Knee Dislocation Surgery Treatment & Management

Reduction

After evaluation, closed reduction should be performed expeditiously. Reduction is performed by stabilizing the distal femur and applying longitudinal traction on the tibia and reversing the direction of the dislocation. The knee should reduce easily with a satisfactory clunk. Neither the physician nor the assistant should apply any pressure over the popliteal fossa during the reduction, to lessen the risk of additional injury to the popliteal artery. A medial skin furrow is indicative of a posterior lateral dislocation, with the medial femoral condyle buttonholed through the capsule or extensor mechanism.^[13] This is usually irreducible by closed means. Gentle longitudinal traction should be applied. If the furrow appears to deepen with traction, an open reduction should be performed promptly. After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer. A Jones dressing can be applied after arteriogram.

Postreduction assessment

After reduction, vascular and neurological status should be recorded again. Repeat anteroposterior and lateral radiographs are obtained to confirm reduction. If the limb is dysvascular, then emergent vascular surgery consultation should be undertaken. If the limb appears well perfused, then arteriography is recommended.^{[14, 15, 10, 16]}

The role of noninvasive Doppler studies has been controversial.^[17] Occult intimal injury to the popliteal artery with initially normal pulses has been reported.^[15] The artery later underwent thrombosis with acute vascular insufficiency. The authors strongly recommend arteriograms be performed on all patients with knee dislocations, unless they have a dysvascular limb, in which case emergent vascular surgery is indicated.^{[18, 19, 20]} Best results are obtained if vascular repair is performed within 6-8 hours of the time of injury. Vascular repairs within 6 hours still have resulted in an 11% amputation rate. Vascular repair after 8 hours resulted in an 86% amputation rate.

Anteroposterior and lateral radiographs should be repeated in the first week to confirm reduction. We generally obtain these radiographs approximately 3 days postinjury, after the knee is placed in a hinged knee brace locked in extension. The films should be scrutinized for tibial subluxation, particularly in the posterior direction. If subluxation is present, external fixation should be considered.

Evaluation of knee ligamentous injury

Although many ligament injuries can be deduced from the mechanism of injury and direction of dislocation, stability is best determined with physical examination.^[21] However, it is very difficult to perform a good examination acutely because of the swelling and pain of the injury.^[22] Since many dislocations are associated with other injuries in motor vehicle accidents, opportunities are often available to examine the knee with the patient under anesthesia in the operating room for another procedure, as in the first image below. Immediate diagnosis is not necessary, since ligament surgery ideally is performed on an elective basis. MRI can be used to determine the extent and location of ligament disruption, meniscal tears, and subtle injuries to the bone, as in the second image below. The authors obtain an MRI on all patients on an elective basis within the first week after injury.

It is important to stress to the patient and the family that a knee dislocation is a devastating injury, and it is unlikely that the knee will be normal again, regardless of treatment. Knees that have dislocated are at risk for significant knee stiffness, chronic pain, arthrosis, and instability.

Nonsurgical management

Nonsurgical management is recommended in patients who have low functional demands or cannot cooperate with postoperative rehabilitation (eg, patients with significant closed head injuries). These patients can initially be treated with a knee immobilizer and Jones dressing and, when swelling diminishes, converted to a hinged knee brace locked in extension. The brace can be unlocked when good quadriceps control is achieved. Rehabilitation continues to maintain range of motion, emphasizing extension.^[5] If tolerated, gentle active and active-assisted flexion is performed in the prone position for 2 months to minimize posterior tibial sag. Strengthening begins with isometric hamstring and quadriceps cocontraction, and progresses to isotonic exercises.

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. Knee arthroscopy can be performed safely after 2 weeks with low pressures (gravity) only and careful monitoring of the leg.

Surgical options

Acute repair can be performed within weeks of injury, and direct repair of ligament avulsions may lead to better results than reconstructive procedures. MRI helps determine tear location and which tears are repairable. Generally, posterolateral corner injuries are repaired acutely because reconstructions are less successful.^[23] Midsubstance tears of the MCL are not repaired acutely because a high percentage may heal with conservative treatment. Midsubstance tears of the ACL and PCL are usually reconstructed later. MCL and LCL avulsions can be repaired primarily with suture or screws with a soft-tissue washer if an avulsion from the origin or insertion is present. ACL and PCL avulsions from their femoral or tibial origins can be repaired primarily in a similar fashion, but midsubstance tears should not be repaired primarily. Meniscal tears can also be addressed with primary repair to the capsule, with or without partial meniscectomy.

Timing of surgery

Ideally, ligament repair should be performed within 3 weeks after injury because scar formation makes later operations more difficult. It is prudent to delay surgical intervention until the skin and soft tissues have recovered from the initial insult (usually 1-2 wk later). Rehabilitation should begin as though patients were going to be treated nonoperatively.

Timing of ligament reconstruction is somewhat controversial, with some surgeons advocating early reconstruction. Delayed reconstruction is often preferred to allow rehabilitation of the knee and to increase the range of motion preoperatively; if the patient complains of knee instability, then reconstruction of the ACL, PCL, and MCL can be performed. Again, the reconstruction of the ligaments can be performed using autografts, allografts, or a combination of both.^{[24, 25, 26]} Generally, all the ligament reconstructions are performed in one operation, since staged operations have not demonstrated superior results.^{[27, 28]} Delayed reconstruction is an option for patients who may not be candidates for acute repair.

