Epidemiological Study on Multiligament Knee Injuries / Estudo epidemiológico das lesões multiligamentares do joelho

Abstract Objective The present paper aims to describe multiligament knee injuries and to associate their features with the profile of the patients and trauma mechanisms. Methods This is a cross-sectional study evaluating 82 patients with multiligament knee injuries from September 2016 to September 2018. Evaluated parameters included age, gender, mechanical axis, affected side, range of motion, trauma mechanism, associated injuries, affected ligaments, and absence from work. Results The sample included patients aged between 16 and 58 years old, with an average age of 29.7 years old; most subjects were males, with 92.7% of cases. The most common trauma mechanism was motorcycle accident (45.1%). The most injured ligament was the anterior cruciate ligament (80.5%), followed by the posterior cruciate ligament (77.1%), the posterolateral corner (61.0%), and the tibial collateral ligament (26.8%). The most frequent type of dislocation was KD IIIL (30.4%). Only 1 patient had a vascular injury, and 13 (15.9%) presented with neurological injuries. Most subjects took medical leave from work (52.4%). Conclusion There is a big difference between patients with multiligament lesions in Brazil compared with international studies. Thus, it is advisable to carry out more specific studies on the topic with our population to improve the treatment of these patients.

Resumo Objetivo Descrever e associar as características das lesões multiligamentares de joelho com o perfil do paciente e mecanismo de trauma. Métodos Trata-se de um estudo transversal que avaliou 82 pacientes com lesões multiligamentares do joelho de setembro de 2016 até setembro de 2018. As variáveis coletadas foram idade, gênero, eixo mecânico, lateralidade, arco de movimento, mecanismo do trauma, lesões associadas, ligamentos afetados e afastamento do trabalho. Resultados A amostra incluiu pacientes de 16 a 58 anos, com média de 29,7 anos, e os homens foram os mais afetados, correspondendo a 92,7% dos casos. O mecanismo de trauma mais comum foi acidente motociclístico (45,1%). O ligamento mais lesado foi o ligamento cruzado anterior (80,5%), seguido do ligamento cruzado posterior (77,1%), do canto posterolateral (61,0%) e do ligamento colateral tibial (26,8%). O tipo de luxação mais frequente era o KD IIIL (30,4%). Apenas 1 paciente apresentou lesão vascular, e 13 (15,9%) apresentaram lesões neurológicas. A maioria das vítimas foi afastada do trabalho (52,4%). Conclusão Há grande diferença entre os pacientes que apresentam lesão multiligamentar no Brasil em relação ao encontrado nos estudos internacionais. Desta forma, convém realizar mais estudos específicos sobre o tema com a nossa população, de modo a aperfeiçoar o tratamento destes pacientes.

Analysis of early treatment of 12 cases with congenital knee dislocation / 中华实用儿科临床杂志

Objective:To investigate the curative effect of the Pavlik harness and polyester material casting bandage for the early treatment of congenital knee dislocation (CDK).Methods:The clinical data of 12 patients (13 knees) with CDK treated in Provincial Hospital Affiliated to Shandong First Medical University from December 2011 and January 2019 were studied retrospectively.There were 3 males and 9 females.The median age at the initial visit was 3 days ( 1-29 days). Eleven patients had unilateral CDK, and 1 patient had bilateral CDK.There were 5 cases(5 knees) with dislocation and 7 cases(8 knees) with subluxation.Associated musculoskeletal anomalies were observed in 7 patients, which included developmental dysplasia of the hip (DDH) in 6 patients, bilateral DDH and right clubfoot in 1 patient.The Pavlik harness was applied to keep the knee in position for 1.5-2.0 months if passive flexion achieved 90°or more.If passive flexion was below 90°, the polyester material casting bandage was employed to increase knee flexion, and the bandage was changed once a week.After passive flexion reached 90°, the patient was treated with the Pavlik harness for 1.5-2.0 months.Cases with DDH who worn the Pavlik harness were evaluated by ultrasonography in the follow-up period, and cases with clubfoot were treated with Ponseti polyester material casting bandages.Results:Three children (4 knees) were directly fixed with Pavlik harness for 1.5-2.0 months, 9 children (9 knees) were fixed with Pavlik harness for 1.5-2.0 months after 1-8 times (average 2.9 times) of plaster fixation. No plaster and Pavlik harness complications were found during the treatment.Twelve patients were followed up for 29.8 months on average (12.0 to 65.0 months). Ten patients (11 knees) were rated excellent, and 2 patients (2 knees) were rated good.Conclusions:The Pavlik harness and polyester material casting bandage for early treatment of CDK is simple, effective and safe.Associated musculoskeletal anomalies can also be corrected in the treatment process.The knee joint dislocation should be treated at first.

