Search

This study aims to evaluate relationships among multiple ligament knee injury (MLKI) patterns as classified according to the knee dislocation (KD) classification and the types of surgical management pursued. We hypothesized that the KD classification would not be predictive of the types of surgical management, and that categorizing injuries according to additional injury features such as structure, chronicity, grade, and topographic location would be predictive of the types of surgical management. This is a Retrospective cohort study. This study was conducted at a level I trauma center with a 150-mile coverage radius. Query of our billing database was performed using combinations of 43 billing codes (International Classification of Diseases [ICD] 9, ICD-10, and Current Procedural Terminology) to identify patients from 2011 to 2015 who underwent operative management for MLKIs. There were operative or nonoperative treatment for individual ligamentous injuries, repair, or reconstruction of individual ligamentous injuries, and staging or nonstaging or nonstaging of each surgical procedure. The main outcome was the nature and timing of clinical management for specific ligamentous injury patterns. In total, 287 patients were included in this study; there were 199 males (69.3%), the mean age was 30.2 years (SD: 14.0), and the mean BMI was 28.8 kg/m 2 (SD: 7.4). There were 212 injuries (73.9%) categorized as either KD-I or KD-V. The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament ( p  > 0.05). Recategorization of injury patterns according to structure, chronicity, grade, and location revealed the following: partial non-ACL injuries were more frequently repaired primarily ( p  < 0.001), distal medial-sided injuries were more frequently treated operatively than proximal medial-sided injuries (odds ratio [OR] = 24.7; p <0.0001), and staging was more frequent for combined PCL-lateral injuries (OR = 1.3; p  = 0.003) and nonavulsive fractures (OR = 1.2; p  = 0.0009). The KD classification in isolation was not predictive of any surgical management strategy. Surgical management was predictable when specifying the grade and topographic location of each ligamentous injury. This is a Level IV, retrospective cohort study., Competing Interests: One or more of the authors have received research funding outside and separate from this work. W.R.L. is a consultant for Arthrex Inc. and DonJoy Orthopaedics. All authors certify that they have no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. R.J.W. was the recipient of the 2017 Young Investigator Award from the Musculoskeletal Transplant Foundation and received textbook royalties from Springer International. No conflicts are reported for the remaining authors., (Thieme. All rights reserved.)

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.

Background: The development of heterotopic ossification (HO) might nullify any benefit of multiple-ligament reconstruction of the knee joint. The purpose of this study was to investigate the incidence and the specific explanatory factors for the development of HO after multiple-ligament reconstruction of the knee joint., Methods: From January 2011 to June 2016, 72 consecutive patients with knee dislocations received multiple-ligament reconstructions, of which 57 (79%) were available for a minimum follow up of 12 months and were included in this study. Anteroposterior (AP) and lateral radiographs were reviewed for all patients. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparisons. In addition, the HO group was divided into three subgroups based on a modified quadrant grading system introduced by the senior author for further evaluation. Multivariate logistic regression analysis was then performed to identify specific explanatory factors predicting development of HO in patients after multiple-ligament reconstructions of the knee joint., Results: Among the 72 consecutive patients, 57 (79%) were available for the clinical evaluations with an average period of 28.4 months (range, 12-51 months). Twenty-one patients (37%) showed radiological evidence of HO. The HO group (n = 21) showed significantly inferior results of knee flexion angle compared with the non-HO group (n = 36) (HO group vs. non-HO group: 124 ± 13° vs. 132 ± 5°; P<0.01). According to the quadrant grading system, there were seven patients with grade I, nine with grade II, and five with grade III HO. Subgroup analysis further revealed that higher HO grade would lead to lower knee flexion angle. In addition, multivariate regression analysis showed that concomitant posterior cruciate ligament reconstruction was the only independent explanatory factor predicting the development of HO after multiple-ligament reconstruction of the knee joint (P=0.018; odds ratio, 8.75; 95% confidence interval, 1.69-39.7)., Conclusion: In this cohort of knee dislocations, the incidence of HO development following multiple-ligament reconstruction was 37%, with grade III HO showing the most inferior range of motion outcome. Moreover, concomitant posterior cruciate ligament reconstruction was the only independent predictor for the development of HO., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty ( p  = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity ( p  = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p  = 0.17), Lysholm score (mean 88.6 vs. 88.8; p  = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p  = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower ( p  = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The knee dislocation is a severe, complex injury that can be difficult to treat and is fraught with complications. The first step in a successful reconstruction of a multiple ligamentous knee injury is gaining an accurate and thorough understanding of the pattern of instability imparted by the injury. Evaluation begins with a detailed review of radiographic and advanced imaging studies followed by a thorough physical examination, often done under anesthesia, in conjunction with dynamic fluoroscopy. Failure to identify and reconstruct a damaged ligament may place undue stress on adjacent structures, resulting in complications and potential failure of the surgical procedure., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Classification systems should enhance communication between providers, facilitate accurate and consistent reporting in the literature, and guide management. However, current classification systems for MLKIs lack sufficient detail to guide clinical management which limit their prognostic value. The purpose of this chapter is to revisit and consider important features of some of the most impactful classification systems developed in the orthopaedic literature and to propose a classification system for MLKIs that may improve communication among providers, facilitate consistent reporting in the literature, and ultimately foster publication of meaningful clinical data., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In this review, we explore the epidemiology and mechanism of multiligament knee injuries (knee dislocation) and their complications, focusing on the morbidity and mortality associated with concomitant vascular injuries. We discuss the various diagnostic and treatment algorithms in use today and finish the report with a brief case example to outline these principles., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee., (Copyright © 2018 Elsevier Inc. All rights reserved.)

