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Murray IR, Makaram NS, Geeslin AG, Chahla J, Moatshe G, Crossley K, Kew ME, Davis A, Tuca M, Potter H, Janse van Rensburg DC, Emery CA, Eun S, Grindem H, Noyes FR, Marx RG, Harner C, Levy BA, King E, Cook JL, Whelan DB, Hatch GF, Wahl CJ, Thorborg K, Irrgang JJ, Pujol N, Medvecky MJ, Stuart MJ, Krych AJ, Engebretsen L, Stannard JP, MacDonald P, Seil R, Fanelli GC, Maak TG, Shelbourne KD, Verhagen E, Musahl V, Hirschmann MT, Miller MD, Schenck RC, LaPrade RF. Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation. Br J Sports Med 2024:bjsports-2024-108089. [PMID: 39237264 DOI: 10.1136/bjsports-2024-108089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 09/07/2024]
Abstract
Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.
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Affiliation(s)
- Iain Robert Murray
- Edinburgh Orthopaedics, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Navnit S Makaram
- Edinburgh Orthopaedics, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | | | | | - Gilbert Moatshe
- Orthopaedic Division, Oslo University Hospital, Oslo, Norway
- Oslo Sports Trauma Research Center, Oslo, Norway
| | - Kay Crossley
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Australian IOC Research Centre, Melbourne, Victoria, Australia
| | | | | | - Maria Tuca
- Pontificia Universidad Catolica De Chile School of Medicine, Santiago, Chile
| | - Hollis Potter
- Weill Cornell Medical College, New York, New York, USA
| | - Dina C Janse van Rensburg
- Section Sports Medicine, University of Pretoria Faculty of Health Sciences, Pretoria, Gauteng, South Africa
- Chair, Medical Advisory Panel, World Netball, Manchester, UK
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - SeungPyo Eun
- Dr. Eun's Korea Orthopaedic Clinic, Seoul, The Republic of Korea
| | - Hege Grindem
- Oslo Sports Trauma Research Center, Oslo, Norway
| | - Frank R Noyes
- Department of Orthopedic Surgery, Mercyhealth-Cincinnati Sports Medicine and Orthopedics, Cincinnati, Ohio, USA
| | - Robert G Marx
- Hospital for Special Surgery, New York, New York, USA
| | - Chris Harner
- Office of Orthopedic Devices, Office of Health Technology 6, Silverspring, Maryland, USA
| | - Bruce A Levy
- Jewett Orthopedic Institute, Orlando Health, Orlando, Florida, USA
| | - Enda King
- Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Ad Dawhah, Qatar
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, Mizzou Joint & Limb Preservation Center, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Daniel B Whelan
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George F Hatch
- USC Keck School of Medicine, Los Angeles, California, USA
| | - Christopher J Wahl
- Surgical Sports Medicine and Trauma, Proliance Orthopedics & Sports Medicine, Seattle, Washington, USA
| | - Kristian Thorborg
- Orthopedic Department, Sports Orthopedic Research Center - Copenhagen (SORC-C), Amager - Hvidovre Hospital, Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - James J Irrgang
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicolas Pujol
- Department of Orthopedics, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Michael J Medvecky
- Section of Sports Medicine, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | - Lars Engebretsen
- Orthopaedic Division, Oslo University Hospital, Oslo, Norway
- Oslo Sports Trauma Research Center, Oslo, Norway
| | - James P Stannard
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | | | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hopsitalier de Luxembourg-Clinique d'Eich, Luxembourg, Luxembourg
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg, Luxembourg
- Human Motion, Orthopaedics, Sports Medicine and Digital Methods (HOSD), Luxembourg Institute of Health (LIH), Luxembourg, Luxembourg
| | - Gregory C Fanelli
- Geisinger Orthopaedics and Sports Medicine, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania, USA
| | - Travis G Maak
- University of Utah Health, Salt Lake City, Utah, USA
| | | | - Evert Verhagen
- Department of Public and Occupational Health, Amsterdam Collaboration on Health & Safety in Sports, Amsterdam, Netherlands
- Movement Sciences, Amsterdam, University Medical Centres - Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Mark D Miller
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Robert C Schenck
- Department of Orthopedic Surgery and Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Robert F LaPrade
- Orthopedic Surgery, Twin Cities Orthopedics Edina-Crosstown, Edina, Minnesota, USA
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Srimongkolpitak S, Chernchujit B. Vascular Injuries in Multiligament Knee Injuries (MLKIs). Indian J Orthop 2024; 58:1196-1205. [PMID: 39170660 PMCID: PMC11333649 DOI: 10.1007/s43465-024-01220-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 06/28/2024] [Indexed: 08/23/2024]
Abstract