Combined posteromedial and anterolateral approach for reduction and internal fixation in the treatment of Wahlquist type C medial tibial plateau fracture with coronal subluxation of knee joint / 中华骨科杂志

Objective:To compare the efficacy of posteromedial and anterolateral approach and single posteromedial reversed L approach for reduction and internal fixation in the treatment of Wahlquist type C medial tibial plateau fracture (mTPF) with coronal subluxation of knee joint.Methods:A retrospective analysis was conducted on 44 surgically treated Wahlquist type C mTPFs from January 2010 to April 2021. They were divided into single-approach group (21 cases, 12 males and 9 females with mean age of 50.71±11.28 years) and combined-approach group (23 cases, 16 males and 7 females with mean age of 51.00±10.07 years) according to their surgical approach. The single-approach group contained 14 left limbs and 7 right limbs, and there were 19 anteromedial-posteromedial-posterolateral mTPF and 2 posteromedial-posterolateral mTPF. The combined-approach group contained 18 left limbs and 5 right limbs, and there were 22 anteromedial-posteromedial-posterolateral mTPF and 1 posteromedial-posterolateral mTPF. The intraoperative blood loss and incidence of blood transferring were assessed according to the anesthetic recording. The incidence of residual knee subluxation and articular surface step, medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) were measured on the postoperative plain radiograph and the function recovery of the affected knee was evaluated by the short musculoskeletal function assessment (SMFA) and the visual analogue scale (VAS).Results:The intraoperative blood loss in combined-approach group was 597.83±89.79 ml and 516.67±79.58 ml in single-approach group, there was a significant difference between the two groups ( t=3.16, P=0.003). The incidence of blood transferring was 17% (4/23) in the combined-approach group and 14% (3/21) in the single-approach group, with no significant difference (χ 2=0.08, P=0.78). All 44 patients were followed up for 8 to 133 months (mean 54 months). The rate of the residual knee subluxation and unsatisfied articular surface reduction in the combined-approach group was lower than that in the single-approach group (34.8% vs. 76.2%, χ 2=7.59, P=0.006; 30.4% vs. 61.9%, χ 2=4.39, P=0.036). There was no significant difference between the combined-approach group and single-approach groups in the postoperative MPTA (86.67°±3.31° vs. 85.86°±4.36°, t=0.88, P=0.386) and PPTA (81.57°±3.22° vs. 83.90°±6.80°, t=1.44, P=0.162). The SMFA and VAS score sin the combined-approach group were significantly better than single-approach groups (20.52±11.04 vs. 31.19±16.79; t=2.51, P=0.016; 2.74±1.32 vs. 3.76±1.04; t=3.13, P=0.007). Conclusion:The efficacy of combined posteromedial and anterolateral approach in the treatment of Wahlquist type C mTPF with coronal subluxation of knee joint is superior to that of traditional single posteromedial reversed L approach.

Anatomical study of the posterolateral ligament complex of the knee: lcl and popliteus tendon / Estudo anatômico do complexo ligamentar posterolateral do joelho: lcl e tendão poplíteo

ABSTRACT Objective: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. Methods: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. Results: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. Conclusion: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

RESUMO Objetivo: Analisar as distâncias entre as inserções femorais do tendão poplíteo (TP) e o ligamento colateral lateral (LCL) através de dissecções de espécimes cadavéricos em uma população miscigenada. Métodos: Cadáveres frescos foram dissecados. Foram registrados dados antropométricos e foi avaliada a distância da origem do TP e do LCL na região femoral com auxílio de paquímetro digital. Foi também avaliado o diâmetro do footprint femoral do TP e do LCL. Resultados: Foram dissecados 11 joelhos não pareados, 8 homens e 3 mulheres com uma idade média de 71,5 ± 15,2 anos, pesando em média 57,2 ± 15,6 kgs e com altura de 170,5 ± 8,2 cm. A distância do centro do footprint femoral do LCL e do TP foi de 10,0 ± 2,4 mm. As distâncias das bordas mais próximas entre si e das mais distantes entre si foram de 3,1 ± 1,1 mm e 16,3 ± 2,4 mm, respectivamente. Conclusão: A distância entre o ponto central do TP e do LCL em nossa população mais miscigenada demonstrou um valor absoluto menor do que é, frequentemente, relatado na literatura. Uma reconstrução ligamentar do CPL com túneis separados para o LCL e o TP pode não ser tecnicamente possível para indivíduos de qualquer população. Nível de Evidência III, Estudos diagnósticos.

Luxación traumática aguda de rodilla. Indicaciones del uso del fijador externo en la urgencia. Revisión bibliográfica sistematizada / Acute knee dislocation. Indications for the use of the external fixator at the emergency room / Deslocamento agudo traumático do joelho. Indicações para o uso do fixador externo na emergência

Resumen: Introducción: la luxación traumática de la rodilla constituye una lesión rara dentro de la patología ortopédica. En muchas ocasiones su diagnóstico pasa desapercibido dado que se dan en el contexto de pacientes politraumatizados, y la falla en el mismo puede derivar en un pronóstico potencialmente letal para el compromiso vital del miembro lesionado. Objetivo: realizar una revisión de la literatura disponible en los últimos veinte años acerca de cuáles son las indicaciones del uso del fijador externo (FFEE) en la luxación traumática aguda de rodilla en la urgencia. Materiales y métodos: se realizó una búsqueda sistematizada a través de los buscadores electrónicos Cochrane, Lilacs, Scielo, Pubmed, Science direct y el portal Timbó. La misma alcanzó un total de 6.495 artículos, y de acuerdo con los criterios de inclusión y exclusión se seleccionaron 14 trabajos para realizarla. Resultados: se destaca que la mayoría de los artículos encontrados son de nivel de evidencia IV. La utilización del uso de la fijación externa en la urgencia como parte de la estabilización temporal y el manejo inicial estaría indicado en los siguientes escenarios clínicos: pacientes politraumatizados, lesión vascular, luxación expuesta, inestabilidad de la articulación, luxación recidivante, luxofracturas, lesiones a nivel del aparato extensor, obesidad mórbida, intolerancia del uso de la férula u ortesis. Conclusión: la sistematización y protocolización a la hora de la toma de decisiones permite disminuir de forma mayoritaria las complicaciones vinculadas a la patología traumática; éstas deben estar dirigidas a la estabilización del paciente en primera instancia, y en segunda instancia a estabilizar la articulación de la rodilla. La fijación externa tiene indicaciones en escenarios clínicos puntuales; sin embargo algunas de estas indicaciones aún son objeto de debate.