"KDIV ligamentous injuries of the knee are frequently high-energy injuries with significant soft tissue disruption, gross knee instability, and rarely are treated nonoperatively. KDIVs frequently require external fixation, but when presenting in an isolated fashion can be reconstructed in one setting. Five presentations of KDIV injury are described: closed with multitrauma/closed head injury requiring external fixation, irreducible KDIV requiring semi-emergent open reduction and repair, isolated KDIV without arterial injury undergoing 4-ligament reconstruction after regaining motion, KDIV with varus and slight thrust undergoing medial opening osteotomy before ligament reconstruction, and KDIV with failed ligaments requiring revision and posterior tibial tendon transfer.", (Copyright © 2018 Elsevier Inc. All rights reserved.)

Multiligament knee injuries remain a challenge for the treating surgeon and little is known about the injury patterns and factors determining clinical and gait outcomes after multiligament knee reconstruction (MLKR). This article aims to identify specificities of this complex injury, in terms of demographics, mechanisms of injury, injury pattern, and associated lesions. The time frame between injury and surgery and distribution of repair versus reconstruction procedures have been analyzed. This study reports functional and clinical outcomes, providing an overview of expected results. Using motion capture gait analysis, knee kinematics and gait characteristics of MLKR patients have been assessed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period., Hypothesis: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria., Material and Methods: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type., Results: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III., Conclusion: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment., Level of Evidence: IV, single-center retrospective series., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Introduction: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis., Material and Methods: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability., Results: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees., Conclusion: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK., Level of Evidence: IV, single-center retrospective series., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Knee dislocation is a rare injury. It represents less than 0.2% of orthopaedic injuries. This case reports a rare form of knee dislocation caused by the impact of a high-energy trauma. In these cases the appropriate assessment and management is needed to ensure that patient receives the proper treatment.

Knee dislocations are catastrophic injuries that demand emergent evaluation and often require a multidisciplinary approach. Long-term outcome studies are relatively scarce secondary to the variability in any given study population and the wide variety of injury patterns between knee dislocations. Multiple controversies exist with regard to outcomes using various treatment methods (early vs late intervention, graft selection, repair vs reconstruction of medial and lateral structures, rehabilitation regimens). Careful clinical evaluation is essential when knee dislocation is suspected., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: This imaging-based article systematically reviews traumatic knee dislocations. After completion, the reader should be familiar with the definition, epidemiology, cause, and classification schemes associated with these injuries, as well as the importance of timely diagnostic imaging and an accurate, detailed description of findings, particularly as it relates to MRI interpretation. Finally, information our orthopedic surgical colleagues consider critical for the preoperative planning and reconstruction of the multiple ligament knee injury will be discussed., Conclusion: Although uncommon, traumatic knee dislocations are an important potentially limb-threatening injury, which if not emergently recognized and appropriately managed, can result in significant patient morbidity, joint dysfunction, chronic pain, and long-term disability. A radiologist familiar with the imaging appearance and potential neurovascular complications associated with these injuries can play an integral role in the multidisciplinary team that manages this increasingly recognized clinical entity.