Purpose Vascular injuries are rarely associated with severe knee injuries; nonetheless, it is imperative to efficiently detect this condition and plan for either immediate or definitive treatment at later stages. The diagnosis and management of multiligament knee injuries still present unresolved issues, particularly in the early detection of vascular issues and the sequential stabilisation of ligaments. High-energy trauma is a frequently encountered cause, however, even low-energy trauma in those who are morbidly obese might pose a significant risk. Advancements in detection and management methods have greatly decreased the occurrence of vascular complications and amputation rates over time. MLKIs after transient knee dislocations are frequently misdiagnosed for vascular injuries, underscoring the necessity for improved diagnostic techniques to avoid avoidable amputations. Methods This article is a new conceptual review of vascular injuries associated with MLKIs. It provides a full overview of these conditions and includes a review of the most recent literature. We have included pertinent citations from the literature, together with suggestions derived from the latest studies. This review article had additional evaluation by proficient specialists with commendable outcomes and more than a decade of expertise in surgical techniques. Results This article offers a detailed overview of orthopaedic management, including new definitions and summaries of the causes, evaluation of patients, clinical assessment, identification of vascular injuries, and initial management in patients with vascular impairment following major limb and joint injuries (MLKIs). Conclusion MLKIs (patients with lower limb ischaemia) who have vascular damage necessitate meticulous physical assessment and sophisticated treatments in order to decrease amputation rates. Prompt identification and timely treatment of vascular lesions, namely in the popliteal artery, can substantially reduce the occurrence of amputations. Emerging research suggests that there is a heightened risk in low-energy situations, particularly amongst individuals who are extremely obese. Progress in vascular intervention has led to a reduction in amputation rates, whilst the implementation of new guidelines has enhanced identification. Thorough patient assessment is essential, utilising physical examinations and imaging techniques such as Computed tomography angiography, magnetic resonance angiography (CTA or MRA) to guide treatment decisions. MRA, in particular, is capable of identifying both vascular and knee structural damage. Level of Evidence Level IV, Literature reviews.
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Affiliation(s)
| | - Bancha Chernchujit
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Bangkok, Thailand
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Temperato J, Rucinski K, Cook JL, Meers A, Albuquerque JBD, Stannard JP. Outcomes after Anatomic Double-Bundle Posterior Cruciate Ligament Reconstructions Using Transtibial and Tibial Inlay Techniques. J Knee Surg 2024; 37:183-192. [PMID: 36507661 DOI: 10.1055/a-1996-1153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Surgical reconstruction is recommended for symptomatic posterior cruciate ligament (PCL) deficiency. While anatomic double-bundle PCL reconstruction (PCLR) has been reported to be associated with biomechanical and clinical advantages over other methods, there is still debate regarding the optimal technique for tibial positioning and fixation. Based on reported advantages and disadvantages, we employed two tibial fixation techniques, transtibial (TT) and tibial inlay (TI) for anatomic double-bundle PCLR with technique selection based on body mass index, comorbidities, and primary versus revision surgery. This study aimed to compare clinical outcomes following PCLR utilizing either TT or TI techniques to validate relative advantages, disadvantages, and indications for each based on the review of prospectively collected registry data. For 37 patients meeting inclusion criteria, 26 underwent arthroscopic TT PCLR using all-soft- tissue allograft with suspensory fixation in the tibia and 11 patients underwent open TI PCLR using an allograft with calcaneal bone block and screw fixation in the tibia. There were no significant preoperative differences between cohorts. Success rates were 96% for TT and 91% for TI with all successful cases documented to be associated with good-to-excellent posterior stability and range of motion in the knee at the final follow-up. In addition, patient-reported outcome scores were within clinically meaningful ranges for pain, function, and mental health after PCLR in both cohorts, suggesting similarly favorable functional, social, and psychological outcomes. Patient-reported pain scores at 6 months postoperatively were significantly (p = 0.042) lower in the TT cohort, which was the only statistically significant difference in outcomes noted. The results of this study support the use of TT and TI techniques for double-bundle anatomic PCLR in restoring knee stability and patient function when used for the treatment of isolated and multiligamentous PCL injuries. The choice between tibial fixation methods for PCLR can be appropriately based on patient and injury characteristics that optimize respective advantages for each technique.
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Affiliation(s)
- Joseph Temperato
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Aaron Meers
- School of Medicine, University of Missouri System Ringgold Standard Institution, Columbia, Missouri
| | - João Bourbon de Albuquerque
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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Krause M, Drenck TC, Eggeling L, Frings J, Akoto R, Frosch KH. German S2e-Guideline "Knee Dislocation". ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:57-62. [PMID: 36063838 DOI: 10.1055/a-1884-0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.