Abstract: Introduction: traumatic dislocation of the knee constitutes an unusual lesion in orthopedic pathology, the diagnosis of which is often missed. This is because it occurs in the context of multiple trauma patients, and failure to diagnose it may result in a potentially fatal outcome for the life-threatening compromise of the injured limb. Objective: to perform a literature review of literature on indications for the use of the external fixator in the acute knee dislocation at the emergency room that has been available in the last twenty years. Method: we conducted a systematized search by means of electronic search engines Cochrane, Lilacs, Scielo, Pubmed, Science direct and the Timbó portal. The search included 6495 articles and according to the criteria of inclusion and exclusion 14 studies were selected. Results: the review highlights that most articles found are level of evidence IV. The use of the external fixator in the emergency room as part of the temporary stabilization and initial handling of the condition would be indicated in the following clinical scenarios: multiple trauma patients, vascular lesion, exposed dislocation, joint instability, recurrent dislocation, fracture dislocation, lesions of the extensor apparatus, morbid obesity, splint or orthosis intolerance. Conclusion: systematization and the observation of protocols when it comes to the making of decisions enables the decrease of most complications associated to trauma pathologies. Actions must be geared to stabilizing patients first and to stabilize the knee joint. The external fixator is indicated for specific clinical scenarios. However, some of these indications are still a matter of debate.

Resumo: Introdução: a luxação traumática do joelho é uma lesão rara na patologia ortopédica. Em muitas ocasiões, seu diagnóstico passa despercebido, por ocorrer no contexto de pacientes politraumatizados, e que sua falha pode levar a um prognóstico potencialmente letal para o envolvimento vital do membro lesado. Objetivo: realizar uma revisão da literatura disponível nos últimos vinte anos sobre as indicações do uso do fixador externo na luxação traumática aguda do joelho em pronto-socorro. Materiais e métodos: foi realizada uma busca sistemática nas bases LILACS, SciELO, PubMed, Science Direct, na Biblioteca Cochrane e no portal Timbó. Foram obtidas 6.495 referencias dos quais 14 artigos foram selecionados de acordo com os critérios de inclusão e exclusão. Resultados: a maioria dos artigos encontrados apresentam evidência de nível IV. O uso de fixação externa na emergência como parte da estabilização temporária e manejo inicial, seria indicado nos seguintes cenários clínicos: pacientes politraumatizados, lesão vascular, luxação exposta, instabilidade articular, luxação recorrente, luxação, lesões ao nível do aparelho extensor, obesidade mórbida, intolerância ao uso de tala ou órtese. Conclusão: a sistematização e protocolização no momento da tomada de decisão é o que possibilita reduzir, em sua maioria, as complicações relacionadas à patologia traumática. Estas devem ter como objetivo em primeiro lugar estabilizar o paciente e, em segundo lugar, estabilizar a articulação do joelho. A fixação externa tem indicações em contextos clínicos específicos; no entanto, algumas delas ainda geram controvérsia.

Efficacy of arthroscopic anchor fixation of medial collateral ligament combined with anterior and posterior cruciate ligament reconstruction in the treatment of type KD-IIIM dislocation of knee joint / 中华创伤杂志