Introduction: Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution., Patients and Methods: From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months)., Results: Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant., Conclusion: The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Multiple ligament injuries of the knee are rare, and severe injuries are often present following a knee dislocation. Appropriate initial evaluation and management is of critical importance for maximizing the potential outcome and avoiding disastrous consequences associated with these difficult injuries. While many of these injuries present acutely in an emergency department or clinic, presentation on a delayed basis is not uncommon. Injuries can present in a variety of situations, such as an isolated knee injury in an athlete or as part of a multisystem-injured trauma patient. In this publication, we review the etiology, classification, and comprehensive initial evaluation of the acute and chronic multiple-ligament injured knee.

Combined posterior cruciate ligament, anterior cruciate ligament, and lateral-side disruption is one of the more common patterns of multiligament knee injury. This is a devastating injury with significant long-term functional sequelae, making accurate diagnosis and management extremely important. While surgical intervention is necessary to restore function, the specific management strategies remain controversial. This article will review the current literature and the authors' preferred approach including physical examination, imaging, timing of surgery, surgical technique, and postoperative rehabilitation.

Multiple-ligament injured knees resulting from knee dislocations are uncommon but serious injuries. These injuries can present to the emergency room acutely or in clinic on a delayed basis, but regardless of the setting they require a complete and detailed assessment to evaluate the extent of the injury. Complicating the diagnosis of a knee dislocation is the fact that acute knee dislocations often spontaneously reduce or are reduced by paramedics in the field before evaluation by a physician. In most cases, pain in the knee, a large knee effusion, and swelling of the effected limb are the only signs and symptoms of a knee dislocation. Quick and accurate assessment of these injuries is required to determine the presence of any limb threatening arterial injuries. In this chapter, we present the complete assessment of acute and chronic multiple ligament knee injuries.

An acute knee dislocation is an uncommon injury, with a high rate of associated vascular and neurologic injuries as well as potentially limb-threatening complications. High-energy trauma is the most common cause of an acute knee dislocation, although lower-energy injuries, such as those sustained during athletic competition, are increasing in incidence. Injuries to the popliteal artery and common peroneal nerve are relatively common, requiring a high index of suspicion and complete neurovascular examination in a timely fashion. All cases of suspected knee dislocation should have an ankle-brachial index performed, reserving arteriography for those with an abnormal finding. Initial management consists of closed reduction, if possible, and application of a hinged brace or external fixator. Definitive management remains an area of controversy, although anatomic surgical repair or reconstruction is favored by most surgeons to help optimize knee function. Most patients treated for a knee dislocation can expect to return to their daily activities, but with less predictable returns to sporting activities.

Knowledge of the mechanisms of bicruciate lesions and dislocation of the knee enables analysis and classification in terms of injuries' location and type, guiding surgery and facilitating assessment. Careful history taking and clinical examination shed light on the mechanism involved, but exact identification of the lesion further requires examination under anesthesia and static and dynamic X-rays and MRI, which together enable precise determination of lesion type and location. There are two types of mechanism: gaping, causing ligament tear; and translation, causing detachment. When a single mechanism is involved, the lesion is said to be "simple". Simple gaping causes bicruciate lesions without medial, lateral or posterior dislocation. Simple translation causes pure anterior or posterior dislocation. Gaping and translation may also occur in combination, causing dislocation with peripheral tearing. There are two types of classification: descriptive, based on X-ray findings--i.e., static classification; and physiopathological, based on clinical and dynamic X-ray findings. MRI further explores ligament detachment and bone lesions that are inaccessible to clinical and conventional X-ray examination. Physiopathological assessment-based techniques enable surgical procedure to be refined, defining the surgical approach according to lesion location and differentiating between lesions requiring repair (tears) and those with a good likelihood of spontaneous healing (capsuloperiosteal detachment). The classification advocated here is largely inspired by that of Neyret and Rongieras, extended to include dislocation with single bicruciate ligament lesion. It covers peripheral lesions completely, specifying type (tear or detachment) and including all bicruciate lesions as well as dislocations.

