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.

Luxación tibioperonea proximal. Tratamiento con fijación interna dinámica. Reporte de un caso y revisión bibliográfica / Proximal tibiofibular dislocation. Dynamic internal fixation. Case report and bibliographic revision

Presentamos el caso clínico de un paciente de cuarenta y un años que ingresa por guardia con dolor agudo de rodilla luego de un traumatismo deportivo (practicando fútbol). Se diagnosticó luxación de la articulación tibioperonea proximal. El tratamiento elegido fue quirúrgico mediante fijación dinámica de la articulación tibioperonea proximal con buena evolución y retorno a la actividad deportiva. Realizamos una búsqueda bibliográfica sobre las últimas publicaciones de dicha patología y sus tratamientos. La luxación de esta articulación proximal es una patología infrecuente y requiere de su sospecha para realizar el diagnóstico inicial. La fijación interna dinámica es una opción de tratamiento válida. Nivel de Evidencia: IV

We present the clinical case of a forty-one-year-old patient who was admitted with acute knee pain after a sports injury (playing football). A diagnosis of dislocation of the proximal tibiofibular joint was made. Surgical treatment was performed by means of dynamic fixation of the superior tibiofibular joint with good evolution and return to sports activity. We carry out a search on the latest publications presented on this pathology and its treatments. The dislocation of the proximal tibiofibular joint is an infrequent pathology and requires its suspicion to make the initial diagnosis. Dynamic internal fixation is a valid treatment option. Level of Evidence: IV

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.

Corrección de la altura patelar en inestabilidad rotuliana / Correction of patellar height in patellofemoral instability

El manejo de la inestabilidad patelofemoral se basa en una adecuada evaluación de alteraciones anatómicas predisponentes. Patela alta es una de las causas más importantes de inestabilidad objetiva. La alteración biomecánica que ésta produce puede conducir a luxación patelar recurrente, dolor y cambios degenerativos focales. El examen físico es fundamental en la toma de decisiones. La evaluación imagenológica ha evolucionado desde métodos basados en radiografía hacia mediciones en resonancia magnética, que permiten una orientación más acabada de la relación existente entre la rótula y la tróclea femoral. El tratamiento se fundamenta en la corrección selectiva de los factores causales, donde la osteotomía de descenso de la tuberosidad anterior de la tibia y la reconstrucción del ligamento patelofemoral medial son herramientas que deben considerarse racionalmente. Este artículo realiza una revisión de la literatura, otorgando los fundamentos quirúrgicos que explican la importancia del tratamiento específico de patela alta en inestabilidad rotuliana.

Patellofemoral instability management is based on a thorough evaluation of predisposing anatomical factors. Patella alta is one of the utmost causes of objective instability. As a result, biomechanical disturbance can lead to recurrent patellar instability, pain, and focal degenerative changes. Physical examination is paramount in decision making. Imaging evaluation has evolved from X-rays based methods to magnetic resonance measurements, which allows a more accurate assessment of the patellotrochlear relationship. Treatment is based on a selective risk factors correction, where tibial tubercle distalization osteotomy and medial patellofemoral ligament reconstruction must be considered altogether. This article reviews the surgical rationale of patella alta treatment in patellofemoral instability.

Comparative study on posterior cruciate ligament reconstruction with autologous hamstring tendon and LARS artificial ligament in the treatment of KD-Ⅲ-M knee dislocation / 中国骨伤

OBJECTIVE@#To observe the curative effect of one-stage reconstruction of anterior cruciate ligament(ACL), posterior cruciate ligament (PCL) and medial collateral ligament (MCL) in patients with KD-Ⅲ-M knee injury, and to compare the operation time, hospitalization cost and curative effect after arthroscopic reconstruction of PCL with LARS artificial ligament and autogenous hamstring tendon, ACL reconstruction with autogenous hamstring tendon and MCL repair combined with limited incision.@*METHODS@#From March 2016 to January 2019, a total of 36 patients met the criteria of this study. Twenty patients in group A were treated with autogenous hamstring tendon reconstruction of ACL and PCL and repair of MCL, including 17 males and 3 females, with an average age of (34.7±9.2) years old. Sixteen patients in group B with LARS artificial ligament reconstruction of PCL, with an autogenous hamstring tendon reconstruction of PCL and MCL repair as before as group B, including 15 males and 1 female, with an average age of (36.8±8.6) years old. The operation time, hospitalization time and total hospitalization cost were compared between the two groups. The preoperative and postoperative functions of the two groups were evaluated by Hospital for Sepcial Surgery (HSS) score and Lysholm score respectively, and the curative effects were compared within and between groups.@*RESULTS@#All the patients in the two groups were followed up for at least 1 year. There were no complications such as infection and poor wound healing in both groups. There was significant difference in operation time between (120.25±9.55) min in group A and (106.63±8.85) min in group B (@*CONCLUSION@#There was no significant difference in the average hospitalization days between the two groups, but the operation time in group A was longerthan that in group B, and the hospitalization cost in group B was higher than that in group A. There was no difference in HSS score and Lysholm score before and follow-up for a certain period of time after operation.

