Popliteal artery occlusion associated with dislocation of the knee-joint. Report of a case with successful surgical repair

Comparison of KD3-M and KD3-L Multiligamentous Knee Injuries and Analysis of Predictive Factors That Influence the Outcomes of Single-Stage Reconstruction in KD3 Injuries

Background:

The knee dislocation–3 (KD3) injury pattern is the most common form of multiligamentous injury. Medial KD3 (KD3-M) and lateral KD3 (KD3-L) are 2 anatomically different varieties of this injury.

Purpose:

To compare the surgical outcomes of KD3-M and KD3-L multiligamentous knee injury patterns and to determine the factors that could influence the outcomes after single-stage reconstruction.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A cohort of 45 patients with multiligamentous knee injuries (31 KD3-M, 14 KD3-L) who were operated on between 2011 and 2015 were compared. The cruciate ligaments were reconstructed, and the collateral ligaments were managed either conservatively or surgically depending on intraoperative laxity, tissue condition, injury site, and chronicity. The mean follow-up was 36 months (range, 24-72 months). The International Knee Documentation Committee (IKDC) score, Lysholm score, knee flexion range of motion (ROM), and laxity on stress radiographs were compared. Various factors likely to influence the outcomes were also analyzed.

Results:

The mean IKDC score, Lysholm score, and knee flexion ROM for the 45 patients were 74.74, 87.66, and 126.78°, respectively. There was no significant difference between the KD3-M and KD3-L groups in terms of the postoperative IKDC score (P = .768), Lysholm score (P = .689), knee flexion ROM (P = .798), and laxity on stress radiographs (P = .011). Patients with a transient dislocation had better outcomes (76.51, 89.41, and 128.61°, respectively) than those with a frank dislocation (67.62, 80.66, and 119.44°) (P = .037, .007, and .043). The acute group had better outcomes (77.00, 89.51, and 127.86°) when compared with the subacute (66.26, 86.00, and 121.00°) and chronic groups (67.40, 76.40, and 125.00°) (P = .045, .006, and .486). Regression analysis showed the influence of these factors on outcomes. The presence or absence of dislocations, time frame in which surgery was performed, and follow-up duration were found to influence the outcome. All other factors had no bearing on outcomes. Two patients had knee stiffness and underwent arthrolysis.

Conclusion:

Despite anatomic and biomechanical differences between KD3-M and KD3-L injuries, single-stage management did not produce any significant difference in results. The presence of a frank dislocation, delay in surgery, and duration of follow-up were found to influence outcomes.

Loss of distal femur combined with popliteal artery occlusion: reconstructive arthroplasty using modular segmental endoprosthesis: a case report

Severe injury to the knee and the surrounding area is frequently associated with injury to ligaments of the knee joint and structures in the popliteal fossa. This case involved a popliteal artery occlusion, severe bone loss of distal femur, loss of collateral ligaments, and extensor mechanism destruction of the knee. Initially, prompt recognition and correction of associated popliteal artery injury are important for good results after treatment. After successful revascularization, treatment for severe bone loss of distal femur and injury of the knee joint must be followed. We treated this case by delayed reconstruction using modular segmental endoprosthesis after revascularization of the popliteal artery. This allowed early ambulation. At 36 months after surgery, the patient had good circulation of the lower limb and was ambulating independently.

Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation

PURPOSE

The purpose of this study was to determine the effectiveness of a new 2-stage surgical treatment for acute traumatic knee dislocation.

METHODS

The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up was 88.9 months (range, 35 to 110 months). In the first surgical stage, medial or lateral ligament complexes were repaired or reconstructed within 2 weeks of injury. In the second surgical stage, once full range of motion was obtained 3 to 6 months later, the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) was reconstructed if significant laxity was present. The final outcomes were assessed based on stress radiographs, range of motion, Lysholm score, Tegner activity stage, and International Knee Documentation Committee rating.

RESULTS

There were 10 cases of medial collateral ligament (MCL) tear and 8 cases of lateral collateral ligament (LCL) tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. After the first stage of MCL/LCL complex surgery, the second-stage surgery involving ACL and PCL reconstruction was deemed necessary in 3 and 7 cases, respectively. Five cases did not require ACL or PCL reconstruction. On stress radiography at the last follow-up, MCL, LCL, ACL, and PCL instability was graded as 0 to 1 in 15, 14, 15, and 11 cases, respectively. PCL instability was graded as 2 in 4 cases. The mean postoperative Lysholm score was 87.6 points.