While it is generally accepted that most partial and isolated medial collateral ligament (MCL) injuries can be treated non-operatively, ideal treatment of the MCL in multi-ligament knee injuries remains controversial. High failure rates with repair of the posterolateral corner in the multi-ligament injured knee have been recently reported, favoring reconstruction instead. The same maybe true for MCL injuries, however evidence-based treatment recommendations are lacking in the current orthopedic literature. The purpose of this study was to perform an evidence-based systematic review of the operative management (repair and/or reconstruction) of the MCL in the setting of multi-ligament knee injuries. A comprehensive search of MEDLINE and the Cochrane databases for all relevant articles published in English from 1978 to 2008 on the outcomes of surgical management (repair and/or reconstruction) of the MCL in the setting of combined ligament injuries was performed. Inclusion criteria included articles published in (1) English, (2) on human subjects, (3) between the years of 1978 and 2008, (4) had minimum 12-month follow-up, with a mean of at least 24 months, (5) on surgical management of MCL injuries, (6) associated with multi-ligament injuries (three or more ligaments) and/or knee dislocation, and (7) reported objective outcome data on the respective patient cohorts. Exclusion criteria consisted of technique papers, case reports, studies that included fractures associated with MCL injury and those that included pediatric patients. The review identified eight relevant studies. Five articles focused on MCL repair, while three articles focused on MCL reconstruction. No prospective studies compared MCL repair or reconstruction with non-operative treatment or directly compared MCL reconstruction with MCL repair. Currently there is a paucity of objective data on the outcomes regarding surgical management of MCL tears in the combined ligament injured knee. This systematic review demonstrated satisfactory results in both repair and reconstruction groups. Future objective outcome-based studies as well as comparative studies are needed to further evaluate the optimal treatment modality before evidence-based recommendations can be made. Therefore, individual treatment decisions for each patient should be based on the characteristics and nature of the injury.

Traumatic dislocation of the knee is among the most severe form of ligament injury to the lower extremity. While the incidence of knee dislocations is low, this injury is associated with a high rate of complications including amputation. There is potential for a traumatic knee dislocation to present to the emergency department after spontaneous or in-field reduction. This requires a vigilant, comprehensive, and systematic approach to the injured knee and extremity to avoid limb-threatening oversights. At the University of Pittsburgh a comprehensive algorithm has been developed to facilitate accurate and efficient diagnosis and treatment of complex traumatic knee injuries. The following manuscript includes a detailed review of the literature and explains our specific approach to this diagnostic dilemma.

Despite the recent focus on the limited use of urgent arteriograms in the evaluation of acute knee dislocations, physical examination remains the cornerstone of assessment. Several clinical scenarios dictate an orthopedic emergency: vascular disruption, open wound, compartment syndrome, or an irreducible joint/dimple sign. In the acute setting, every attempt should be made to rule out associated injuries and the need for intervention. The multiple ligament knee injury or knee dislocation is a complex dilemma that requires close attention. Concomitant injuries about the knee often arise and must be addressed prior to ligamentous repair, and therefore the orthopedic surgeon must maintain a high index of suspicion for associated injuries in the evaluation of a multiple ligament knee injury.

Knee dislocations are rare but devastating injuries. The ACL-PCL-lateral side injury combination is representative of the challenges these injuries present. Early management is focused on vascular integrity. When possible, acute repair and reconstruction within 3 weeks from injury is preferred. Chronically deficient knees generally will require lateral side reconstruction rather than repair and may require limb realignment. Addressing all injured structures is imperative to afford the best chance at a reasonable outcome. Good results with surgery are possible, but some degree of persistent disability is to be expected.