Luxación recurrente habitual femorotibial en un paciente con síndrome de Larsen / Femorotibial habitual recurrent dislocation in patient with Larsen Syndrome

El síndrome de Larsen (OMIM 150250) fue descripto por primera vez en 1950 como una entidad caracterizada por rasgos faciales distintos y dislocaciones de múltiples articulaciones, paladar hendido, pérdida de audición y anomalías en la columna vertebral. Se estima que la prevalencia del síndrome de Larsen es uno por cada cien mil nacidos vivos.El manejo de múltiples luxaciones de las grandes articulaciones a menudo resulta difícil, particularmente si un paciente tiene una luxación completa de la rodilla. Tratamos a un niño con una luxación recurrente en forma habitual femorotibial completa. Según nuestro conocimiento, no hemos encontrado en la literatura ningún trabajo que describa el tratamiento de esta rara patología en un paciente que luxe completamente la tibia anteriormente sobre el fémur de manera habitual

Larsen syndrome (OMIM 150250) was first described in 1950 as an entity characterized by distinct facial features and dislocations of the multiple large joint, and cleft palate, hearing loss, and spinal abnormalities. The prevalence of Larsen syndrome is estimated to be one in hundred thousand live births. Management of multiple large-joint dislocations often proves difficult with a tendency toward recurrence, particularly if a patient has complete dislocation of the knee. We treated a boy with a clinical habitual recurrence femorotibial luxation. We have not found in the literature any paper in our knowledge that describes the treatment of this rare pathology of a patient who completely dislocate the tibia anteriorly on the femur in the usual way

Realineamiento Proximal del Mecanismo Extensor en la Luxación Congénita de la Rótula en Niños y Adolescentes / Proximal Realignment of the Extensor Mechanism in Congenital Dislocation of the Knee in Children And Adolescents

Introducción La luxación congénita de la rótula (LCR) es una entidad poco frecuente. El diagnóstico precoz suele ser difícil porque la rótula en el recién nacido es pequeña y de difícil palpación. El tratamiento no quirúrgico ha demostrado ser ineficaz. El enfoque terapéutico de esta patología requiere de la liberación externa y extensa del cuádriceps, el avance del vasto interno oblicuo y de la transferencia o hemitransferencia del aparato extensor. Materiales y métodos se busca evaluar la funcionalidad de los pacientes tratados quirúrgicamente mediante realineamiento proximal del mecanismo extensor por la técnica descrita por Green y modificada por los autores. Desde el año 2000 hasta el año 2015 se recolectaron 15 pacientes (20 rodillas) con diagnóstico de LCR tratados quirúrgicamente mediante la técnica descrita. Resultados Los resultados postoperatorios fueron evaluados mediante el cuestionario Kujala: 93.8/100 en promedio. Discusión El tratamiento de la LCR es un desafío y más aún si se encuentra asociada a retracción idiopática del recto anterior. Los resultados clínicos y funcionales obtenidos sugieren que la recolocación anatómica y estable de la rótula dentro de la tróclea femoral permite una satisfactoria alineación extensora del cuádriceps, desapareciendo su acción flexora inicial, lo que permite la elongación progresiva del mecanismo extensor durante las fases postoperatorias de rehabilitación. La técnica quirúrgica descrita ofrece una buena alternativa para el tratamiento de esta infrecuente patología congénita de la rodilla.