CONCLUSIONS

The 2-stage surgical approach described resulted in good outcomes for acute knee dislocation patients in terms of range of motion and stability.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Knee dislocation. Complications of nonoperative and operative management

Because of the nature and extreme severity of the injury, complications will continue to be a common denominator in traumatic knee dislocations. The major complications that cause significant morbidity, including amputation and death, are now relatively infrequent. Prompt recognition and treatment of these complications are of utmost importance to assure functional viability of the extremity. These complications must continue to be addressed preoperatively and postoperatively. Minor complications will persist after significant knee surgery. New complications will evolve as newer techniques, instrumentation, and procedures are introduced. Ligament reconstructive surgery is relatively new and technically demanding. The surgeon must continue to use meticulous technique and attention to detail. Orthopedic surgeons must continue to closely evaluate the procedures they perform, making sure they are as technically correct as possible. Each surgeon must observe and determine what technique will be of true benefit to the patient. Most complications that do occur can be corrected or at least improved if they are handled early and with a true understanding of the problem.

Outcomes of the operatively treated knee dislocation

Despite being a serious injury with early complications associated with a high degree of morbidity, the outcomes of knee dislocations have improved dramatically since the days of Sir Astley Cooper. Currently, most authors favor early surgical reconstruction of the injured ligamentous structures. With modern surgical techniques and rehabilitation protocols, most patients are able to achieve functional range of motion and stability necessary for everyday life. Despite improvements in treatment, stiffness and pain, rather than instability, can be a problem. Patients continue to have difficulty returning to pre-injury levels of athletic competition and manual labor, although a significant number of patients have achieved these goals. As physicians, we must be knowledgeable in the current surgical techniques and rehabilitation protocols used in the treatment of knee dislocations, and the typical prognosis of the injury. By informing our patients of hurdles that they will be forced to overcome, in their path to recovery, before initiating treatment, patients will better understand the seriousness of the injury, which, it is hoped, will lead to compliance with their rehabilitation and thus better outcomes.

Popliteal Artery Occlusion in a Wrestler in the Absence of Known Trauma

In brief: A college wrestler was first seen by an athletic trainer when he complained of a burning pain in his right foot. He recalled no traumatic event that might have caused the pain. He was referred to the athletic department's consulting podiatrist. An examination showed that the patient's right foot was cool and pale and that the pedal pulses were absent. Immediate referral was made to a vascular surgeon. A right femoral arteriogram showed complete occlusion of a 3.5-cm segment of the popliteal artery. A femoral popliteal artery bypass was performed. The patient recovered fully but was discouraged from participating in competitive sports.

Stability and motion after traumatic dislocation of the knee

In a series of 10 patients with traumatic dislocation of the knee joint, closed reduction could be accomplished in nine. Conservative treatment was employed in four and operative repair of the ligaments and capsule in six patients. In two of three patients with complicating artery injury, vascular repair was successful. Above-knee amputation was performed in one patient because of delay in the diagnosis of vascular injury and in another patient because of arteriosclerotic gangrene. At follow-up examination, on average 6 years after the accident, the stability and motion of the knee were evaluated as good in five patients (three operated), fair in two (one operated) and as poor in one operated patient. The conclusions are that good knee function can thus be achieved with both conservative and operative treatment, and that limb salvage depends on prompt diagnosis and treatment of vascular complications.

Principles in the management of arterial injuries associated with fracture/dislocations

Ten out of 355 patients admitted with fracture and/or dislocations of long bones secondary to blunt trauma had associated vascular injuries. The clinical recognition of the associated vascular injury and its vertification of arteriography, Doppler study or surgical exploration resulted in early vascular repair and limb salvage. The controversial aspects of bone stabilization followed by vascular repair versus primary vascular repari, skeletal traction and delayed internal fixation together with fasciotomy-fibulectomy are discussed. Our results with the injuries seen justify the principle of bone stabilization followed by vascular repair, particularly since a team effort resulted in little time lost prior to circulatory restoration. The problems following vascular repair-namely anterior compartment snydrome, acute renal failure and cardiac arrest are present with their principles of management.