Abstract
Purpose
The purpose of this study was (1) to describe a staged protocol for management of the dislocated knee and (2) to describe clinical and functional outcomes for patients who received initial spanning external fixation as part of this protocol.
Method
Nine knees in 9 patients, consisting of 6 males and 3 females, mean age 30.4 (range 19–44) years with diagnosis or presumption of knee dislocation were treated with a protocol of stabilization with external fixator. Mean follow-up was 24 (range 13–42) months. Indications for spanning external fixation included significant vascular injury, gross instability on examination with failure to maintain joint reduction, open knee dislocation, inability to tolerate mobilization in a brace. The standard protocol involved vascular examination including ankle-brachial index, ligamentous examination (under anesthesia when applicable), stabilization with temporary joint spanning external fixator, thromboprophylaxis, reconstructive knee surgery, and standard rehabilitation.
Results
Mean range of motion (ROM) was 97.4° (range 80°–150°, SD 20.75, median 127.5). Median IKDC score was 80 (range 30–95), and mean Lysholm score was 76.7 (range 46–95). Heterotopic ossification (HO) was noted in 4 knees (44%).
Conclusion
The treatment algorithm utilized in this series for management of the dislocated knee demonstrated satisfactory clinical and functional outcomes. This staged protocol provides a management option for those patients who may be best served with initial spanning joint external fixation. Larger prospective studies are needed to fully understand the merit of staged protocols in this setting.
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References
Almekinders LC, Dedmond BT (2000) Outcomes of the operatively treated knee dislocation. Clinic Sports Med 19:503–518
Bonnevialle P, Chaufour X, Loustau O, Mansat P, Pidhorz L, Mansat M (2006) Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 14 cases. Rev Chir Orthop Reparatrice Appar Mot 92:768–777
Bonnevialle P, Pidhorz L (2006) Dislocation and fractures around the knee with popliteal artery injury: a retrospective analysis of 54 cases. Rev Chir Orthop Reparatrice Appar Mot 92:508–516
Chhabra A, Cha PS, Rihn JA, Cole B, Bennett CH, Waltrip RL, Harner CD (2005) Surgical management of knee dislocations. J Bone Joint Surg Am 87(Suppl 1):1–21
Collins D, Barnes C, McCowan T, Nelson C, Carver D, McAndrew M, Ferris E (1992) Vena caval filter use in orthopaedic trauma patients with recognized preoperative venous thromboembolic disease. J Orthop Trauma 6:135–138
Darmanis S, Papanikolaou A, Pavlakis D (2002) Fatal intra-operative pulmonary embolism following application of an Esmarch bandage. Injury 33:761–764
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ (2005) Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 19:448–455
Fanelli G, Gianotti B, Edson C (1996) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy 12:5–14
Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2–10 year follow up. Arthroscopy 18:703–714
Fanelly GC, Orcutt DR, Edson CJ (2005) The multiple ligament injured knee: evaluation, treatment, and results. Arthroscopy 21:471–486
Frassica FJ, Sim FH, Staeheli JW et al (1991) Dislocation of the knee. Clin Ort Relat Res 263:200–205
Giannoulias CS, Freedman KB (2004) Knee dislocations: management of the multiligament-injured knee. Am J Orthop 33:553–559
Haidukewych G, Sems SA, Huebner D, Horwitz D, Levy B (2007) Results of polyaxial locked-plate fixation of periarticular fractures of the knee. J Bone Joint Surg Am 89:614–620
Ibrahim SA (1999) Primary repair of the cruciate and collateral ligaments after traumatic dislocation of the knee. J Bone Joint Surg Br 81:987–990
Kendall RW, Taylor DC, Salvian AJ, O’Brian PJ (1993) The role of arteriography in assessing vascular injuries associate with dislocation of the knee. J Trauma 35:875–878
King J, Cerynik D, Blair J, Harding S, Tom J (2009) Surgical outcomes after traumatic open knee dislocation. Knee Surg Sports Traumatol Arthrosc 17:1027–1032