Background Congenital dislocation of the patella (CDP) is a rare condition. The early diagnosis is difficult, as the patella in the newborns is small and also difficult to recognise. The therapeutic approach of this disorder requires the extended and external release of the quadriceps, the forward movement of the internal oblique vastus, and the transfer or hemi-transfer of the extensor compartment. Methods To review the functionality of those patients who have received surgical treatment with proximal realignment of the extensor mechanism using Green's surgical technique and the one modified by the author. Between the years 2000 and 2015, a total of 15 patients with 20 knees found to have had congenital dislocation of the patella, and had received the abovementioned surgical treatment. Results The post-operative results were evaluated using the Kujala questionnaire, which gave a mean result of 93.8 / 100. Discussion The CDP treatment is a challenge, and even more so if it is associated with an idiopathic retraction of the anterior rectus. The clinical and functional results obtained suggest that an anatomic and stable realignment of the patella in the femoral trochlea allows a satisfactory extensor alignment of the quadriceps. This leads to the disappearance its initial flexor action, which allows the gradual elongation of the extensor mechanism during the postoperative phases of rehabilitation. The surgical technique described offers a good alternative for the treatment of this rare congenital disorder of the knee.

Retrospective analysis on treatment methods and curative effects of reducing the disability rate of multiple ligament injuries and dislocations of the knee joint / 中国骨伤

OBJECTIVE@#To investigate the clinical effects of individualized repair and reconstruction surgery for multiple ligament injury and dislocation of knee joint based on stage classification diagnosis.@*METHODS@#From January 2018 to January 2019, 42 patients with multiple ligament injury and dislocation of the knee joint were treated. There were 27 males and 15 females, aged from 30 to 63 (47.35±11.90) years old, including 17 left knees, 23 right knees and 2 bilateral knees. All patients with multiple ligament injuries and dislocations of the knee joint were classified by stages and improved Schenck diagnosis. Among them, 23 cases were in acute stage (≤3 weeks), 19 cases were in old stage (>3 weeks), 27 cases were type Ⅲ dislocation and type Ⅳ dislocation. There were 9 cases of dislocation and 6 cases of type Ⅵ dislocation. The corresponding repair methods such as closed manipulation and open release reduction, direct suture of ligament, anchor suture, bone penetrating suture, and routine ligament reconstruction were performed. The corresponding "progressive progressive excitation" rehabilitation program was adopted after the operation. After 2, 4, 6, 8 weeks and 3, 6, 9, 12 months after operation, the outpatient consultation and evaluation of knee joint function and stability were completed. The knee joint stability, excellent and good rate, disability rate and complication rate were compared before and after operation. Internation Knee Documentation Committee (IKDC) grade, IKDC subjective score, Lysholm score and Tegner score were used to evaluate knee joint function.@*RESULTS@#All patients completed the outpatient follow-up and follow-up on schedule. All patients had gradeⅠwound healing, 4 patients had lower extremity venous thrombosis after operation, and there were no serious complications after anticoagulant treatment; 5 patients with common peroneal nerve injury were treated with release surgery and active postoperative rehabilitation, and neurological function gradually recovered. At 12 months after operation, the muscle strength of the affected limb reached grade Ⅴ and the active and passive range of motion recovered to more than 120 degrees. In the acute stage, the IKDC subjective scores were 20.46±12.61, 22.58±16.83, 0.71±1.14, 69.55±16.57, 77.73±15.14 and 3.14±1.67, respectively. One year after operation, IKDC subjective score was 67.04±19.07, Lysholm was 74.87±14.58, Tegner was 3.06±1.70, and 6 of them were grade A. After 12 months, the knee function scores of all patients were significantly improved compared with those before operation(@*CONCLUSION@#According to the classification of multiple ligament injuries and dislocations of the knee joint, the corresponding surgical repair and reconstructiontreatment were adopted, and the corresponding rehabilitation program was adopted after the operation. The patients achieved good clinical treatment effect 12 months after operation, and the patients' satisfaction was high, which improved the excellent and good rate of treatment and reduced the disability rate.

