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the weed, who it was an ordinary is now consultant. So we'll be talking about knee dislocations. Uh, so we're gonna have a bit of background, A few questions here in the, um, some information about assessment and management. And then, Mr, we will talk more about the sort of surgical approaches, Uh, or how he kind of tackles this issue because he actually does these operations, uh, and then housing cases at the end. So question, first up, So obviously you can come to any. You see this 25 year old man who's fallen off his motorbike? But overall, how common are these knee dislocations? I think looks kindly. Got these polls. Got the pole. And I think these figures are Is this all orthopedic injuries, is it? Yes, overall. All orthopedic. Okay. Okay, That should come up now. Should I look, uh, decide when you want to end it? I think you can just leave it running. It's already got 14 15 people. Let's see what people are saying. Okay. Yeah. So So, Yeah. 70 people responded. Uh, we'll see similar to what Mr Hopkins spoke, So, Yeah, most people 47% of said less than 470.2, and that is correct. Um, I guess the point of this slide straight away, it's just a highlight looking at this bit of epidemiology. First of all, it's It's a really uncommon injury, but it is very significant. And it is one that is talked about the F r C s, uh, trauma bit. Uh, and I know that cause it was the first scenario I had when I did my exam. So just generally, in terms of epidemiology, it's Yeah, that's the 0.2% of all the orthopedic injuries, Uh, roughly 4 to 1 ratio, male to female. And that's probably because, you know, potentially men do more like, Can I say this dangerous things? Uh, with motorbikes, etcetera so potentially they're more like to come in. Um, it is just associated with multiple trauma, and between 14 to 44% and up to 17% based on the literature can be open injuries. And it's 5% of patient's have bilateral injuries. So you know when it does occur, Um, anecdotally, I've only seen one in real life, Um, but when they do occur, you know, they can be in, quite, uh, significantly injured patient's. So I'm not going to go through a lot of anatomy or really that much in from Honest. It's just more to just highlight the fact that obviously you've got your bony articulations, which aren't that congruent in the knee. Uh, you know, we've it allows for sort of eight degrees or so of rotation. Uh, but more importantly, the dissected posterolateral corner there is just to highlight that very important structures, which again commonly you're not injured can get injured in this injury. Uh, and so it's something to be to, to consider and be be aware of, because ultimately it's not just the bones, obviously, into the fractures that can happen. It's more the soft tissue injury, the multi ligament injuries that were concerned about. So yeah, so, as I said, um, roughly 8 to 12 degrees of rotation for it to be a multi multiple ligament injury, you need at least two of the four main ligament stabilizers. So the cruciate in the two collaterals Rarely you do get only one cruciate injured. And as you can see from this table, which I found from a really good summary paper, which I've listed at the end um, you can see that sort of. Most of the injuries are ACL PCL and MCL. So you do have multiple injuries. Uh, and that's something to be aware of and to highlight in the examine, talking through your answers about the fact that you're aware that multiple ligament injuries can occur. So next question. So what percentage of dislocations reduced spontaneously before arrival to E. D. Let's confess what I read this. I write for the exam. And even when I was revising it right now for this talk, I it all surprises me. It really does. Can you really consider it's such a major injury? Cool. So you're 16 people responded so far. Um, so the answer is actually, where is it? Uh, 50%. And, you know, I I honestly probably would have said 10% myself and most people have this. 44% of people have said 10%. So when I first, uh, I was changing, uh, when I first, um, uh, sort of looked at this topic, I thought, Oh, it'll probably be like 1% 10%. You know, most people probably come with your knee, sort of completely separated, but up to 50%. And the significance of that of, of course, is when you come to review a patient, always have the suspicion, your mind based on certain signs, which we'll discuss later on. So mechanism injury. I probably would just separate this out into high energy and low energy. You do get high, low and ultra low, But just be aware that essentially it's, you know, motorbikes falling off buildings from heights, Um, and in fact, motor vehicle accidents and more than 50% of cases. And then you've got your low ultra low, which essentially is sports injuries in the sense that you know, um uh, contact sports, etcetera, but also, uh, morbid obese patient's who can just, for example, be doing daily activities of living. And then they twist and fall down. And that's probably the only other thing. I've only seen one in E. D. And I've only seen one on the ward when I joined