Objective:To compare the clinical effect of anchor fixation of medial collateral ligament（MCL）and non-repaired treatment combined with arthroscopic anterior and posterior cruciate ligament reconstruction in the treatment of type KD-IIIM（Schenck classification）dislocation of knee joint.Methods:A retrospective case-control study was conducted to analyze the clinical data of 41 patients with type KD-IIIM dislocation of the knee joint admitted to Xi'an Honghui Hospital of Xi'an Jiaotong University from September 2015 to September 2017. There were 26 males and 15 females，with the age range of 15-62 years［（37.7±13.9）years］. A total of 21 patients were treated by arthroscopic anterior and posterior cruciate ligament reconstruction and anchor fixation of MCL（repaired group）and 20 patients by arthroscopic anterior and posterior cruciate ligament reconstruction without MCL repair（non-repaired group）. The perioperative complications were observed. Comparisons between the two groups were made before operation，4 months after operation and at the last follow-up in terms of Lysholm score，International Knee Documentation Committee（IKDC）score，Visual Analogue Scale（VAS）and range of motion of joint flextion and extension. The medial opening distance of stress X-ray of lower limbs was also observed at the last follow-up.Results:All patients were followed up for 48-66 months［（54.4±5.1）months］. No perioperative complications were noted. The Lysholm score，IKDC score，VAS and range of motion of joint flextion and extension showed no statistical differences between the two groups before operation（ P>0.05），and all were improved from the preoperative level at 4 months after operation and at the last follow-up（ P<0.05）. The Lysholm score in repaired group were（69.7±5.1）points and（83.8±4.9）points at 4 months after operation and at the last follow-up，significantly higher than those in non-repaired group［（61.0±5.5）points and（74.6±6.0）points］（ P<0.05）. The IKDC score in repaired group was（71.8±4.0）points at 4 months after operation，significantly higher than that in non-repaired group［（71.1±3.9）points］（ P<0.05）. The IKDC score in repaired group was（82.3±5.1）points at the last follow-up，similar with that in non-repaired group［（83.2±4.0）points］（ P>0.05）. The VAS in repaired group was（2.5±0.6）points at 4 months after operation，significantly decreased in comparison with（3.2±1.2）points in non-repaired group（ P<0.05）. The VAS in repaired group was（2.0±1.4）points when compared to（2.2±1.3）points in non-repaired group at the last follow-up（ P>0.05）. The range of motion of joint flextion and extension in repaired group was（107.6±6.9）° and（125.9±7.8）° at 4 months after operation and at the last follow-up，significantly increased in comparison with（89.6±4.0）° and（120.9±5.2）° in non-repaired group（ P<0.05）. The medial opening distance in repaired group was（2.3±0.2）mm at the last follow-up，significantly decreased when compared to（3.1±0.2）mm in non-repaired group（ P<0.05）. Conclusion:For type KD-IIIM knee dislocation，arthroscopic anchor fixation of MCL or without MCL repair combined with anterior and posterior cruciate ligament reconstruction are both effective in satisfactory functional recovery，but MCL repair contributes to earlier function recovery，faster pain relief and more reliable joint stability.

Application of transosseous suture in situ technique in repair of anterior cruciate ligament for multiple ligament injuries with knee dislocation / 中国修复重建外科杂志

Objective: To investigate the method and effectiveness of transosseous suture in situ technique in repairing anterior cruciate ligament (ACL) avulsion injury for the multiple ligament injuries with knee dislocation (MLIKD). Methods: The clinical data of 27 patients (27 knees) with MLIKD between September 2010 and April 2016 were analyzed retrospectively. There were 21 males and 6 females, with an average age of 42 years (range, 24-60 years). The injury was caused by traffic accident in 9 cases, heavy-weight crushing in 9 cases, sports sprain in 6 cases, falling from height in 3 cases. The interval from injury to operation was 1-19 days (mean,10.8 days). There were 20 cases of femoral avulsion injury of ACL, 7 cases of tibial avulsion injury of ACL, and there were 17 cases of posterior cruciate ligament (PCL) injuries. According to the Schenck classification, there were 15 cases of KD-Ⅲ-M type, 8 cases of KD-Ⅲ-L type, and 4 cases of KD-Ⅳ type. All patients were positive in the posterior drawer test and Lachman test; 8 cases were degree Ⅲ positive in varus stress test, and 15 cases were degree Ⅲ positive in valgus stress test. The Lysholm score of knee was 27.6±6.5, the International Knee Documentation Committee (IKDC) score was 25.5±6.2, and the range of motion (ROM) of knee was (45.1±10.2)°. The injured PCL was reconstructed with a single bundle of autologous hamstring tendon. ACL was repaired with double bundle traction by transosseous suture in situ technique. Medial cruciate ligament, lateral cruciate ligament, joint capsule, and other damaged structures were repaired at the same time. Results: All incisions healed by first intention. There were 3 cases with joint effusion and 3 cases with incomplete flexion. All patients were followed up 12-36 months (mean, 22 months). The X-ray films showed good stability in all directions. At last follow-up, the anterior and posterior drawer tests were all negative; Lachman test was degreeⅠpositive in 4 cases, valgus stress test was degreeⅠpositive in 3 cases, varus stress test was degreeⅠpositive in 1 case; and all tests were negative in the rest patients. At 1 year after operation, the ROM of knee was (119.3 ±12.6)°, Lysholm score was 87.2±6.3, and IKDC score was 87.9±6.3, showing significant differences when compared with the preoperative scores ( P<0.05). Conclusion: Transosseous suture in situ technique can be used to repair the ACL avulsion injury for MLIKD, which can significantly improve the stability, mobility and function of the knee joint, and obtain satisfied short-term effectiveness.

Tratamiento conservador en luxación congénita de rodilla: reporte de un caso y revisión de la literatura / Conservative treatment in congenital knee dislocation: report of a case and review of the literature

Introducción: la luxación congénita de rodilla es una de las alteraciones anatómicas muy poco frecuente, que su diagnóstico se basa en los hallazgos clínicos obtenidos al nacimiento y corroborados con exámenes radiológicos. La evolución y complicaciones que puede acarrear esta patología dependerá del grado de severidad y del momento de la instauración del tratamiento, ya que un tratamiento oportuno conducirá a una movilidad adecuada y un desarrollo sicomotor apropiado. Presentación del caso: presentamos un caso observado en nuestro hospital con seguimiento por cinco meses, en donde se le realizo un cambio paulatino de inmovilizaciones cruropédica y controles radiológicos sucesivos. Se realiza una revisión de caso clínico y revisión bibliográfica. Resultado: el presente caso muestra un manejo conservador en un recién nacido con Luxación Congénita de Rodilla, con el que se obtuvo una adecuada reducción mediante un manejo conservador oportuno. Conclusiones: un diagnóstico apropiado acompañado de un tratamiento oportuno otorgó una recuperación eficaz llevando a una movilidad adecuada, evitando complicaciones serias tanto musculo esqueléticas y sicosociales(AU)