Repair sequence is controversial. Some advocate first reconstructing the PCL and repairing the posterolateral corner. Then at a later time, the ACL can be reconstructed, if necessary. Some believe that posterolateral corner repairs should not be performed without simultaneous PCL reconstruction. Most surgeons favor early posterolateral corner repair since repairs have better results than late reconstructions. The authors advocate delayed ligament surgery on those patients who do not have a posterolateral corner injury. In patients with posterolateral corner tears and significant posterior sag on lateral radiograph in a hinged knee brace locked in full extension, the authors reconstruct the PCL at the time of the posterolateral corner repair. Rehabilitation generally takes longer than that for a single or double ligament tear to the knee because of the severity of the injury. The authors have found that most patients are ready for cruciate ligament reconstruction by 3 months.

Prior to any surgical intervention for ligament repair or reconstruction, ensure that the skin condition is optimized. Any abrasions or lacerations should receive local wound care. Consider a plastic surgery consultation in injuries with tissue loss. If necessary, delay surgery until the skin is healed.

An operative strategy based on the surgeon's experience and preference is critical to optimize results and decrease complications.^[29] There are advocates of many different sequences and techniques, but few data to allow objective comparison of results.

The authors prefer an acute repair of the posterolateral corner. The peroneal nerve is identified at the fibular neck and traced proximally, so that it can be protected throughout the surgery. After identifying the location of injury of each of the posterolateral structures, repair proceeds from deep to superficial.

Repairing or reconstructing the popliteus tendon is important. The popliteus tendon is usually torn from its femoral attachment or midsubstance and can be repaired with nonabsorbable suture, with or without a suture anchor. The lateral capsule is often peeled off the tibia and can be repaired with transosseous sutures or suture anchors approximately 1 cm below the joint line. The arcuate complex, LCL, and biceps femoris can be repaired as a unit if avulsed together off the fibular head. They can be repaired safely together or separately through drill holes in the fibular head if the peroneal nerve is protected. The most superficial structure, the iliotibial band, is repaired last. The wound is closed over a small Hemovac drain, which is removed the following day.

An important aspect of knee dislocation surgery is postoperative rehabilitation.^[30] After a posterolateral corner repair, the knee is placed in a Jones dressing and the knee brace is locked at 30° for 2 weeks to promote wound healing and to minimize stress on the peroneal nerve and popliteal artery. Active quadriceps exercises are begun immediately.

Early protected range of motion is important to prevent arthrofibrosis.^[30] When both cruciates are torn, knee flexion is performed in the prone position to minimize the posterior tibial sag.

Complications of knee dislocation include popliteal arterial injury, peroneal nerve injury, knee instability, knee arthrosis, knee stiffness, and chronic pain.^{[13, 14]} After surgical intervention, complications include graft failure, infection, incisional dehiscence, knee arthrofibrosis, and the need for future surgery and/or knee manipulations.

Multiple outcome studies after surgical intervention for knee dislocation universally report that patients rarely claim that their knee function is normal.^{[31, 32]} Wascher reported results after ACL reconstruction, PCL reconstruction, or both in 13 patients with knee dislocations, and results after a mean of 38 months follow-up care.^[25] One patient claimed his knee felt normal, 6 patients returned to unrestricted sports activities, and 4 returned to modified sports.

Shapiro reported the outcome after allograft reconstruction of the ACL and PCL after traumatic knee dislocation.^[24] Seven patients had an average of 51 months follow-up care postoperatively. Only one patient had significant pain, 3 patients had occasional or rare sensations of knee instability, and all 7 were able to return to work or school. Four patients required knee manipulation at an average of 16.8 weeks postoperatively for knee arthrofibrosis. The functional grading was excellent in 3, good in 3, and fair in 1 patient.

Yeh reported the outcome after arthroscopic reconstruction of the PCL with open repair of collateral ligaments and capsule.^[26] Twenty-three patients had a mean follow-up of 27 months. At latest follow-up visit, the mean knee extension was 1° and knee flexion was 129.6°.

With technological advances in Doppler imaging, the need for arteriograms in postreduction limbs that have normal vascular examination findings is controversial.^[17] Some argue that unremarkable findings using Doppler obviate the need for arteriogram, which is more expensive and is associated with a low but real risk of complications.^[33] The authors had a patient who was discharged home 2 days after initial unremarkable findings on arterial Doppler study and returned the next day with an acute occlusion of the popliteal artery from an intimal flap. The authors continue to strongly recommend routine arteriography in these cases.

Discussion continues on which type of graft is best. Because so few clinical series of knee dislocations have been published, and such small numbers of patients reported, scientific data are insufficient to recommend one graft type over another. Because of the extent of trauma to a dislocated knee, the authors have been reluctant to harvest tissue from the same knee. The authors recommend patellar tendon allograft, which can be split to perform both ACL and PCL reconstruction with exposure to a single donor. In those patients who are uncomfortable with cadaver tissue, the authors recommend harvesting contralateral central third quadriceps and patellar tendon for PCL and ACL reconstruction, respectively.