a team, and that was probably the only other case I've seen. It was really morbidly obese lady who essentially just was stepped, I think, stepped off a pavement, twisted a knee, and she dislocated it. And that's obviously increasing with the obesity epidemic that we have so and b m I over 40 is considered. It's something worth mentioning as well, because things interesting said the 50% reduced, um upon their own before they present to E. D. So you would have actually seen a lot more than that. So you probably you think you may have seen one true dislocation that's presented as a dislocation, but you've probably seen in clinic or any patient's that have dislocated and spontaneously reduced. Um, both were mentioning Very good point. Yes, exactly. Yeah, absolutely. Um so always bear that in mind. So based on the type So we've discussed the fact. Obviously, these do occur. What is the most common direction? Sorry should say direction of dislocation. So if you guys just put that up, of course, 15 people responded, um, 60 per 62 percent of the posterior and 37 that anterior. So by and large, looking at things I found anterior was considered to be slightly more. Now, the reason why this is important because again, when you're talking in the exam based on the associate injuries, which will touch upon in a bit, um, the direction doesn't matter, so they can ask. You know what is the most common type? So just something to be aware of. Um, you know, for the exam as well. So to the classifying these you can do it sort of time based and anatomically. That's the way I thought of it. When? When the exam. So time is an obvious one is acute recess chronic and by and large in the literature, less than three weeks is considered acute. More than three weeks is chronic and then anatomical, which you guys will definitely be probably more aware of. So first of all this direction of tibial, the tibial travel relative to the femur, and that's the Kennedy and then the number of ligaments injured was this shank. So it's going through these. So Kennedy, first of all, I mean, I think is pretty straightforward, and I would stick with this when looking at radiographs when they present it to you. Just because it's an obvious one that you can real real off. And it's pretty straightforward. It's, you know, where is the tibia relatives? The femur? Um, I'm sure you persistent lows. Weather talks. Just remember, don't start talking about classifications. If you can't real them off in detail because potentially, uh, that will be a sticking point. Um, so as you can see, anterior is sort of up to 50%. Uh, it's not too different between posterior and anterior, but it's up to 50% usually too hyper extension, whereas posterior or more of an axial load to flex nieces such as a dashboard injury. And then you've got your medial lateral, and then don't forget your rotational as well. Um, with the shank, it's to do with the number of ligaments ruptured. And there is a modification, uh, that that does exist. But to keep it simple, if you were asking the exam, which I think is probably the right thing to do, is just talk about okay, Do you want to five. Based on, um, the number of injuries present because you don't wanna get stuck and be able to remember sort of the subgroups so associate injuries. And this is probably one of the most important bits of the entire sort of management of this, because essentially, the knee yes, is dislocated. You're gonna try to reduce it as you would with any fracture or any injury dislocation. It's more about the associated injuries and soft tissue injuries. So number one you have to consider is a popular pill artery. So in terms of in the literature, there's a variation in terms of how common it is. You're looking at 5% or so in low velocity injuries and up to 65% of high, uh, energy injuries. Uh, and it occurs as I'm sure you guys are aware because the popliteal artery is tethered approximately distantly. Um, but remember that, uh, sort of full scenario can occur where you can feel a pulse. And obviously they could ask you, you know, does that mean that the blood supply is absolutely fine? And the answer, of course, is no. Because, um, there's always a chance of collateral flow masking any potential intimal injury in in the in the popliteal artery and then looking in sort of in the literature. Um, as you can see posterior dislocations that have more prevalence of arterial injuries. Uh, and that's an obvious sort of, if you think about it, if you go back to the previous image, so here you can see that obviously comes in my mouth probably because you were the posterior bit. You know, the back of the TV is going to go straight into the into the artery itself, so that's an obvious thing to to say, whereas with anterior, it's more of an intimal tear. Another next thing to consider is a comparing kneeling nerve. So commonly people quote 20% as being it's risk of injury, but it can be up to 45% with a p c. L a posterolateral corner just based on its anatomical location. And then don't forget fractures. So the case I had didn't have any fractures in it when they showed me any imaging. But it's