Introduction: congenital knee dislocation is one of the very rare anatomical alterations, whose diagnosis is based on the clinical findings obtained at birth and corroborated with radiological examinations. The evolution and complications that this pathology can bring will depend on the degree of severity and on the time of the initiation of the treatment, since an opportune treatment will lead to an adequate mobility and an appropriate psychomotor development. Case: we present a case observed in our hospital with follow-up for five months, in which a gradual change of cruropic immobilizations and successive radiological controls was made. A clinical case review and bibliographic review is carried out. Result: the present case shows a conservative management in a newborn with Congenital Knee Dislocation, with which an adequate reduction was obtained through opportune conservative management. Conclusions: an appropriate diagnosis accompanied by an opportune treatment granted an effective recovery leading to an adequate mobility, avoiding serious musculoskeletal and psychosocial complications(AU)

Open Reduction of Neglected Knee Dislocation: Case Report of a Rare Injury

Old neglected dislocation of knee joint is a rare injury. Any orthopaedic surgeon would have faced only a few cases of unreduced neglected dislocation in his life time practice. We report the case of a 30-year old male patient with one month old unreduced knee dislocation which was managed with open reduction and stabilization with two intra-articular crossed Steinman pins for six weeks, followed by removal of the pins and gradual weight bearing in hinged knee brace. At the end of one year, range of movement of knee joint was 0 to 50 degree with minimal knee pain on walking.

Posterior Keen Dislocation with Anterior Tibial Plateau Fracture: Report of 25 Cases / 昆明医科大学学报

Objective To discuss the injury mechanisms of posterior keen dislocation with anterior tibial plateau fracture and to provide theoretic support for clinic diagnosis and treatment.Methods Total of 25 cases with posterior knee dislocation and anterior tibial plateau fracture were enrolled from June,2009 to June,2012.Injury mechanisms were analyzed from the point of view of mechanics by combining with detailed histories,X-ray,CT scan and MRI results,and surgical findings.Results All of 25 cases were high-energy injury,with 13 falling from heights (about 2-5 meters),10 injured in traffic accident,1 falling down by carrying heavy backpacks and 1 rolling down hill.Posterior knee dislocation with the anterior tibial plateau fracture were found in all the 25 cases,among which 5 cases were with common peroneal nerve injury and popliteal artery rupture,and 1 case was with capitulum fibulae fracture and the rest were with no obvious artery nerve injury One years after operation,the average HSS score of the knee joint was 88.5 and the excellent and good rate was 93.7％.Conclusion The main reason of the backward dislocation of knee joint with the anterior border fracture of tibial plateau was high energy trauma and it was a new type of fracture-dislocation of knee joint.After backward dislocation of knee joint,we should carefully check whether there is the anterior-edge fracture of tibial plateau before operation to avoid misdiagnosis;reduction of the anterior-edge fracture of tibial plateau must be done Anatomically in operation,which can reduce the occurrence of instability of knee joint after operation and improve the operation effect.

Uso do fixador externo articulado no tratamento cirúrgico da instabilidade multiligamentar crônica do joelho

INTRODUÇÃO: A instabilidade multiligamentar do joelho, normalmente, é provocada por um trauma que determina sua luxação, um evento pouco frequente, mas, que pode trazer sequelas devastadoras. Mesmo com o tratamento cirúrgico preconizado é alto o índice de complicações. A mobilização precoce no pósoperatório provoca afrouxamento dos ligamentos reconstruídos, o que leva à instabilidade residual. A imobilização melhora a estabilidade, mas provoca dor e rigidez. Este trabalho tem o objetivo de avaliar se o uso do fixador externo articulado proporciona melhora na mobilidade, estabilidade e na função subjetiva de pacientes submetidos à reconstrução ligamentar. MÉTODOS: Neste ensaio clínico randomizado com grupos paralelos, 33 pacientes do ambulatório do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo com mais que 3 semanas de lesão dos ligamentos cruzados anterior e posterior associado à lesão de ligamento colateral fibular e/ ou ligamento colateral tibial foram submetidos à cirurgia de reconstrução multiligamentar, após alocação cega aleatória ao grupo 0 - controle (18 pacientes), com órtese rígida ou ao grupo 1 - fixador externo articulado por 6 semanas (15 pacientes), no período entre novembro de 2010 e novembro de 2013. Após seguimento mínimo de um ano de pós-operatório, a estabilidade dos ligamentos reconstruídos foi avaliada ao exame físico, foram mensurados os déficits de extensão e de flexão residual em relação ao joelho contralateral não acometido e foi aplicado o questionário específico para sintomas do joelho de Lysholm...