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Affiliation(s)
- Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Tobias C Drenck
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Lena Eggeling
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Jannik Frings
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ralph Akoto
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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Makaram NS, Murray IR, Geeslin AG, Chahla J, Moatshe G, LaPrade RF. Diagnosis and treatment strategies of the multiligament injured knee: a scoping review. Br J Sports Med 2023; 57:543-550. [PMID: 36822842 DOI: 10.1136/bjsports-2022-106425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs). DESIGN Scoping review. DATA SOURCES Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary. RESULTS Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups. CONCLUSIONS There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | - Iain R Murray
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,The University of Edinburgh, Edinburgh, UK
| | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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6
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Lineham B, van Duren B, Harwood P, Pandit H. The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature. Strategies Trauma Limb Reconstr 2023; 18:37-43. [PMID: 38033931 PMCID: PMC10682560 DOI: 10.5005/jp-journals-10080-1578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/20/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Knee joint distraction (KJD) is a potential technique for cartilage regeneration in young patients with osteoarthritis of the knee. Static distraction has been utilised typically; however, a significant proportion of patients complain of knee stiffness post-distractor removal. The use of a hinged distractor may reduce the duration and severity of post-treatment knee stiffness by maintaining the range of motion during distraction. Furthermore, improved cartilage regeneration has been demonstrated in hinged ankle joint distraction as compared to static, and this may also be demonstrated at the knee. An evidence review was undertaken to inform further research and a potential change in practice. Aim A systematic review of all primary research on hinged knee joint distraction for cartilage regeneration. Methods An online systematic search of citation databases was conducted. Quality assessment and data extraction were undertaken by two separate researchers. Results The literature search returned a small number of relevant studies, of which 7 were included. Three of these were animal studies, two cadaveric and two case series. The study quality was low or very low. There was significant methodological heterogeneity with difficulties encountered in the transfer of constructs from animal and cadaveric studies to humans. Issues faced included difficulties with hinge placement and pin site pain in motion. Conclusion The feasibility of hinged knee joint distraction has yet to be proven. Any further research attempting to establish the benefits of hinged-over static knee distraction will have to take construct design considerations into account. How to cite this article Lineham B, van Duren B, Harwood P, et al. The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature. Strategies Trauma Limb Reconstr 2023;18(1):37-43.
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Affiliation(s)
- Beth Lineham
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Bernard van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Paul Harwood
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
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Lee JHY, Cook JL, Wilson N, Rucinski K, Stannard JP. Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques. J Knee Surg 2022; 35:502-510. [PMID: 32977346 DOI: 10.1055/s-0040-1716356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m2, mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.
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Affiliation(s)
- John Hee-Young Lee
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Nichole Wilson
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
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8
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Ramírez-Bermejo E, Gelber PE, Pujol N. Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review. Arch Orthop Trauma Surg 2022; 142:255-261. [PMID: 33222023 DOI: 10.1007/s00402-020-03684-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/04/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator. MATERIAL AND METHODS The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports. RESULTS Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups. CONCLUSIONS External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Eduard Ramírez-Bermejo
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain.
| | - Pablo Eduardo Gelber
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, C/Sant Quintí 89, 08041, Barcelona, Catalunya, Spain
- ICATME, Hospital Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Nicolas Pujol
- Department of Orthopaedic Surgery and Traumatology, Versailles Hospital, University of West Paris-St Quentin, Versailles-Paris, France
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9
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Bird ML, Chenard KE, Gonzalez LJ, Konda SR, Leucht P, Egol KA. A Comparative Study of Clinical Outcomes and Functional Status after Knee Fracture and Knee Fracture Dislocation. J Knee Surg 2021; 36:695-701. [PMID: 34952544 DOI: 10.1055/s-0041-1741392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to compare outcomes of tibial plateau fracture dislocations (FD) with tibial plateau fractures alone. This study was an analysis of a series of tibial plateau fractures, in which FD was defined as a fracture of the tibial plateau with an associated loss of congruent joint reduction and stability of the knee, and classified by the Moore system. Patient data collected included demographics, injury information, and functional outcomes (short musculoskeletal function assessment [SMFA] score and Pain by the visual analog scale). Clinical outcomes at follow-up were recorded including knee range of motion, knee stability and development of complications. There were a total of 325 tibial plateau fracture patients treated operatively, of which 22.2% were identified as FD (n = 72). At injury presentation there was no difference with regard to nerve injury or compartment syndrome (both p > 0.05). FD patients had a higher incidence of arterial injury and acute ligament repair (both p < 0.005). At a mean follow-up of 17.5 months, FD patients were similar with regard to pain, total SMFA scores, and return to sports than their non-FD counterparts (p = 0.884, p = 0.531, p = 0.802). FD patients were found to have decreased knee flexion compared with non-FD patients by 5 degrees (mean: 120 and 125 degrees) (p < 0.05). FD patients also had a higher incidence of late knee instability and subsequent surgery for ligament reconstruction (p < 0.005 & p < 0.05). However, there was no difference in neurological function between groups at follow-up (p = 0.102). Despite the higher incidence of ligamentous instability and decreased range of motion, FD patients appear to have similar long-term functional outcomes compared with non-FD of the tibial plateau. While FD patients initially presented with a higher incidence of arterial injury, neurovascular outcomes at final follow-up were similar to those without a dislocation.