just nothing to be wary of that you kind of up to 16% and it can be quite subtle. So you can either have like a second factor as per that image, which is a capsule avulsion. Or you can even have, which I'll show you later, um, sort of an accurate injury whereby you have an avulsion of the fibula head and then also one thing to remember is other soft tissue injuries. So amongst the knee, you can also have attendant patella tendon rupture, uh, periarticular avulsion and displaced meniscus. So the intra articular side of things is very important. And that's a bearing on your management with which Mr we'd obviously will touch upon. Uh, because with this injury, you don't want to start. You know, it's not a traditional injury where you're going to say, I want to put a scope in straight away and start repairing minusca I because it's obviously high risk of compartment syndrome as well. Um, and then this is just another summary table from the literature just showing that we are roughly, you know, vascular. I would stick with 25% or so 2025 then CPN as well, 20%. So you've got your patient, uh, scenario, you know, they'll show you an X ray or something, and I think with the way I did it was I separated it out into E D management and then surgical definitive management. And if I'm honest with you, the the management leading up to theater is pretty much how much time you'll have to discuss this case. Because that's the key. They want to make sure you're safe when initially managing the ABC aspect of it so The first thing I'll say is, Do not forget because it's very easy to under pressure is the A T. L s aspect. Remember this? First stabilize the patient, then the knee. Uh, many of these patient's, as mentioned before are poly traumas, and you don't want to just go straight to the knee. It's like any trauma scenario. You have to go through your spiel, go through all the basics, and if they just push you along, just, you know, take the Q and just go straight to the need. But you do not forget that I would also highlight. So when I had my case, I straight away said, You know, my immediate concerns are vascular injury. Whether it's open compartment syndrome, um irreducible and unstable is more to do with after the reduction bit. But the top three I would definitely mention early on. And ultimately your management, in a nutshell, is based upon the presentation, the history, the examination of the patient's um, as well as a clinical examination which will be done, most likely a better, uh, just the idea. I think I made a good point. So essentially, it's, uh, you know, it's to pass the station. So if you get this is an exact exam question to pass, you have to get this first. It's right. I think you basically you've got to be able to get the patient worked up and packaged and ready for a new surgeon to become and, you know, devise a ultimate plan in terms of how to reconstruct. So I think if you if you get the first half of this slide right, that'll give you a pass. But what I'll go through and the homes Amigo, too, as well is, um you know how to decide on when and what what to fix? Uh, yes, exactly. No, thanks. Yeah. So it's it's about the basics. And then you know you pretty much when you say that you almost definitely will get to the point of them discussing. Okay, so, you know, how would you approach it surgically, or you know what? Your strategy and that's something which, um will get you the higher marks. So ultimately it's about, you know, in a nutshell. If you said based upon presentation, history examination, clinical examination slash EU a. The MRI finding in an m d. T. Approach because Obviously, if it's an open injury or concerns, you want plastics. There is a vascular injury. You want the vascular surgeons that and then having a multi ligament knee expert, um, present as well, which might also mean referring to your local major trauma center. So putting that together, that will ultimately give you so this slide basically summarizes as an overview what you need to really kind of how you approach the overall assessment and management in the exam, however, in more detail, slightly more detail now. So with history, uh, it's stuff you probably would ask yourselves anyway. But it's just remember history of injury pretty obvious, uh, mechanism, injury timing. Whether sometimes, you know, if it's relocated, someone might try to take some steps because they didn't realize what happens. Uh, then obvious instability because they probably fell back down again, Uh, deformity at any point and any previous surgery. And that picture on the top, right, basically summarizes that key suspicion you have to have. There's actually someone you know. The patient has, um, hyperextension. They're lifting the foot up from the heel, and, um, they're demonstrating obvious subluxation. But, for example, someone might not have an obvious subluxation but have that bruising pattern posture, laterally or laterally, and that is very highly suggestive of potentially a capsule avulsion, uh, and hematoma that you need to be aware of and then and thus have a high suspicion of a of a knee dislocation in terms of