NTRODUCTION: Multiligament knee instability is normally caused by a trauma which results in its dislocation, an infrequent event, but one which can have devastating aftereffects. Even with the recommended surgical treatment the rate of complications is high. Early post-operative mobilization provokes loosening of the reconstructed ligaments, which leads to residual instability. Immobilization improves the stability, but causes pain and stiffness. This study aims to assess whether the use of an articulated external fixator provides improvements in the mobility, stability and the subjective function of the patients submitted to ligament reconstruction. METHODS: In this randomized clinical trial with parallel groups, 33 patients of the outpatient clinic of the Institute of Orthopaedics and Traumatology of the Hospital das Clínicas of the University of Sao Paulo with more than 3 weeks of injury to the anterior cruciate ligaments and the posterior cruciate ligaments associated with injury to the fibular collateral ligament and/or medial collateral ligament, were submitted to multiligament reconstruction surgery, after blind random allocation to either: Group 0 - control (18 patients), with rigid bracing, or to Group 1 - articulated external fixator for 6 weeks (15 patients), in the period from November, 2010 to November 2013. The stability of the reconstructed ligaments were assessed after 1 year postoperatively by physical examination, the deficit of residual extension and flexion was measured in relation to the unaffected contralateral knee and the Lysholm knee scoring scale questionnaire was applied...

Luxación congénita de rodillas: presentación de un caso / Congenital Dislocation of the Knee: A Case Report

Se presenta el caso de una recién nacida con diagnóstico de luxación congénita de rodilla bilateral sin patologías asociadas, con adecuada evolución tras la instauración de tratamiento ortopédico. La luxación congénita de rodillas es una patología infrecuente (1 en 100.000 nacidos), 80 veces menos frecuente que la displasia en el desarrollo de las caderas y, por ende, con pocos casos en la literatura mundial y ningún caso en la literatura nacional. Se caracteriza por hiperextensión de la rodilla y marcada limitación para la flexión. El diagnóstico y el tratamiento tempranos se asocian a un buen pronóstico

We present a case of a newborn diagnosed with Bilateral Congenital Knee Dislocation, without associated pathologies and with a proper progression after orthopedic treatment. Bilateral Congenital Knee Dislocation is uncommon; with an incident of 1 in 100,000 births, which is 80 times less frequent than hip dysplasia. Therefore, fewer cases have been reported in global literature and no cases have been reported in national literature. Bilateral Congenital Knee Dislocation is characterized by knee hyperextension and a strong limitation in flexion. Early diagnosis and treatment are associated with a good prognosis.

Knee dislocation: descriptive study of injuries / Luxação do joelho: estudo descritivo das lesões

OBJECTIVE:Describe the ligamentous and associated injuries that occur in the traumatic knee dislocation, relating them to the mechanisms of trauma and to identify patterns of injuries. METHODS: Twenty three knee dislocations were described in the period between March 2010 and March 2011. After the diagnosis of the lesions, the reduction and transarticular external fixation of the dislocated knees were done. At the second moment, the patients were evaluated with physical examination under anesthesia and the surgical exploration of peripheral lesions was perfomed by a surgeon of the knee surgery group of this institution.The patients data with the description of the injuries were found and registered. RESULTS: 65% of patients were male, the average age was 35 years and the most common mechanism of trauma was the motorcycle accident (60%). The lesion of the anterior cruciate ligament (ACL) occurred in 75% of the cases, and the lesion of posterior cruciate ligament (PCL) in 95%. The medial peripheral injuries happened in 65% of the dislocations, and the lateral lesions in 40%. The most common dislocations were classified as KDI (25%) and as KDIIIm (25%). The arterial injury was present in 15% of the cases, and the nervous injury where registered in one patient (5%). At the initial radiographic evaluation, 45% of the dislocations presented reduced. CONCLUSION: The characteristics of the knee dislocations described showed a great range of variability demonstrating that an individualized evaluation of each case is mandatory. The surgeon should be able to recognize and choose the correct treatment to these lesions. .

OBJETIVO:Descrever as lesões ligamentares e associadas ocorridas nas luxações traumáticas do joelho, relacioná-las aos mecanismos de trauma e identificar padrões de lesões. MÉTODOS: Foram descritas 23 luxações do joelho entre março de 2010 e março de 2011. Após o diagnóstico das lesões, foi procedida a redução e fixação externa transarticular das luxações. Num segundo tempo, os pacientes foram avaliados sob anestesia e a exploração cirúrgica das lesões periféricas foi feita pelos membros do grupo de cirurgia do joelho da instituição. Os dados dos pacientes, junto com as descrições das lesões encontradas, foram registrados. RESULTADOS: 65% dos pacientes eram do sexo masculino, a média de idade foi de 35 anos, o mecanismo de trauma mais comum foi o acidente com motocicleta (60%). A lesão do ligamento cruzado anterior (LCA) ocorreu em 75% dos casos, a lesão do ligamento cruzado posterior (LCP) em 95%. A lesão periférica medial aconteceu em 65% das luxações e as lesões laterais em 40%. As luxações mais comuns foram as classificadas como KDI (25%) e KDIIIm (25%). A lesão arterial esteve presente em 15% dos casos e a lesão nervosa foi registrada em um paciente (5%). Na avaliação radiográfica inicial, 45% das luxações apresentavam-se reduzidas. CONCLUSÃO: As luxações do joelho descritas apresentaram grande variabilidade, demonstrando que é preciso a avaliação individualizada de cada caso, sendo que o ortopedista precisa estar apto para o reconhecimento e tratamento específicos dessas diversas lesões. .