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 25:430–438
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 17:197–206
Levy BA, Zlowodzki MP, Graves M, Cole PA (2005) Screening for extermity arterial injury with the arterial pressure index. Am J Emerg Med 23:689–695
Liow RY, McNicholas MJ, Keating JF, Nutton RW (2003) Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br 85:845–851
Lysholm J, Gillquist J (1982) Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 10:150
Mills W, Tejwani N (2003) Heterotopic ossification after knee dislocation: The predictive value of the injury severity score. J Orthop Trauma 17:338–345
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 56:1261–1265
Montgomery I, Savoie F, White J, Roberts T, Hughes J (1995) Orthopedic management of knee dislocations. Comparison of surgical reconstruction and immobilization. Am J Knee Surg 8:97–103
Norwood S, McAuley C, Berne J, Vallina V, Kerns D, Grahm T, McLarty J (2001) A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients. J Am Coll Surg 192:161–167
Noyes FR, Berrios-Torres S, Barber-Westin SD, Heckmann TP (2000) Prevention of permanent arthrofibrosis after anterior cruciate ligament reconstruction alone or combined with associated procedures: a prospective study in 443 knees. Knee Surg Sports Traumatol Arthrosc 8:196–206
Richter M, Lobenhoffer P (1998) Chronic posterior knee dislocation: treatment with arthrolysis, posterior cruciate ligament reconstruction and hinged external fixation device. Injury 29:546–549
Rios A, Villa A, Fahandezh H, de Jose C, Vaquero J (2003) Results after treatment of traumatic knee dislocation: A report of 26 cases. J Trauma 55:489–494
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 25:232–242
Schwarcz T, Quick R, Minion D, Kearney P, Kwolek C, Endean E (2001) Enoxaparin treatment in high-risk trauma patients limits the utility of surveillance venous duplex scanning. J Vasc Surg 34:447–452
Sems S, Levy B, Herrera D, Templeman D, Dajani K (2009) Incidence of Deep Venous Thrombosis After Temporary Joint Spanning External Fixation for Complex Lower Extremity Injuries. J Trauma Injury Infect Crit Care 66:1164–1166
Shapiro M, Freedman E (1995) Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation. Am J Sports Med 580-587
Shelbourne K, Porter D, Clingman J, McCarroll J, Rettig A (1991) Low-velocity knee dislocation. Orthop Rev 20:995–1004
Simonian PT, Wickiewicz TL, Hotchkiss RN, Warren RF (1998) Chronic knee dislocation: reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med 26:591–596
Stannard J, Wilson T, Sheils T, McGwin G, Volgas D, Alonso J (2002) Heterotopic ossification associated with knee dislocation. Arthrosc J Arthrosc Relat Surg 18:835–839
Stannard JP, Sheils TM, McGwin G, Volgas DA, Alonso JE (2003) Use of a hinged external knee fixator after surgery for knee dislocation. Arthroscopy 19:626–631
Stuart MJ (2001) Evaluation and treatment principles of knee dislocations. Oper Tech Sports Med 9:91–95
Subasi M, Cakir O, Kesemenli C, Arslan H, Necmioglu S, Eren N (2001) Popliteal artery injuries associated with fractures and dislocations about the knee. Acta Orthop Belg 67:259–266
Walker D, Hardison R, Schenck R (1994) A baker’s dozen of knee dislocations. Am J Knee Surg 7:117–124
Wang CJ, Chen HS, Huang TW, Yuan LJ (2002) Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury 33:815–821
Wascher D, Becker J, Dexter J, Blevins F (1999) Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation: results using fresh-frozen nonirradiated allografts. Am J Sports Med 27:189–196
Wright D, Covey D, Born C, Sadasivan K (1995) Open dislocation of the knee. J Orthop Trauma 9:135–140
Yeh W, Tu Y, Su J, Hsu R (1999) Knee dislocation: treatment of high-velocity knee dislocations. J Trauma 46:693–701
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Levy, B.A., Krych, A.J., Shah, J.P. et al. Staged protocol for initial management of the dislocated knee. Knee Surg Sports Traumatol Arthrosc 18, 1630–1637 (2010). https://doi.org/10.1007/s00167-010-1209-y
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DOI: https://doi.org/10.1007/s00167-010-1209-y