative treatment of the multiligament-injured knee yielded improved functional and clinical outcomes compared with nonoperative management or delayed surgery. Repair of the posterolateral corner (PLC) may yield higher revision rates compared with reconstruction.<\/sup> In our own series of repair versus reconstruction of the fibular collateral ligament\/posterolateral corner (FCL\/PLC), we observed a 40% failure rate with repair alone compared to a 6% failure rate with reconstruction (p = 0.04).<\/sup> Numerous reconstruction techniques for the FCL\/PLC have been reported with varying degrees of success.10,11<\/sup> LaPrade has popularized the “anatomic” reconstruction, which hopefully will lead to improved patient outcomes.12<\/sup><\/p>\n


\nFigure 2.<\/strong> Arthroscopic view of the ACL and PCL grafts after fixation.<\/p>\n

\nWith regard to the medial collateral ligament\/posteromedial corner (MCL\/PMC), the decision to repair versus reconstruct is even less clear. A recent systematic review on the surgical management of the MCL in the setting of the multiligament-injured knee demonstrated satisfactory results in both repair and reconstruction groups. In this review, only eight studies in the English literature met inclusion criteria, and no studies directly compared repair to reconstruction.12<\/sup> At the 2009 American Orthopaedic Society of Sports Medicine annual meeting, Stannard et al<\/a> presented an abstract on 73 multiligament-injured knees, comparing MCL\/PMC repair to reconstruction. This was a prospective but non-randomized series. They found a 20% failure rate in the repair group and a 4% failure rate in the reconstruction group. Several authors are now working on “anatomic” reconstruction techniques with encouraging preliminary results.<\/p>\n

Most authors agree that reconstruction, as opposed to repair, of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) is the treatment of choice. Controversy persists regarding single-bundle versus double-bundle techniques and in particular, trans-tibial versus inlay PCL reconstruction. To date, there are no clinical data to justify one technique over the other.13<\/sup><\/p>\n


\nFigure 3.<\/strong> Anteroposterior radiograph taken after a multiligament knee reconstruction.<\/p>\n

\nPerforming research studies with high levels of evidence for these complex injuries is extremely difficult, predominantly due to the heterogeneity of the study group and wide variation of injury patterns\/combinations. Randomized clinical trials may, in fact, not be feasible in light of these considerations. Recognizing the benefits of pooling data from multiple centers and the success of other Canadian orthopaedic working groups, a Knee Dislocation Study Group has been formed with members from Canada and the United States. The establishment of multicentre prospective databases may hold the key to future research endeavors and ultimately lead to improved patient outcomes.<\/p>\n

Reprinted with permission from the Fall 2009 edition of the COA Bulletin<\/em><\/p>\n

References<\/h3>\n
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  1. Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg ER, 2002. “Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.” J Trauma 52 (2): 247-51; discussion 251-2<\/li>\n
  2. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G, Robinson JT, Volgas DA, 2004. “Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography.” J Bone Joint Surg Am 86-A (5): 910-5<\/li>\n
  3. Levy BA, Zlowodzki MP, Graves M, Cole PA, 2005. “Screening for extermity arterial injury with the arterial pressure index.” Am J Emerg Med 23 (5): 689-95<\/li>\n
  4. Mills WJ, Barei DP, McNair P, 2004. “The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study.” J Trauma 56 (6): 1261-5<\/li>\n
  5. Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA, 2008. “Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography.” Orthopedics 31 (8): 761-7<\/li>\n
  6. Niall DM, Nutton RW, Keating JF, 2005. “Palsy of the common peroneal nerve after traumatic dislocation of the knee.” J Bone Joint Surg Br 87 (5): 664-7<\/li>\n
  7. Bodily KD, Spinner RJ, Bishop AT, 2004. “Restoration of motor function of the deep fibular (peroneal) nerve by direct nerve transfer of branches from the tibial nerve: an anatomical study.” Clin Anat 17 (3): 201-5<\/li>\n
  8. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG, 2009. “Decision making in the multiligament-injured knee: an evidence-based systematic review.” Arthroscopy 25 (4): 430-8<\/li>\n
  9. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ, 2010. “Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee.” Am J Sports Med 38 (4): 804-9<\/li>\n
  10. Arciero RA, 2005. “Anatomic posterolateral corner knee reconstruction.” Arthroscopy 21 (9): 1147<\/li>\n
  11. Schechinger SJ, Levy BA, Dajani KA, Shah JP, Herrera DA, Marx RG, 2009. “Achilles tendon allograft reconstruction of the fibular collateral ligament and posterolateral corner.” Arthroscopy 25 (3): 232-42<\/li>\n
  12. Kovachevich R, Shah JP, Arens AM, Stuart MJ, Dahm DL, Levy BA, 2009. “Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review.” Knee Surg Sports Traumatol Arthrosc 17 (7): 823-9<\/li>\n
  13. Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ, , 2009. “Controversies in the treatment of knee dislocations and multiligament reconstruction.” J Am Acad Orthop Surg 17 (4): 197-206<\/li>\n<\/ol>\n