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Affiliation(s)
- Mackenzie L Bird
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | | | - Leah J Gonzalez
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York.,Department of Orthopedic Surgery, Jamaica Hospital Medical Center, New York, New York
| | - Philipp Leucht
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
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Li T, Xiong Y, Zhang Z, Tang X, Chen G, Li Q, Fu WL, Li J. Results of multiple ligament reconstruction after knee dislocation--A prospective study with 95 patients and minimum 2-year follow up. BMC Musculoskelet Disord 2021; 22:904. [PMID: 34706679 PMCID: PMC8554847 DOI: 10.1186/s12891-021-04596-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 08/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background There is still a lack of clinical data in arthroscopic treatment for treating multiple ligament injuries. This study aims to evaluate the clinical outcomes of patients with multiple ligament injuries undergoing treatment based on the classification stage and type of injury. Methods A prospective, clinical trial on multiple ligament injuries was planned, which included 95 patients (58 men and 37 women; age: 42.8 ± 11.9 [range, 18–63] years) from October 2017 to June 2018. Injuries were classified into three stages (emergency stage < 24 h; acute stage: 24 h to 3 weeks, and chronic stage: > 3 weeks) and six types (KD I–VI) based on injuries time and structures, which indicated appropriate treatments. The clinical outcomes were evaluated at 2, 4, 6, 8, and 12 weeks and at 6, 9, 12 months and 24 months after surgery. The final choices in efficacy index included International Knee Documentation Committee (IKDC) score, Lysholm score, visual analog scale (VAS) score, and range of motion. Results During the follow-up, all patients exhibited statistically significant functional improvement in the injured limb compared with their preoperative situation. The mean postoperative scores of acute stage patients at 2-year follow-up were IKDC subjective score, 77.54 ± 11.53; Lysholm score, 85.96 ± 9.39; Tegner score, 4.13 ± 1.08; and VAS score, 1.21 ± 0.76. The mean postoperative scores of chronic stage patents at 2-year follow-up were IKDC subjective score, 74.61 ± 12.38; Lysholm score, 81.71 ± 10.80; Tegner score, 3.96 ± 1.14; and VAS score, 1.71 ± 0.60. The IKDC subjective score, Lysholm score, and Tegner score were significantly improved (P < 0.01) and the VAS score was significantly decreased (P < 0.01) at 2-year follow-up. Regarding the multiple ligament injuries classification, patients with more structural damage in stages V and VI showed less progress in functional recovery than those in stages I–IV. Conclusions This new classification with three stages and six types helps to identify the severity of injury and plan the management effectively. The outcomes were encouraging and the subjective functional results showed significant improvement at 2-year follow-up. Study design Prospective clinical trial. Level of evidence II
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Affiliation(s)
- Tao Li
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Sichuan, Chengdu, China
| | - Yan Xiong
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China
| | - Zhong Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Sichuan, Chengdu, China
| | - Xin Tang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China
| | - Gang Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China
| | - Qi Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China
| | - Wei Li Fu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China
| | - Jian Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P. R. China.
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11
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Maxwell GT, Warth RJ, Amin A, Darlow MA, Bailey L, Lowe WR, Harner CD. Multiple Ligament Knee Injuries: Does the Knee Dislocation Classification Predict the Type of Surgical Management? J Knee Surg 2021; 34:273-279. [PMID: 32185787 DOI: 10.1055/s-0039-1695739] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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/m2 (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.