Treatment strategy and clinical outcome of knee dislocation / 中华骨科杂志

Objective To discuss the treatment strategy of knee dislocation and to evaluate its outcome.Methods Thirty-six patients with unilateral knee dislocation treated with individualized protocol were studied retrospectively,including 22 males and 14 females with an average age of 35 years (range,19-72 years).There were 30 acute and 6 chronic knee dislocations.According to the modified Schenck's classification of knee dislocation,there were 7 KD- Ⅰ and 23 KD-Ⅲ cases in the acute category,and all 6 chronic cases were KD-Ⅲ.Seven acute KD- Ⅰ and 6 chronic KD-Ⅲ cases underwent one-stage arthroscopic surgery.In 23 acute KD-Ⅲ cases,2 were treated conservatively with splint or brace due to advanced age,18 with staged surgery,3 with one-stage surgery due to concomitant vascular and nerve injury.Functional and clinical evaluation was conducted at final follow-up.Results All 36 patients were followed up for an average of 27 months (range,18-36 months).The Lysholm score (82.0±11.4),Tegner score (5.5±1.3),and knee range of motion (118.3°±19.2°) at final follow-up showed a statistically significant improvement compared with preoperative results (P＜O.O1).Eight (23.5％) patients had residual knee instability:posterior drawer test and Sag sign were positive (++ or +++) in 8 knees,valgus instability (++) in 1 and varus instability (+++) in 1.The remaining 28 knees were stable.Conclusion Special attention should be paid to rotational knee dislocation with single cruciate ligament rupture.Properly individualized treatment plan is the key to optimal outcome.Arthroscopic surgery can lead to successful outcome.Early one-stage arthroscopic surgery is recommended for acute KD-Ⅰ and chronic KD-Ⅲ dislocation,staged arthroscopic surgery for acute KD-Ⅲ dislocation.

Treatment of Multiple Ligaments Injuries

Multiple ligament injury, which means disruption of at least 3 of the 4 major ligaments, generally occurs due to high energy trauma. Knee dislocation usually leads to the multiple ligament injury, and the terms 'knee dislocation' and 'multiple ligament injury' are used interchangeably. In some cases, a dislocated knee may have been spontaneously reduced immediately after the trauma. This is the reason why we should consider the possibility of knee dislocation and carry out a thorough vascular and neurologic evaluation when a patient with multiple ligament injury presents to an emergency department. Multiple ligament injury, when not properly treated, may lead to instability of the knee joint, resulting in posttraumatic arthritis. Though treatment and rehabilitation of multiple ligament injury is difficult, we should pursue full recovery of the knee joint through precise examination and proper treatment. There is controversy about conservative vs. surgical treatment, early vs. delayed surgeory, and repair vs. reconstruction, but surgical treatment and early reconstruction are now preferred.

Luxação aguda isolada da articulação tibiofibular proximal / Acute isolated anterolateral dislocation of the proximal tibiofibular joint

A luxação traumática isolada da articulação tibiofibular proximal é rara. Esta lesão pode não ser reconhecida ou diagnosticada no atendimento inicial. A ausência de suspeita clínica pode causar problemas para o diagnóstico. O diagnóstico necessita de história precisa do mecanismo e sintomas da lesão, avaliação clínica e radiográfica adequada de ambos joelhos. Casos não reconhecidos são fonte de alterações crônicas. O tratamento é feito por redução fechada e imobilização ou, em casos irredutíveis ou instáveis, redução aberta com fixação interna temporária. Um caso raro de luxação tibiofibular proximal isolada em um jogador de basquetebol é relatado para ilustrar essa lesão.

The isolated traumatic dislocation of the proximal tibiofibular joint is rare. The injury could go unrecognized or be misdiagnosed at the initial presentation. Lack of clinical suspicion can cause diagnostic problems. The diagnosis requires accurate history of the mechanism and symptoms of the injury, and adequate clinical and radiographic evaluation of the both knees. Overlooked injuries are a source of potentially chronic changes. The treatment is closed reduction and immobilization or, in case of a failed or unstable reduction, open reduction with temporary internal fixation. A rare case of acute isolated anterolateral dislocation of the proximal tibiofibular joint in a basketball player was described to illustrate this injury.

Luxação traumática de joelho: análise clínica / Traumatic knee luxation: clinical analysis

