WHERE WE WERE 25 YEARS AGO
Knee dislocations were initially managed nonsurgically with cast treatment, and early reports indicated reasonable outcomes. Several reports compared surgical to nonsurgical treatment of knee dislocations, and indicated the surgical treatment provided a more stable and functional knee. Advancements in procurement and sterilization of allograft tissue, improved arthroscopic surgical instruments, better graft fixation methods, improved surgical techniques, and improved understanding of ligament anatomy and biomechanics of the knee ushered in the surgical treatment of posterior cruciate ligament (PCL)-based multiple ligament knee injuries and knee dislocations.1
WHERE WE ARE TODAY
Today, we recognize that knee dislocations and PCL-based multiple ligament injured knees are often part of a multisystem injury complex involving knee ligaments, blood vessels, skin, nerves, fractures, head injuries, and other organ system trauma, and these other system injuries will affect knee dislocation treatment and the outcomes of that treatment.2,3
The incidence of arterial injuries in knee dislocations is variable, but what is critical to understand is that the incidence of arterial injuries in bicruciate ligament tears is the same as knee injuries presenting as tibiofemoral knee dislocations.4 Vascular evaluation of acute knee dislocations includes physical examination and an ankle brachial index. Asymmetrical pulses or an ankle brachial index <0.9 require advanced arterial imaging studies.5 Arterial and venous ultrasound is also helpful to evaluate for arterial intimal flap tears and posttraumatic deep venous thrombosis. Peroneal nerve injuries occur in knee dislocations and may contribute to poor outcomes. Treatment of peroneal nerve injury includes peroneal nerve decompression, nerve grafting, direct nerve transfer, and posterior tibial tendon transfer.6
Correct diagnosis and treatment of the multiple planes of instability in knee dislocations and the multiple ligament injured knee is essential for successful outcomes. PCL and anterior cruciate ligament injuries will result in increased anterior posterior laxity. Medial and lateral side injuries will result in valgus, varus, and axial rotation instability patterns. Examination of the injured knee under anesthesia combined with fluoroscopy compliments magnetic resonance imaging studies, and enables the surgeon to identify the multiple planes of instability.7–9 Spanning external fixation is useful preoperatively in the treatment of open knee dislocations, following vascular repairs, and with the inability to maintain reduction. Postoperatively, external fixation can also be used to protect the knee ligament reconstructions.10–13
Surgical timing in the acute knee dislocation/PCL-based multiple ligament injured knee is dependent upon the vascular status of the injured extremity, the medial and lateral side injury severity, and the degree of instability and reduction stability. Delayed reconstruction of 2 to 3 weeks when possible or staged reconstruction results in less postoperative motion loss. The author’s preferred approach is a single stage procedure within 2 to 4 weeks of the initial injury. Ideal surgical timing may not be possible secondary to vascular injuries, irreducible dislocations, open injuries, skin condition, extensor mechanism disruption, reduction stability, fractures and articular surface injuries, other orthopedic injuries, head trauma, and other system injuries.2,14
Surgical reconstruction using allograft and autograft tissue are both successful in PCL and multiple knee ligament reconstruction with no statistically significant difference between allograft and autograft tissue in acute and chronic cases evaluated with arthrometer, stress radiography, and 3 different knee ligament rating scales with long-term stability retained 22 years postoperatively.15–23 Posterolateral and posteromedial primary repair with allograft or autograft augmentation/reconstruction provides better success than primary repair alone in the multiple ligament injured knee.3,22,23
Arthroscopic single bundle and double bundle transtibial PCL reconstruction and tibial inlay PCL reconstruction are both successful surgical techniques in the PCL-based multiple ligament injured knee and knee dislocations. Elements contributing to successful PCL reconstruction in the multiple ligament injured knee include correction of all planes of instability, strong graft material, accurate tunnel placement with functional graft insertion sites, minimize graft bending, mechanical graft tensioning, secure fixation, and the appropriate postoperative rehabilitation program.24–30 Posterolateral reconstruction is successfully accomplished with a fibular head–based figure of 8 posterolateral reconstruction using allograft or autograft combined with a lateral posterolateral capsular shift or primary repair. A second graft through the proximal tibia is utilized when there is hyperextension (positive heel lift off test), proximal tibia fibula joint disruption, or revision posterolateral reconstruction. Posteromedial reconstruction is accomplished with posteromedial capsular shift or primary repair combined with allograft or autograft augmentation. Screw and washer or socket fixation techniques may be used for both posterolateral and posteromedial reconstructions. The author prefers screw and washer fixation because of the ability to adjust tension.31–36
PCL-based multiple ligament knee injuries and knee dislocations occur in children and adolescents. The procedure is determined by the stage of physeal development. Patients with closed or nearly closed growth plates may be treated as adults. In patients with open growth plates, no fixation device should cross the physis. Adherence to these principles leads to successful functional outcomes with no growth arrest or angular deformity.37–39
Postoperative rehabilitation of the multiple ligament injured/dislocated knee includes slowly progressive range of motion, weight bearing, strength, and proprioceptive skills training with return to unrestricted activity at the end of postoperative month 12 when symmetrical strength, proprioceptive skills, and range of motion have been achieved. Each patient must be carefully observed and the rehabilitation program must be individualized to the patient.29,30
Outcomes of surgical treatment of PCL-based multiple ligament reconstructions and knee dislocations demonstrate allograft and autograft tissue are both successful with no statistically significant difference between allograft and autograft tissue in acute and chronic cases evaluated with arthrometer, stress radiography, and 3 different knee ligament rating scales with long-term stability retained 22 years postoperatively.15–21 Mechanical graft tensioning improved the posterior drawer from 46% normal to 87% normal in PCL reconstructions in knee dislocations.40 Both single bundle and double bundle PCL reconstructions are both successful in PCL-based multiple ligament knee reconstructions with no statistically significant difference in acute or chronic knees, static stability, and return to preinjury level of function.25 There is a 23% to 30% rate of degenerative joint disease following multiple ligament reconstruction even with achievement of stability.19,20 PCL-based multiple ligament reconstruction outcomes in patients 18 years of age and younger show return to preinjury level or 1 Tegner grade lower level of function in 82% in the PCL collateral group and 75% in the knee dislocation group with no growth arrest or angular deformity with up to 17-year follow-up.37–39
WHERE WE WILL BE IN THE FUTURE
The goal for the future will be to diminish the incidence of posttraumatic arthrosis in surgically treated knee dislocations and the PCL-based multiple ligament injured knee. This will occur through improvement of surgical procedures and graft types to more accurately restore the normal biomechanics of the knee.
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