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Affiliation(s)
- Garrett T Maxwell
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Ryan J Warth
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Adeet Amin
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Matthew A Darlow
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Lane Bailey
- Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
| | - Walter R Lowe
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.,Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
| | - Christopher D Harner
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.,Ironman Sports Medicine Institute, Memorial Hermann Medical System, Houston, Texas
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12
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Abstract
A knee dislocation that involves at least 2 of the 4 major ligament groups-such as the anterior cruciate ligament, the posterior cruciate ligament, or the posterolateral corner-is a catastrophic event for an athlete or trauma patient. Careful evaluation of these patients is needed to avoid disastrous outcomes. Surgeons must be cognizant of a number of key treatment concerns-such as tunnel crowding, controversies over graft fixation methods, and sparsity of level I clinical data-to make proper ligament repair decisions. This manuscript will review treatment principles that govern high-quality care of this complex injury.
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13
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Mosquera MF, Jaramillo A, Gil R, Gonzalez Y. Controversies in acute multiligamentary knee injuries (MLKI). J Exp Orthop 2020; 7:56. [PMID: 32715370 PMCID: PMC7383048 DOI: 10.1186/s40634-020-00260-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/08/2020] [Indexed: 01/12/2023] Open
Abstract
Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.
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Affiliation(s)
- Manuel F Mosquera
- Clinica Erasmo, Valledupar, Colombia. .,Clinica La Carolina, Carrera 14 # 127-11 Cons 307-308, Bogota, Colombia.
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14
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Flowers D, Olmedo M. Non-surgical management of a tibiofemoral knee dislocation in a patient with sarcoidosis. BMJ Case Rep 2019; 12:12/11/e229605. [PMID: 31678917 DOI: 10.1136/bcr-2019-229605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case presents a patient who sustained a knee dislocation, and who due to her diagnosis of sarcoidosis, other comorbidities, and prolonged use of corticosteroids, external fixation and physical therapy were implemented versus soft tissue reconstruction/repair. Research indicates worse functional outcomes with non-surgical treatment, and guidelines on optimising outcomes in this population are lacking. Integrated care of the patient-even when complex injuries and comorbid medical conditions are present-can lead to positive functional recovery, despite previous data. Evidence from related injuries can be successfully adapted in non-surgical management of these injuries, providing general treatment guidelines.
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Affiliation(s)
- Daniel Flowers
- Rehabilitation Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Margaret Olmedo
- Orthopaedic Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
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15
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Sobrado MF. State of the art in multiligament knee injuries: from diagnosis to treatment. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S97. [PMID: 31576817 DOI: 10.21037/atm.2019.04.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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16
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Matthewson G, Kwapisz A, Sasyniuk T, MacDonald P. Vascular Injury in the Multiligament Injured Knee. Clin Sports Med 2019; 38:199-213. [DOI: 10.1016/j.csm.2018.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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18
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Abstract
The multiple ligament injured knee (knee dislocation) is oftentimes part of a multisystem injury complex that can include injuries not only to knee ligaments but also to blood vessels, skin, nerves, bones (fractures), head, and other organ system trauma. These additional injuries can affect surgical timing for knee ligament reconstruction and also affect the results of treatment. This article presents the author's approach and experience to the initial assessment and treatment of the multiple ligament injured (dislocated) knee.
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Affiliation(s)
- Gregory C Fanelli
- Geisinger Orthopaedics, 115 Woodbine Lane, Danville, PA 17822-5212, USA.
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19
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Abstract
The purpose of this paper is to present an overview of the progress in treatment of knee dislocations and posterior cruciate ligament (PCL)-based multiple ligament knee injuries over the past 25 years. The perspectives of where we were 25 years ago, where we are today, and where we will be in the future will be explored.
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20
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Maslaris A, Brinkmann O, Bungartz M, Krettek C, Jagodzinski M, Liodakis E. Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:1001-1015. [PMID: 29470650 DOI: 10.1007/s00590-018-2148-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/03/2018] [Indexed: 01/11/2023]
Abstract
Traumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation.
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Affiliation(s)
- Alexander Maslaris
- Department of Orthopaedics, Rudolf-Elle-Hospital, Friedrich-Schiller-University of Jena, Campus Eisenberg, Klostersnitzer Straße 81, 07607, Eisenberg, Germany.