examination and obvious thing is gross deformity, whether it's open closed vascular exam, uh, looking for hard signs. So ultimately, I'll show you guys a an algorithm, which essentially is what you need to know for the exam. But the fact is, if you essentially have any of these vascular injury signs, so hemorrhage expanding hematoma, no problem pulses, pallor any obvious ischemia that is basically call vascular and get into theater. In a nutshell. Everything else can be managed, sort of lets us see. Do we need some imaging? Do we not doing to go theater? Do we not? So that's the key. And I think that's those four points, probably something you need to commit to memory, uh, and have in your arsenal when it when planning your management in the exam into the neurologic examination sensorimotor. You guys all know this already. But just as a revision uh, central deficit to lateral leg endorser of the foot for the comparable nerve and instability, inability or weakness and the version endorse reflection, which again they can ask you. They can say, you know, how do you examine for this? The other thing to do is obviously assess the soft tissues and looking for pinched, discolored, attentive skin as demonstrated before. Um, and if you look at the picture on the right, that shows what's called the dimple sign so they could show you this as a separate case. And essentially that is buttonholing of the medial thermal candle through the medial capsule, which is associated with the posture lateral dislocation. And this is basically a Contra indication to a close reduction due to risk of skin necrosis, and you'll need to take this the better. So this is one of the other kind of cases where you see it and think, Okay, we need to escalate this and take it to theta, uh, sooner rather later ligamentous laxity. So it's interesting. When I was reading some papers reviews some people suggest, Oh, you know, when the patient to be sedated in in, uh, any having reduced that you can try to start assessing them. I mean, I don't know how far you'll get with that. And I think in the u A. Um, Mr, we probably can shed more light on this in real life. But anyway, probably is a better option, uh, for that and then obviously never forget, like, pretty much anything. The lower limb check for compartment syndrome. Just have that automatically, um, there on the tip of your tongue and you'd probably say you would want to monitor that for 24 to 48 hours. It, respectively, of how the patient gets treated. Going forward. So reduction. By and large, it's essentially longitudinal traction for posterior desiccation to move the tibia upwards. Uh, and vice versa. For anterior anecdotally, uh, the only posterior one I've ever seen. We kind of flex the knee a bit, took a bit of the pressure off the, uh full of the hamstrings, and then it just reduced a bit more easily, So you probably wanna potentially flex it a bit. And then ultimately you wanna reduce it. Put it in a back slab with 20 degrees of flexion to offload the new vascular structures. And don't forget to say you would cut out windows in the splint because you would want to monitor and check the pulses as well. Um, so with imaging, obviously it's obviously dislocated, so you want to reduce it, and then you will get to radiographs. Now with radiographs the key things to look out for, I guess in what in a patient who potentially doesn't have an obvious deformity is looking for with widening of the medial joint space on the AP film, which could suggest a dislocation power to you know this happening to them arriving story and then also look for fractures such as Second, which I mentioned before, As you can see in the top, right, that picture, which suggests which shows an, uh, fibula head fracture. It's an archaic fracture, which is basically the version of the LCL are accurate ligament complex, um, in terms ct, ct A. So the CT a bit we'll talk about in a bit, uh, when off after going through the algorithm. But a CT might be indicated for cases where you reduced it, you see a fracture and then you want to plan for surgery, and then MRI is the obvious thing which you definitely will need to suggest, uh, simply to assess the soft tissues, uh, multi ligament injuries, um, to plan for operative definitive management. And as you can see, that you saw the picture on the left. First of all, just shows how much disruption there is. How much demand Soft tissue disruption you get with these, uh, with these injury as well as bone breezing, um, and then the one on the right. The arrow basic is pointing to imagination of the soft tissue around the medial condo, so that can cause a blocking. Uh, is this something again to be to be wary of? So if I'm honest with you, this is probably the slide. You guys need to kind of commit to memory, uh, for the initial bit that as Mr we were saying for the exam, we'll get you your pulse. So you've got your case. Okay, Your patient's come in with the knee dislocation and assume you've got a multi ligament with that as well. Um, you wanna immediately reduced? But before, before that, the one thing you definitely will do is do your pulses. So