Objetivo: comparar o resultado funcional final, obtido no tratamento da luxação traumática de joelho, com diferentes modalidades de tratamento. Pacientes e Método: na classificação das luxações, utilizou-se os critérios de Schenck e foram excluídos casos que apresentavam comorbidades que pudessem interferir no resultado funcional do joelho acometido.Os pacientes foram reexaminados e a avaliação constou dados objetivos e subjetivos:anamnese, exame físico e Escala de Lysholm. Resultados: a média de idade foi de 35,6 ±14,4 anos, com predomínio do gênero masculino. O mecanismo de trauma mais freqüente foi o acidente de trânsito. O padrão de luxação mais observado foi o KD-III. O ligamento cruzado posterior foi o mais lesado (86,8%), seguido pelo cruzado anterior (80%). Quatro pacientes (26,7%) tiveram lesão do nervo fibular comum, dois com recuperação completa.O tratamento cirúrgico na fase aguda foi realizado em 11 pacientes, dando-se prioridade para a reconstrução do ligamento cruzado posterior. A dor foi a queixa mais freqüente. Os pacientes operados, na fase aguda, obtiveram melhores resultados do que os tratados conservadoramente ou os operados na fase crônica. Não houve perda importante de amplitude de movimentos, mas foi observada a instabilidade residual, o que não chegou a limitar os pacientes na vida cotidiana. Conclusão: a luxação de joelho, sem dano vascular, tem bom prognóstico com tratamento adequado. Um grau variável de instabilidade residual é esperado e bem tolerado. Já o reparo ou reconstrução das lesões periféricas e do LCP (Ligamento Cruzado Posterior) foram satisfatórios, considerando-se os critérios subjetivos e objetivos.

Objective: to compare the final functional result, obtained in the treatment of traumatic knee luxation, with different treatment modalities. Patients and Methodology: the Schenk criteria were used in the luxations classification and the cases with comorbidities that might interfere in the impaired knee functional result were excluded. The patients were reexamined and the evaluation counted with objective and subjective data: anamneses, physical exam and Lysholm Scale...

Luxación de rodilla con lesión aislada del ligamento cruzado anterior: reporte de un caso / Knee dislocation with anterior cross ligament isolated lesion: one case report

We describe a very unusual case of a 28 year old man with a complete anterior knee dislocation, following anterior cruciate ligament (ACL) disruption without any other ligament tears. The pathology of the knee joint was torn ACL, intact meniscus and other ligaments and bone bruise of the trochlear grove. After joint reduction the ACL reconstruction was performed two weeks after the injury, obtaining a complete functional recovery. He had a Lysholm score of 95 points and a normal IKDC score.

Este artículo escribe un caso poco usual de una luxación anterior de rodilla, con lesión aislada de ligamento cruzado anterior en un paciente deportista de 28 años. El estudio clínico y de resonancia magnética demostró lesión aislada el ligamento cruzado anterior (LCA), edema óseo en la tróclea femoral y ausencia de otras lesiones ligamentosas y meniscales de la rodilla. Luego de la reducción ortopédica, se programó una reconstrucción del LCA, dos semanas después el accidente. La evaluación alejada a dos años plazo, muestra una articulación estable. La aplicación de la escala de Lysholm fue de 95 puntos y un IKDC normal.

Two Stage Surgical Treatment of Acute Traumatic Knee Dislocation / 대한정형외과학회잡지

PURPOSE: The purpose of this study was to determine the effectiveness of a new two stage surgical treatment for acute traumatic knee dislocation. MATERIALS AND METHODS: The study involved 15 knees in 14 patients treated between October 1997 and November 2001. The mean follow-up period was 24 months. In the first surgical stage, medial and/or lateral ligament complexes were repaired or reconstructed within two weeks of the injury. In the second surgical stage, once full range of motion was obtained 3-6 months later, anterior or posterior cruciate ligaments (ACL or PCL) were reconstructed if significant laxity was present. The final outcomes were assessed using stress X-rays, range of motion and Lysholm score. RESULTS: There were ten cases of MCL tear and eight cases of LCL tear. All MCL and LCL injuries were either repaired or reconstructed. All cases had both ACL and PCL tears. Following the first stage of MCL/LCL surgery, the second stage surgery of ACL or PCL reconstructions was deemed to be necessary in three and seven cases, respectively. Five cases did not require ACL or PCL reconstruction. In stress X-rays at the last follow up examination, MCL, LCL, ACL and PCL instability was graded as 0 or 1 in 15, 14, 15 and 11 cases, respectively. PCL instability was graded as 2 in four cases. The mean postoperative Lysholm score was 87.6 points. CONCLUSION: The two stage surgical approach described here resulted in good outcomes for patients suffering from acute knee dislocation patients in terms of range of motion and stability.

Operative Treatment of Traumatic Dislocation of the Knee Joint: Result of Staged Reconstruction of Cruciate Ligament

PURPOSE: To evaluate clinical result of staged treatment of traumatic dislocation of the knee joint. MATERIALS AND METHODS: This study population included 15 men and 1 women who were treated between 1996 to 2001. MCL injury was treated with primary repair/ conservative treatment and posterolateral instability was treated with primary repair /augmentation. Combined meniscal injury was treated with repair/partial meniscectomy. After 3 monthes, ACL or PCL was treated by reconstruction if needed. PCL reconstruction was performed in 7 and after 5 monthes in 3 of them ACL reconstruction was performed. In 6, only ACL reconstruction was performed. In 3, no cruciate ligament reconstruction was performed. The evaluation included range of motion, Lyaholm score, stress radiogram. RESULTS: Lysholm mean value was 82.8 and ROM 124 degrees. Complication is 1 peroneal nerve palsy and 1 arthrofibrosis. Average posterior drawer compared with contralateral limb is 5.1mm. CONCLUSION: We suggest that this staged treatment for traumatic dislocation of the knee joint reduce the frequency of complication such as arthrofibrosis and obtain stability of knee joint. Acute PCL reconstruction is necessary for complete PCL tear on MRI in multiple ligament injuries.