| | - Olaf Brinkmann
- Department of Orthopaedics, Rudolf-Elle-Hospital, Friedrich-Schiller-University of Jena, Campus Eisenberg, Klostersnitzer Straße 81, 07607, Eisenberg, Germany
| | - Matthias Bungartz
- Department of Orthopaedics, Rudolf-Elle-Hospital, Friedrich-Schiller-University of Jena, Campus Eisenberg, Klostersnitzer Straße 81, 07607, Eisenberg, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Michael Jagodzinski
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Emmanouil Liodakis
- Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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21
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Tanaka Y, Kita K, Takao R, Amano H, Uchida R, Shiozaki Y, Yonetani Y, Kinugasa K, Mae T, Horibe S. Chronicity of Anterior Cruciate Ligament Deficiency, Part 2: Radiographic Predictors of Early Graft Failure. Orthop J Sports Med 2018; 6:2325967117751915. [PMID: 29479543 PMCID: PMC5818097 DOI: 10.1177/2325967117751915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Accumulating evidence suggests that long-term anterior cruciate ligament (ACL) deficiency can give rise to an abnormal tibiofemoral relationship and subsequent intra-articular lesions. However, the effects of chronic ACL deficiency (ACLD) on early graft failure after anatomic reconstruction remain unclear. HYPOTHESIS We hypothesized that patients with long-term ACLD lasting more than 5 years would have a greater rate of early graft failure due to insufficient intraoperative reduction of the tibia and that the preoperative and immediately postoperative abnormal tibiofemoral relationship in the sagittal plane, such as anterior tibial subluxation (ATS), would correlate with the graft status on postoperative magnetic resonance imaging (MRI). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 358 patients who had undergone anatomic ACL reconstruction with hamstring grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken in all patients to evaluate the tibiofemoral relationship, specifically with regard to ATS, space for the ACL (sACL), and extension angle. All patients underwent MRI at 6 months to reveal graft status. Groups with a high rate of graft failure were further analyzed to compare demographic and radiographic factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. RESULTS Graft failure without trauma was observed in 4 (1.8%), 0 (0%), 1 (3.7%), 3 (9.7%), and 8 patients (17.7%) in groups 1, 2, 3, 4, and 5, respectively. Of the 76 patients in groups 4 and 5, significant differences were noted between the failure and intact subgroups in preoperative ATS (4.9 vs 2.4 mm, respectively; P < .01), side-to-side differences in sACL (sACL-SSD) (4.7 vs 1.9 mm, respectively; P < .01), extension deficit (4.4° vs 1.3°, respectively; P < .01), and chondral lesions (P = .02), while postoperative ATS and sACL-SSD showed no differences. Multivariate logistic regression analysis revealed that of these factors, preoperative sACL-SSD could be a risk factor for early graft failure (odds ratio, 3.2; 95% CI, 1.37-7.46). CONCLUSION Early graft failure at 6 months increased in patients with ACLD longer than 2 years. In this population, preoperative sACL-SSD was the most significant risk factor for early graft failure on MRI. However, immediately postoperative radiographic measurements had no effect on graft failure rates.
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Affiliation(s)
- Yoshinari Tanaka
- Department of Sports Orthopedics, Osaka Rosai Hospital, Sakai, Japan
| | - Keisuke Kita
- Department of Sports Orthopedics, Osaka Rosai Hospital, Sakai, Japan
| | - Rikio Takao
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
| | - Hiroshi Amano
- Department of Sports Orthopedics, Osaka Rosai Hospital, Sakai, Japan
| | - Ryohei Uchida
- Department of Orthopedic Surgery, Seifu Hospital, Sakai, Japan
| | | | - Yasukazu Yonetani
- Department of Orthopedic Surgery, Hoshigaoka Medical Center, Hirakata, Japan
| | - Kazutaka Kinugasa
- Department of Sports Orthopedics, Osaka Rosai Hospital, Sakai, Japan
| | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shuji Horibe
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
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22
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Gatti G. Conceptual design and implantation of an external fixator with improved mobility for knee rehabilitation. Comput Methods Biomech Biomed Engin 2017; 20:884-892. [PMID: 28332404 DOI: 10.1080/10255842.2017.1307342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A hinged external fixator is used to allow early knee rehabilitation in case of injury or trauma, as an alternative approach to immobilization. It is mainly adopted for the treatment of dislocations, which involve tearing of the ligaments, and it basically consists of two links connected to each other by a revolute joint. Each link is fixed to the femur and tibia via pin fixation, and the revolute joint is approximately aligned to the knee flexion-extension (FE) axis. The advantage in its implantation is to protect ligament reconstruction, while allowing for an aggressive rehabilitation. Traditional fixators only accommodate the functional flexion movement in a limited range, i.e. where the anatomical movement is closer to a planar circular trajectory. This paper presents the conceptual design and implantation procedure of a double-axis fixator, which accommodates both FE and longitudinal internal-external rotation. The procedure is based on accurate knee kinematics measurements and on computer-aided multibody simulations to assist clinicians in the implantation. An experimental test is presented using an artificial knee, and guidelines are given for in vitro studies. The proposed technique may allow for a better understanding of knee kinematics and have the potential advantage to increase the range of motion in postoperative rehabilitation.