sorry. The one thing that should say is do a quick pulse check before reduce, and then do your pulse check again. Now, by and large, the thinking now is everyone gets an A BP i. And the reason why Because that with your pulses determines where you're going to go next. So if you start from the left, which is sort of the good scenario relatively speaking, um, peripheral pulses are present, they're equal on both sides. Normal re provision and a BP is more than 0.9. You're gonna, you know, provide everything is stable. You know, the knee is not constantly dislocating. You're gonna take them up, admit them and at least 24 hours of observation followed by, uh, sort of further imaging and then referring to a knee surgeon for definitive management. If in the middle scenario, you have peripheral pulse asymmetry, so these are considered soft signs, a normal re profusion or on a PPI of sort of point less than less than 240.0.9, then you're going to want to do some imaging. So the key phrase here, I guess, is something called selective angiography. Um, going on the days now, there's still controversy about this, but most papers and most reading I've done suggest that. Actually. Now you choose a patient for this when relative when necessary. Sorry. Rather than just sort of doing an imaging for everyone. Um, and then your options Pretty much our CT, which to be told is probably the real option, because it's the quickest thing we can quickly get our hands to. It doesn't have the subjectivity that ultrasound duplex would have and then move in. Realistically, when you've got a trauma patient, getting a CT scan is a lot easier, isn't it? Um, And then finally, you've got your case where you've got peripheral pulses are absent or hard signs, which are the four I mentioned before. Ischemia expanding hematoma, hemorrhage, etcetera. Uh, then you're gonna want to contact vascular and consider, um, immediate operative reduction, uh, surgeon exploration with on table artiach arteriography. Now, some places do say that if your imaging potentially on route will not hold you up, you could get it. But I would say probably get the ball rolling, because realistically, in the NHS, getting people to theater takes time, so I probably just quickly get things the ball rolling and get them into a theater for for the aforementioned procedures just for interest. Um, decision algorithm for common peroneal nerve. Don't worry. You don't have to know all of this for the exam. But just to highlight the fact that if you have an incomplete palsy, you know, 80 per 7% apparently reach sort of MRC five out of five. Um, so within eight months or so and similar and 38% for a complete. So, you know, these numbers are worth having just if you want to sort of push the boat a bit, but don't get bogged down by this too much. And so this is the paper I was just referring to before. It's a quite a good paper that pretty much summarizes how to treat up to the point of, um but just before theater Sorry. So in any and this is their summary. Okay, so don't worry. Don't have any. Don't panic about this, but this is kind of covering all eventualities the real bit or the bits and the blue that you need to know. And that's pretty much a summary of what I've just said before. But just to show you that this is within a larger bigger management. And essentially, if you look down to where it says, um, sort of two, that's basically two and then go across to where CT duplexes. That's basically you know, you're a and the management. And then everything else is basically going to theater. And realistically, they will throw in a case where potentially the A BP is fine. And then they'll throw in one where a PPI isn't or they'll go straight to the one that isn't. And just being aware that you need to get vascular and theater, uh, and then do your own table angiography Now the order of what to do again. You know, officially, I guess it's about getting the bypass in first by the vascular team. Then you put your expects, and then they do their repair really anecdotally from people who have spoken to. They kind of say You put the expects on give them the stability in the 20% 20 degrees of flexion along around which they can then do their bit and then vascular do their bit fully. Um, but you know, there is that exam answer as well and then in the actual to the management going forward, you got your plus or powers that can be used definitively or bracing. And that's usually for sort of low demand, medically unfit or, um, anecdotally, you know, very obese Patient's, um, who, I guess, are low demand and who you don't want to, you know, have too many operations for due to increased risk of infections, etcetera, and then your operative management. So there's, uh, firstly, you might need to open reduction. So that's for irreducible means. Posterolateral dislocations open fractures that common, um, common cases, um, and then consider an X Vicks. And that's sitting for vascular repairs, open ones, uh, compartment syndrome. And for those who would say you prophylactically do a fasciotomy as well and then in the polytrauma patient as well. And then finally, it comes