    Viewpoint 2: James Patrick Halloran, MD; Paul Andr\u00e9 Martineau, MD, FRCSC<\/h3>\n

    Late Treatment of Knee Dislocations<\/h3>\n

    The management of knee dislocations and knee dislocation patterns remains a challenging problem in orthopaedic surgery. Although this debate focuses on early or late treatment of knee dislocations, many variables come into play when a rational treatment algorithm is applied to the management of these complex injuries.
    \nFor example, we doubt that anyone would debate the need for urgent surgery on open or irreducible knee dislocations or in limbs with overt vascular injury or compartment syndrome. In these cases however, the urgent condition is addressed and the knee dislocation is often temporized with reduction and possible application of an external fixator. In addition, there is widespread agreement as to early treatment being preferred for acute bony ligament avulsions, particularly of the cruciate ligaments.<\/p>\n

    <\/span>Read more…<\/span><\/p>\n


    \nFigure 1a.<\/strong> AP radiograph of patient with reconstructed knee dislocation performed by tibial inlay allograft achilles PCL reconstruction, allograft hamstring ACL reconstruction and Laprade lateral collateral posterolateral corner achilles allograft reconstruction.<\/p>\n


    \nFigure 1b.<\/strong> Lateral radiograph of same patient.<\/p>\n

    \nAlthough the present treatment algorithm in place at our level 1 trauma centre is to treat knee dislocations early, this is not always possible. For example, many knee dislocations occur in the context high energy trauma, and as such occur concomitantly with a constellation of other injuries. In these cases, the definitive treatment of the unstable knee is often delayed until more life-threatening issues are dealt with, acute fractures have been definitively managed, local soft tissue has regained homeostasis and wounds have undergone appropriate orthoplastic reconstruction.<\/p>\n

    Therefore, it can occasionally take more than three weeks for the conditions to be met to go ahead with major knee ligament reconstruction. In addition, although we see the high energy injuries acutely, patients with low or ultralow energy knee dislocation patterns are often referred to our team only outside of the acute period for multiple reasons. Hence, perhaps more important than being in either the early or late camp of the debate, is understanding the potential outcomes of early vs. late treatment of knee dislocations.<\/p>\n

    There is a paucity of reliable evidence-based data available to guide our decision making with regards to surgical timing for the definitive treatment of knee dislocations. A review of the literature yields only a few retrospective cohort studies comparing the early and late management of knee dislocations.1-5<\/sup> As a whole, these retrospective studies show a trend towards improved objective measurements, knee Lysholm and IKDC scores and higher sports activity scores on Knee Outcome Survey in the early treatment group. Early surgery has been implicated as a risk factor for arthrofibrosis.6-8<\/sup> One of the studies comparing early and late management of knee dislocations had a higher incidence of postoperative arthrofibrosis in the early treatment group.<\/sup> However, statistically, there were no significant differences found in any of the studies comparing early and late management with regards final ROM or ADLs. All these studies were included in a recent excellent systematic review by Levy et al on the topic of the multiligament injured knee.<\/sup><\/p>\n


    \nFigure 1c.<\/strong> Arthroscopic photograph of ACL and PCL reconstruction.<\/p>\n

    \nThe definition most commonly employed in the literature for describing early and late in terms of surgical timing is three weeks for late treatment. This three-week cutoff is mildly arbitrary and perhaps becoming less definite with more modern operative techniques. In fact, historically, surgery within a three-week period from injury was recommended particularly for the associated posterolateral complex injuries, as it was felt to be the time period when the quality of tissues available for repair was optimal and dissection planes were still easily discernible.<\/p>\n