Irreducible Knee Dislocation with Vastus Medialis Muscle Interposition

Knee dislocation is one of the rare orthopedic emergencies that require special management with an annual incidence rate of less than 0.02%. Knee dislocations are classified by Kennedy, according to the direction of tibial dislocation in relation to the femur, as anteromedial, posteromedial, anterolateral, and posterolateral. Operative intervention and multi-ligament reconstruction are usually required in knee dislocation. Interposition of the vastus medialis inside the joint of a dislocated knee is an uncommon scenario where reduction becomes impossible. In this report, we present a case of irreducible knee dislocation with vastus medialis muscle interposition. Before reduction, we performed arthroscopy of the knee and removal of the interposed muscle to prevent extravasation of the fluid by sealing the torn capsular area.

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)

Luxación expuesta de rodilla: ¿Qué hemos aprendido en los últimos 20 años? / Open knee dislocations: what have we learn about it in the last 20 years?

INTRODUCCIÓN: La luxación expuesta de rodilla es compleja, de incidencia baja con grandes secuelas funcionales. Existen escasos reportes de series en la literatura relativos a su manejo y resultados. OBJETIVO: El objetivo de este trabajo fue describir los resultados obtenidos de todos los pacientes con luxación expuesta de rodilla tratados durante las últimas dos décadas en nuestro hospital bajo un mismo estándar de tratamiento. MÉTODO: Estudio descriptivo retrospectivo en una serie quirúrgica de 11 pacientes con luxación expuesta de rodilla, tratados entre 1994 y 2015. Todos fueron estudiados y manejados según esquema estandarizado: Angiografía/ angioTC, aseo quirúrgico, fijador externo y reparación neurovascular en casos necesarios. Revisión de registros clínicos e imagenológicos consignando datos demográficos, lesiones concomitantes, número y tipo de cirugías, y complicaciones asociadas. Seguimiento promedio fue de 10,7 años con evaluación mediante encuesta funcionales SF-12/IKDC durante el mes de marzo de 2015. RESULTADOS: Diez pacientes eran hombres, 1 mujeres. Edad promedio al accidente 38,6 años. Mecanismo lesional de alta energía; como referencia la clasificación de Schenck, 1 lesión III-M, 4 tipo IV y los 6 restantes una tipo V. 4 lesiones vasculares (36.4%) y 7 lesiones neurológicas (63.6%). Tratamiento definitivo consistió en 4 reconstrucciones ligamentarias, 2 prótesis, 3 artrodesis y 2 amputaciones supracondíleas. Evaluaciones funcionales dieron como resultados un puntaje promedio de 37 y 48,5 para SF-12 físico y mental respectivamente, y de 44,1 para IKDC. CONCLUSIÓN: La luxación expuesta de rodilla es una lesión infrecuente, muy compleja, asociada a accidentes de alta energía, con complicaciones severas, lo que determina resultados funcionales relativamente malos. La estandarización permite sistematizar las distintas etapas de atención, racionalizar los recursos disponibles evitando la improvisación en momentos críticos, lo que podría incidir en la obtención de resultados.

INTRODUCTION: Open knee dislocation is a complex lesion of low incidence and large functional sequelae. There are few series reports in the literature regarding its management and outcomes. OBJECTIVE: Describe the results obtained from all patients with open knee dislocation treated during the last two decades in our hospital under the same treatment standard. METHOD: Retrospective descriptive study in a surgical series of 11 patients with open knee dislocation, treated between 1994 and 2015. All were studied and managed according to a standardized protocol: Angiography/angioCT, surgical debridement, external fixation and neurovascular repair in necessary cases. Review of clinical and imaging records, recording demographic data, concomitant injuries, number and type of surgeries and associated complications. Average follow-up was 10.7 years, with an evaluation through functional surveys SF-12/IKDC during March 2015. RESULTS: 10 patients were men, 1 woman. Average age at accident 38.6 years. High-energy trauma mechanism of injury; Schenk classification as reference, 1 lesion type III-M, 4 type IV and the remaining 6 type V. 4 vascular lesions (41.7%) and 7 neurological lesions (63.6%). Definitive treatment consisted in 4 ligamentous reconstructions, 2 prostheses, 3 arthrodesis and 3 supracondylar amputations. Functional evaluations showed an average score of 37 and 48.5 for SF-12 physical and mental respectively, and 44.1 for IKDC. CONCLUSION: Open knee dislocation is a rare, very complex, associated to high-energy trauma, with severe complications, which determines relatively poor functional outcomes. Standardization allows to systematize the different stages of attention and rationalize available resources avoiding improvisation at critical moments, which could affect the results.

