Arterial injuries in orthopaedics: the posteromedial approach for vascular control about the knee

Knee Dislocations: Lessons Learned From 20-Year Follow-up

Background:

Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.

Purpose:

To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee.

Study Design:

Review and case reports.

Methods:

Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form–36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability.

Results:

The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject’s IKDC score to “C.”

Conclusion:

Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

Neurologic and vascular injuries associated with knee ligament injuries

BACKGROUND

Multiple ligament knee injuries are commonly associated with neurovascular complications such as popliteal artery, common peroneal nerve, and tibial nerve injuries.

HYPOTHESIS

While the importance of identifying these complications in association with bicruciate and triligamentous injuries has been well established, it is important to recognize that any biligamentous and some single ligament knee injuries present with neurological and vascular complications as well.

STUDY DESIGN

Literature review.

CONCLUSION

Popliteal artery injuries require immediate intervention to help prevent limb loss. Peroneal and tibial nerve injuries can be a significant cause of morbidity and, therefore, require an understanding of their natural history, anatomy, and pathophysiologic implications to maximize functionality.

CLINICAL RELEVANCE

This review explores the types, mechanisms, and classifications of common neurovascular complications of knee ligament injuries, discusses their diagnosis, and reviews the therapeutic options available to optimize patient outcomes.

Surgical approaches to the posteromedial and posterolateral aspects of the knee

Surgical approaches to the posterior aspect of the knee are not commonly needed, and their use has become even rarer with the increasing sophistication of arthroscopic technology. As a result, physicians in orthopaedic surgical training are not often exposed to the practical use of surgical dissection around the posterior corners of the knee. For certain procedures, however, greater clinical utility and decreased surgical morbidity render focused posterior exposure the preferred alternative to the classic popliteal dissection with its wide exposure of the popliteal anatomy. Surgical indications include ligament repair or reconstruction around the posteromedial or posterolateral aspect of the knee, inside-out meniscal repair, posterior cruciate ligament tibial inlay reconstruction, and Baker's cyst excision. To minimize complications, these focused approaches require adeptness with the complex anatomy of the posterior, posteromedial, and posterolateral aspects.

Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: An analysis of techniques and a safe operative approach to the popliteal fossa

The arthroscopically assisted posterior cruciate ligament tibial inlay technique, frequently used in athletic individuals and in revision cases, requires a thorough and comprehensive understanding of posterior knee anatomy. Importantly, variations in the posterior vascular anatomy may be encountered. A safe and methodical posteromedial approach in a layered fashion to achieve proper and safe tibial inlay graft placement and fixation is described. The authors advocate use of a double-bundle quadriceps tendon autograft. Graft position of the double strands, fixation, and tensioning issues are presented.