    However, just as surgical treatment of cruciate injuries has evolved toward reconstruction over repair in most cases, the same evolution may be happening in the treatment of posterolateral corner (PCL) injuries.10<\/sup> Stannard et al recently reported in a level II prospective study that clinical stability was significantly better in cases of acute posterolateral complex reconstruction in comparison with traditional acute repair of the PLC.11<\/sup> In addition, failures were significantly more common in the acute repair group. In fact, 37% of PLC repairs failed compared to 9% of reconstructed PLC. We have also favored reconstruction of the associated lateral and posterolateral injuries in our patients, and thus have put a lesser emphasis on the need to abide by the 21-day cutoff.<\/p>\n

    Although no trial has directly compared open vs. arthroscopic reconstruction, the trend has been toward arthroscopic management of the cruciate injuries. However, when these injuries are dealt with in an arthroscopically assisted manner, a few weeks should be allowed to pass for the associated capsular injuries to heal in order to decrease the risk of iatrogenic compartment syndrome from extracapsular accumulation of arthroscopic fluid. Therefore, arthroscopic management of knee dislocations may be more safely performed late.<\/p>\n

    In conclusion, although we agree with the results of the systematic review by Levy et al that early operative treatment of knee dislocations yields improved functional or clinical outcomes, if surgery is delayed longer than three weeks, the surgeon should not feel that excellent results are unattainable7. Surgical management of knee dislocations yields superior results to nonoperative management irrespective of surgical timing.1,12-14<\/sup><\/p>\n

    Reprinted with permission from the Fall 2009 issue of the COA Bulletin<\/em><\/p>\n

    References<\/h3>\n
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    1. Fanelli GC, Giannotti BF, Edson CJ, 1996. “Arthroscopically assisted combined posterior cruciate ligament\/posterior lateral complex reconstruction.” Arthroscopy 12 (5): 521-30<\/li>\n
    2. Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ, 2004. “Surgical management of knee dislocations.” J Bone Joint Surg Am 86-A (2): 262-73<\/li>\n
    3. Liow RY, McNicholas MJ, Keating JF, Nutton RW, 2003. “Ligament repair and reconstruction in traumatic dislocation of the knee.” J Bone Joint Surg Br 85 (6): 845-51<\/li>\n
    4. Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A, 2006. “Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.” Knee Surg Sports Traumatol Arthrosc 14 (8): 739-49<\/li>\n
    5. Wascher DC, Becker JR, Dexter JG, Blevins FT, 1999 Mar-Apr. “Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts.” Am J Sports Med 27 (2): 189-96<\/li>\n
    6. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH, 1992 Sep-Oct. “Loss of motion after anterior cruciate ligament reconstruction.” Am J Sports Med 20 (5): 499-506<\/li>\n
    7. Mohtadi NG, Webster-Bogaert S, Fowler PJ, 1991 Nov-Dec. “Limitation of motion following anterior cruciate ligament reconstruction. A case-control study.” Am J Sports Med 19 (6): 620-4; discussion 624-5<\/li>\n
    8. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M, 1991 Jul-Aug. “Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation.” Am J Sports Med 19 (4): 332-6<\/li>\n
    9. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG, 2009. “Decision making in the multiligament-injured knee: an evidence-based systematic review.” Arthroscopy 25 (4): 430-8<\/li>\n
    10. Mariani PP, Santoriello P, Iannone S, Condello V, Adriani E, 1999. “Comparison of surgical treatments for knee dislocation.” Am J Knee Surg 12 (4): 214-21<\/li>\n
    11. Stannard JP, Brown SL, Farris RC, McGwin G, Volgas DA, 2005. “The posterolateral corner of the knee: repair versus reconstruction.” Am J Sports Med 33 (6): 881-8<\/li>\n
    12. Fanelli GC, Edson CJ, 2002. “Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up.” Arthroscopy 18 (7): 703-14<\/li>\n
    13. Fanelli GC, Edson CJ, 2004. “Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up.” Arthroscopy 20 (4): 339-45<\/li>\n
    14. Karataglis D, Bisbinas I, Green MA, Learmonth DJ, 2006. “Functional outcome following reconstruction in chronic multiple ligament deficient knees.” Knee Surg Sports Traumatol Arthrosc 14 (9): 843-7<\/li>\n<\/ol>\n

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