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Affiliation(s)
- Gianluca Gatti
- a Department of Mechanical, Energy and Management Engineering , University of Calabria , Arcavacata di Rende (CS) , Italy
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23
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Helito CP, Foni NO, Bonadio MB, Pécora JR, Demange MK, Angelini FJ. Migração extra‐articular e transcutânea de parafuso de interferência de poly L,D‐lactide após reconstrução do tendão poplíteo. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Helito CP, Foni NO, Bonadio MB, Pécora JR, Demange MK, Angelini FJ. Extra-articular and transcutaneous migration of the poly-l/d-lactide interference screw after popliteal tendon reconstruction. Rev Bras Ortop 2017; 52:233-237. [PMID: 28409145 PMCID: PMC5380794 DOI: 10.1016/j.rboe.2017.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/30/2016] [Indexed: 11/19/2022] Open
Abstract
Knee ligament reconstructions are commonly performed orthopedic procedures. Graft fixation is generally performed with metallic or absorbable interference screws. In a recent study, only ten reports of screw migration were retrieved; of these, only one was not related to the anterior cruciate ligament, and the majority was related to the use of poly-l-lactic acid (PLLA) screws. Only one case retrieved in the literature reported screw migration in reconstructions of the posterolateral corner, and that was to the intra-articular region. In the present article, the authors report a case of extra-articular and transcutaneous migration of a poly-l/d-lactide (PDLLA) interference screw following popliteal tendon reconstruction. Besides being the first case of popliteal tendon migration with extra-articular screw migration, no reports of PDLLA screw migration were retrieved in the literature.
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25
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Zhang C, Li J. Comments on: Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator by Angelini FJ, Helito CP, Bonadio MB, da Mota E Albuquerque RF, Pecora JR, Camanho GL published in Orthop Traumatol Surg Res 2015 Feb;101(1):77-81. Orthop Traumatol Surg Res 2016; 102:139. [PMID: 26774905 DOI: 10.1016/j.otsr.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/01/2015] [Indexed: 02/05/2023]
Affiliation(s)
- C Zhang
- Sichuan University, West China Hospital, Sichuan, China
| | - J Li
- Guo Xue Xiang, Chengdu No.37, 610041 Sichuan, China.
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Angelini FJ, Helito CP, Bonadio MB, Guimarães TM, Barreto RB, Pécora JR, Camanho GL, da Mota E Albuquerque RF. External fixator for treatment of the sub-acute and chronic multi-ligament-injured knee. Knee Surg Sports Traumatol Arthrosc 2015; 23:3012-8. [PMID: 26289092 DOI: 10.1007/s00167-015-3719-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE To assess whether the use of an articulated external fixator provides improvements in the mobility, stability and subjective function of patients undergoing ligament reconstruction. METHODS Thirty-three patients with sub-acute and chronic knee dislocation were subjected to multi-ligament reconstruction surgery. These patients were randomly allocated to two groups for immobilization after reconstruction: group 0-control (18 patients), with rigid knee bracing, and group 1-articulated external fixator (15 patients). The stability of the reconstructed ligaments was assessed after at least 14 months (26.6-month average) postoperatively by physical examination. Deficit of extension and flexion was measured in relation to the unaffected contralateral knee, and the Lysholm knee scoring scale questionnaire was applied. RESULTS There was no difference in the assessment of joint stability between the groups. In group 1, patients showed less flexion deficit (4.8° ± 5.4° vs. 18.2° ± 14.8°, p < 0.05), and the percentage of patients with a flexion deficit of 5° or less were higher compared with group 0 (64 vs. 18 %, p < 0.05). There was no difference between groups in relation to extension loss. Group 1 also presented better Lysholm scores, with 73 % of patients rated as excellent or good compared with 35 % in group 0 (p < 0.05). CONCLUSIONS Compared with the control rehabilitation protocol with rigid knee bracing in extension, the use of an articulated external fixator in the treatment of chronic multi-ligament-injured knees provided the same ligament stability, better final range of motion and improved Lysholm score. Patients presenting with chronic multi-ligament instability should be considered for articulated external fixation to supplement reconstruction procedures. LEVEL OF EVIDENCE Randomized controlled trial, Level I.