down to sort of the whole controversy is. Do you do an early versus late repair? Do you do repair or reconstruction? And this is where the literature is still split. So just cut few papers. Um, this systematic review in injury, which essentially summarize from 2019, which essentially summarize that the best treatment does not really exist. So essentially it's what's best in your hands. They do suggest that reconstruction is better than repair. But I've put the results up there for you guys to have a look at, you know, at a later point if you like. Um, but again, this is again. It shows you that there's a lot of controversy as to what is the best option? Another paper, I think in the exam. If you reach this stage, you've done well. And I think as long as if you if you answer the exam in and tell them Look, there's lots of controversy, they'll then just put their question back to you and say, What would you do? So as long as you have a sensible approach, um, and the way of deciding whether to structural repair and how, um can back it up with you, your experience or evidence, then you'd be fine. Um, but maybe as homes A said at the beginning, just highlight the fact that there's not. There's a consensus exactly into the timing and what to repair and reconstruct. Yeah, absolutely. Uh, this is another paper, for example, in the knee, Um, which was a meta analysis that showed the early intervention, uh, produces superior clinical outcome, but they recognize that the range of motion improvement was pretty minuscule. And actually, if I go back to the previous line, you can see here they suggested an early repair or or early management at least 229 224 degrees. I don't know if a patient would necessarily notice those five degrees, Um and so this paper, I think, suggests that the clinical relevance is quite small. And then finally, another paper, um, which is just was, you know, a multi center study which suggested that repairing, um, an augmenting the ACL and PCL, you know, leads to good results. But early stages and long term results, uh, you know, are still needed. So again, as I said correctly, it's just being aware the exam. And as you guys, I'm sure you guys know already from whilst providing for it. It's they love touching about controversial subjects and having one answer. You know there's not one right answer, and therefore, if you justify or just provide some evidence or suggestions as to why you think what you feel is probably your management, they you know they'll respect it, and as long as you can support it. Fine. So key point, I think from this bit of the talk was one is just remember, it is a rare but significant injury. You know, it will come up in the exam because of the implication of it. Do not forget a TLS. Do not forget vast vascular injuries comparing meal and compartment syndrome. A BP. I sit a for all of them and then suggests elective angio, depending on the A BP r. Result. Do not forget your heart. Vascular signs. Um, and definitive Ortho management is controversial at this point. Cool. So, um, my references, if I could just before Oz takes over, can I just want to do just plug two things? If that can guys, quickly, One is if I can Please. Please, please ask everyone in the beanery or even beyond if anyone here from outside the scenery. If you guys got to scan this, um, and fill in the survey, it's part of a project that Mr McDonnell and I are doing. Um, it's the final survey. Also, get patience to do it. So if you guys have it on your phone and you guys can give the links to patient's get them to do a soft tissue injury. Patient's basically, uh, it's a priority setting partnership. And then, for those of you who aren't but aren't part of Boston but interested in Basta to join, it's only 25 lbs a year, which is literally cheapest chips compared to other, uh, organizations. We're gonna have a category course for trainees and, um, medical students, etcetera in January. The arthroscopy courses Webinar series starting in Feb with the options of fellowship awards. And if you're interested in sports injuries, trauma, etcetera, this is the society for you. So please do join. Who else do you wanna upload? Your side and then That's great. Thanks. Um, so so I think you may have to stop. Okay? Yes. Um, yeah. There we go. That's the one. What's that? Uh, say one thing. Just have it. I guess it should just be down the bottom. I was I was looking some questions here. Um, So Omarosa Miller says even if no pulse reduce, Yes. Absolutely. Omar. Yes, you're right. So if it's if there's no pulse, you do definitely. Sorry. Try to make that clear. Apologies. So yeah. What? Whatever happens, you don't feel it. You've got to reduce it closed and then reassess to make sure. Because if, for example, it comes back, you know, you're potentially your well, stress levels will go down and be the urgency with which we need to go to theater. You know, reduces. But definitely. Sorry. If that wasn't clear, you do definitely to reduce irrespective Lee. Um, and then some messaging. Kate about You'll be okay. Okay, Cool. That's great. I'm just going to stop the recording whilst we get that.