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Management of knee dislocations Fahad Siddique Hossain Consultant Sports and Arthroplasty Knee Surgeon Director of Research and Development Walsall Healthcare NHS Trust United Kingdom• No conflicts of interest Objectives • Review assessment and management for day one orthopaedic consultant • Discuss recent literature on definitive management• Potential for ischaemia and limb loss independent of mechanism and energy • Average rate of popliteal artery injury 16% (1.6 to 40%) • 20% amputation rate associated with vascular injury in knee dislocation – LEAP study Epidemiology • Extremely rare! – 2-29 per million orthopaedic injuries • Up to 50% self reduce before formal assessment • Predominantly young population – Male:Female 4:1 Aetiology High Energy Injuries • – 50 % of all knee dislocations – Crush injuries, RTA etc • Low Energy Injuries – Third of knee dislocations – Sports injuries and falls • Ultra low Energy Injuries – BMI greater than 48 – Normal ADLs Classification • Kennedy et al. 1963 – Anterior – Posterior – Lateral Medial – – Rotatory (anteromedial and anterolateral) • Difficult to apply in clinical situationSchenk et al. 1999 Clinical Assessment • ATLS protocol in the setting high energy/multiple trauma • Then focus on knee – Ensure perfusion, reduction and stabilization – Grossly deformed – Medial puckering of skin • Invaginated capsule – Swelling and haemoarthrosis not always present Vascular Injury Up to 40% may have concomitant arterial injury • Hard signs – Pallor, coolness – Pulsatile haematoma Delayed capillary refill – – Absent distal pulses semitendinosus 3 2 1 8 Biceps Semimembranosus femoris 9 10 Lat. Gastroc Med. Gastroc 4 7 5 11 6 Vascular Assessment • Arteriogram is gold standard – Modern non invasive methods such as CT Arteriogram • No consensus on indications or when after knee dislocation • In all casesvs cases with hard signs of ischaemia Current Thinking! • Latent period of vascular injury – Non – flow limiting arterial lesion in acute post reduction period – Delayed progression of intimal tear – Secondary ischaemia from thrombosisSelective Arteriography Protocol Clin J Sport Med 2009;19 [2]:125-129 Nerve Injury • Up to 40% of cases –Common peroneal nerve most common –Usually traction related injury Nerve Injury • Up to 40% of cases –Common peroneal nerve most common –Usually traction related injury • Suspect LCL and PLC injury– Foot drop requiring orthosis to prevent equinus contracture – Exploration and neurolysis if no improvement by time of definitive treatment – If no evidence of nerve continuity by 3 months than surgery Initial Management • Reduce (often closed) – Up to 50% present after spontaneous reduction • Immobilise • Reassess Irreducible joint • Buttonhole of MFC through MCL • Compromised medial skin with pinching • May require open reductionDefinitive Management• Surgery better than non operative treatment Improved Tegner, Lysholm and IKDC score after surgery – – Higher rate of return to sport and work • Repair vs Reconstruction – not clear! – Similar Lysholm and Tegner Scores – Higher failure rate in PLrepair – Better return to sport after reconstruction (similar rates of return to work)• Early surgical intervention better than delayed – Cut off 3 weeks • Tissue planes can be identified • Allows easy re-approximation and suture placement – Higher Tegener Lysholm and IKDC score with early surgery – Higher rate of return to sports• No difference between early and late surgery in Schenck Type 3+ injuries Staged surgical treatment yields best functional • outcomes (79.1% vs 58.4% with excellent or good scores) Summary • Rare Injury • High Index of suspicion • High rate of associated neurovascular injury • Initial treatment – ATLS – Reduce and re-perfuse – Restrict – Reassess • Plan definitive managementThank you