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Affiliation(s)
- Fabio Janson Angelini
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil.
| | - Camilo Partezani Helito
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - Tales Molica Guimarães
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - Ronald Bispo Barreto
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - José Ricardo Pécora
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - Gilberto Luis Camanho
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
| | - Roberto Freire da Mota E Albuquerque
- Knee Surgery Division, Department of Orthopedics and Traumatology, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP, CEP 05403-010, Brazil
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Lachman JR, Rehman S, Pipitone PS. Traumatic Knee Dislocations: Evaluation, Management, and Surgical Treatment. Orthop Clin North Am 2015; 46:479-93. [PMID: 26410637 DOI: 10.1016/j.ocl.2015.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- James R Lachman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, 3509 North Broad Street #5, Philadelphia, PA 19140, USA.
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, 3509 North Broad Street #5, Philadelphia, PA 19140, USA
| | - Paul S Pipitone
- Department of Orthopaedic Surgery, Nassau University Medical Center, East Meadow, NY 11554, USA
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Sabharwal S, Nelson SC, Sontich JK. What's New in Limb Lengthening and Deformity Correction. J Bone Joint Surg Am 2015; 97:1375-84. [PMID: 26290092 DOI: 10.2106/jbjs.o.00298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
| | - Scott C Nelson
- Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 214A, Loma Linda, CA 92354
| | - John K Sontich
- MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109
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Affiliation(s)
- John A Tanksley
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
| | - Richard Ma
- Missouri Orthopaedic Institute, 1100 Virginia Avenue, Columbia, MO 65212
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, Kaufmann Medical Building, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908
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Angelini FJ, Helito CP, Bonadio MB, da Mota E Albuquerque RF, Pecora JR, Camanho GL. Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator. Orthop Traumatol Surg Res 2015; 101:77-81. [PMID: 25530481 DOI: 10.1016/j.otsr.2014.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 10/27/2014] [Accepted: 11/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Knee dislocations are defined as ligament injuries involving at least two of the four most important knee ligaments. Results from recent studies have shown a tendency towards improvement of the functional outcomes with use of an articulated external fixator during the postoperative period following multiligament reconstruction. Our hypothesis was that good knee stability and early gain of range of motion could be achieved with the use of the external fixator after ligament reconstructions. METHODS Fourteen patients with knee dislocations were evaluated after multiligament reconstruction in association with use of a lateral monoplanar external fixator for six weeks. Reconstructions were performed using grafts from a tissue bank. Range of motion was measured after one, two, three, six, twelve months and at the final evaluation at a mean time of 49 months. The assessments were made using objective and subjective IKDC, Lysholm and Tegner scales. RESULTS The mean scores were 71.7 for the subjective IKDC score, 81.5 for the Lysholm score. No patient was able to return to previous Tegner score. Out of the 45 ligament reconstructions performed, only four failed during the follow-up time. The mean range of motion of the knee presented a progressive increase from the first to the twelfth month, from 67.8° to 115.7°. Two cases of superficial infection on the site of the external fixator pins were observed. CONCLUSION The use of an external fixator enabled early rehabilitation with range of motion gains starting from the first postoperative month, a low rate of reconstruction failure and minimal complications. Nevertheless, none of the patients returned to the level of activity prevailing prior to the injury. LEVEL OF EVIDENCE Level IV, retrospective therapeutic case series.
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Affiliation(s)
- F J Angelini
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil
| | - C P Helito
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil.
| | - M B Bonadio
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil
| | - R F da Mota E Albuquerque
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil
| | - J R Pecora
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil
| | - G L Camanho
- Department of Orthopaedics and Traumatology, Institute of Orthopedics and Traumatology, Hospital and Clinics, Faculty of Medicine, University of São Paulo (IOT-HCFMUSP), 04078011 São Paulo, Brazil
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Nuelle CW, Stannard JP. Placement of a Compass Knee Hinge: Surgical Technique. JBJS Essent Surg Tech 2014; 4:e2. [PMID: 30775109 DOI: 10.2106/jbjs.st.m.00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The Compass Knee Hinge can be a useful part of the treatment regimen for highly unstable knee dislocations. Step 1 Initial Alignment of Wires Make sure to place the centering wire at the isometric point of the knee. Step 2 Placement of the Compass Knee Hinge Take the necessary steps to place the Compass Knee Hinge over the wire. Step 3 Application of the Compass Knee Hinge with Concurrent Procedures If repair or reconstruction of either the posteromedial or the posterolateral corner is part of the planned surgical procedure, place the centering wire prior to the repair or reconstruction of the injured corner. Step 4 Postoperative Protocol Postoperatively, use progressive protocols to enable the patient to regain knee motion following the application of the hinge. Results The above technique was used to treat fifty-five patients with a total of fifty-six knee dislocations who had various concurrent ligamentous reconstructions14.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
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