Knee Dislocation Surgery 

  • Author: John R Green III, MD; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: May 1, 2012
 

Background

Knee dislocations are uncommon. A knee dislocation is defined as complete displacement of the tibia with respect to the femur, with disruption of 3 or more of the stabilizing ligaments.[1, 2] Small avulsion fractures from the ligaments and capsular insertions may be present.

An image depicting a knee dislocation can be seen below.

Knee dislocations. Lateral radiograph of anterior Knee dislocations. Lateral radiograph of anterior knee dislocation.
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Epidemiology

Frequency

The Mayo Clinic recorded 14 knee dislocations during an interval of 2 million admissions.[3] The largest reported series of knee dislocations is from Los Angeles County Hospital, where 53 knee dislocations were reported over a 10-year period. The true incidence of knee dislocations is higher than reported because as many as 50% of knee dislocations spontaneously reduce before patients present to the emergency department.

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Etiology

Most knee dislocations are the result of high-energy injuries, such as motor vehicle or industrial accidents. They also can occur with low-energy injuries, such as those that occur in sports. The reported mechanisms of injury are variable, but the most common are motor vehicle accidents (50-60%), followed by falls (30%), industrial-related accidents (3-30%), and sports-related injuries (7-20%).

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Pathophysiology

Multiple ligament injuries are required for knee dislocation. Generally, both cruciates and one or both collateral ligaments are injured. However, knee dislocations have been described with one of the cruciates intact. It is important to evaluate the competence of each ligament and to consider the possibility of a knee dislocation in knees with 3 or more ligaments torn. Vigilance is required because of the high incidence of neurovascular injuries associated with knee dislocation (vascular injuries 5-79%, nerve injuries 16-40%).

Classification

The 5 types of knee dislocations, based on the direction of tibial displacement, are anterior, posterior, medial, lateral, and rotational.[4] An anterior knee dislocation usually results from a hyperextension injury to the knee that initially tears the posterior structures and drives the distal femur posterior to the proximal tibia. A posterior knee dislocation usually results from a direct blow to the proximal tibia that displaces the tibia posterior to the distal femur. Valgus forces cause medial dislocations. Varus forces cause lateral dislocations of the knee.

Rotational or rotatory dislocations are the result of indirect rotational forces, usually caused by the body rotating in the opposite direction of a planted foot. Rotatory dislocations can be of 4 different types, named for the direction of the displaced tibial plateau. For example, posterolateral rotatory dislocation describes a posterior position of the lateral tibial plateau and is the most common rotatory dislocation reported.

Knee dislocations can also be classified as open or closed and as reducible or irreducible.

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Presentation

In isolated knee dislocations, patients are usually able to describe the mechanism of injury and the intense pain associated with dislocation. Since many of these injuries are high-energy motor vehicle collisions, evaluation for life-threatening injuries is the first priority.[5]

In the secondary survey, evaluation of the limb usually reveals an obvious deformity of the knee. The appearance of knee dislocations may be less dramatic in individuals who are obese. The limb should be examined thoroughly for pulses, capillary refill, sensation, and motor strength. Vascular compromise may present as a stocking-glove type distribution of hypesthesia or anesthesia, decreased capillary refill, cyanosis, and poikilothermia.[6] Distal pulses may be absent, and an expanding hematoma, bruit, or thrill may be present in the popliteal fossa.

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Indications

Emergent vascular surgery is indicated for dysvascular limbs (see Postreduction assessment, Medical therapy).

For indications for surgical repair of ligament avulsions, see Surgical options, Surgical therapy.

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Relevant Anatomy

Knee anatomy relevant to dislocations is related to the 4 main ligament and neurovascular structures. The anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and posterolateral corner (lateral collateral ligament [LCL], arcuate complex, popliteus, and biceps femoris) together with the joint capsule are responsible for knee stability.[1]

Knee dislocation requires injury to at least 3 of the 4 main ligaments. The popliteal artery is relatively fixed proximally as it exits a fibrous tunnel at the level of the adductor hiatus, enters the popliteal space, and then is again tethered distally under the soleus. When the knee dislocates, the popliteal artery is stretched and vulnerable to injury. Popliteal artery injury occurs in up to 53% of patients with knee dislocations. The peroneal nerve is tethered as it winds around the fibular neck. With knee dislocation, the peroneal nerve is at risk. Peroneal nerve injury may occur in up to 23% of patients with knee dislocations. Nearly one half of the patients with peroneal nerve injuries have a permanent deficit.[7]

Fractures about the knee are fairly common in knee dislocations. These can be severe periarticular fractures, commonly tibial plateau fractures or ligamentous and tendonous avulsion fractures.[8] Few data exist on the true incidence of these fractures, as many reports do not mention them. One unpublished study noted a 35% (8 of 23 cases) incidence of fractures associated with high-velocity knee dislocations (Owens, unpublished data, 2003). The presence of the fracture may alter management and require supplemental bony fixation or may allow ligamentous repair versus reconstruction.

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Contraindications

Nonsurgical management is recommended in patients who have low functional demands or cannot cooperate with postoperative rehabilitation, such as those with significant closed head injuries (see Nonsurgical management, Medical therapy).

Knee arthroscopy is contraindicated within 2 weeks of knee dislocations because capsular tears cause fluid extravasations into the leg that may result in compartment syndrome (see Surgical therapy).

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Contributor Information and Disclosures
Author

John R Green III, MD  Associate Professor, Chief of Sports Medicine, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center

John R Green III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Southern Medical Association, Southern Orthopaedic Association, and Washington State Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Cambize Shahrdar, MD  Gratis Professor, Department of Orthopedic Surgery, Louisiana State University School of Medicine in Shreveport; Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic Clinic

Cambize Shahrdar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Brett D Owens, MD  Associate Professor of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of Health Sciences

Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Orthopaedic Trauma Association, and Society of Military Orthopaedic Surgeons

Disclosure: Musculoskeletal Transplant Foundation Consulting fee Consulting

Specialty Editor Board

Robert D Bronstein, MD  Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine

Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds None; Musculoskeletal Transplant Foundation Grant/research funds None; Histogenics Grant/research funds None; Advanced Biomedical Technologies Stock Options Medical Director, North America

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

Additional Contributors

The authors and editors would like to acknowledge Margaret L Olmedo, MD, for the contributions made to this article.

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Knee dislocations. Lateral radiograph of anterior knee dislocation.
Knee dislocations. MRI showing significant disruption medially and laterally with tibial bone bruise.
Knee dislocations. Examination under anesthesia revealing recurvatum and lateral ecchymosis.
 
 
 
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