Luxacion traumatica aguda de la articulacion tibioperonea proximal: Reporte de un caso y revision bibliográfica / Acute traumatic dislocation of the proximal tibiofibular joint: case report and review

La luxacion tibioperonea proximal es poco comun, se relaciona con lesiones deportivas, como consecuencia de un trauma en rotacion con el pie en inversion y flexion plantar, la rodilla en flexion y la pierna en rotacion externa simultaneamente. Provoca dolor en la region lateral de la rodilla y la pierna, con arcos de movilidad completos de la rodilla, pero dolorosos. El diagnostico es clinico y radiologico. Es una entidad que pasa inadvertida en el Servicio de Urgencias (60%), con consecuencias funcionales y biomecanicas si no se diagnostica oportunamente. El objetivo es describir la experiencia diagnostica y el tratamiento ortopedico de una entidad inusual en trauma de rodilla. Se presenta a un paciente de 23 anos que sufrio una caida patinando y refiere protuberancia proximal en la cara lateral de la pierna izquierda, edema, dolor y limitacion para extender la rodilla. Nivel de Evidencia: IV

Proximal tibiofibular dislocation is uncommon, and it is related to sport injuries as a result of an external rotation trauma with the knee in fully flexed position, and foot pointing inwards and downwards. It causes pain in the anterolateral aspect of the knee, motion is complete but painful. Diagnosis is clinical and radiological. This entity goes unnoticed in the emergency department (60%), with functional and biomechanic consequences if diagnosis is no immediate. The objective is to describe diagnostic experience and orthopedic treatment of an unusual knee condition. We present a 23-year-old patient who fell while skating. He refers a proximal protuberance in the lateral face of the left leg, edema, pain, and limitation for knee extension. Level of Evidence: IV

Bilateral knee dislocation with associated bilateral popliteal arterial injury / Luxação bilateral dos joelhos com lesão bilateral da artéria poplítea

ABSTRACT Tibiofemoral unilateral knee dislocations are uncommon, making bilateral dislocations even rarer injuries. Knee dislocation is considered one of the most serious injuries that can affect this joint. Associated complications such as popliteal artery injury are responsible for the important morbidity in these patients. The authors report the case of a 52-year-old man with a traumatic bilateral knee dislocation with associated bilateral popliteal arterial injury. His clinical presentation along with radiographic and angiographic findings are described. Surgical and non-surgical treatment and functional outcomes are also reported.

RESUMO As luxações unilaterais tibiofemurais do joelho são incomuns, o que torna as luxações bilaterais ainda mais raras. A luxação do joelho é considerada um dos ferimentos mais graves nessa articulação. As complicações associadas, tais como a lesão da artéria poplítea, são responsáveis pela importante morbidade observada nesses pacientes. Os autores relatam o caso de um homem de 52 anos com luxação traumática bilateral do joelho associada a lesão bilateral da artéria políptea. O estudo descreve a apresentação clínica e os achados radiográficos e angiográficos. Os tratamentos cirúrgico e não cirúrgico e os resultados funcionais também são relatados.

Estado funcional actual de pacientes con reconstrucción quirúrgica de esquina posteromedial de rodilla por lesiones KD I: serie de casos / Current functional status of patients with surgical reconstruction of KD I posteromedial injuries of the knee injuries: Case series

Introducción Se evalúan los resultados funcionales actuales obtenidos en los pacientes intervenidos por lesión de esquina medial de la rodilla KD I. Se comparan los resultados obtenidos en pacientes con compromiso anteromedial (ligamento cruzado anterior, LCA) con los de compromiso posteromedial (ligamento cruzado posterior, LCP). Materiales y métodos Estudio descriptivo observacional transversal de tipo serie de casos donde se valoraron pacientes con lesiones de esquina posteromedial de rodilla KD I intervenidos entre 2008 y 2013. La valoración clínica y funcional actual se realizó con las escalas IKDC, Lysholm, Tegner y EVA, y pruebas de movilidad y de estabilidad. Resultados Se examinaron 9 pacientes con 2 años y medio de seguimiento. La media de edad fue 36 años. Hubo 6 casos por accidentes de tránsito, con 4 lesiones del LCP y 5 del LCA. Durante la valoración clínica, se encontró a 7 pacientes asintomáticos durante las actividades cotidianas; la mitad obtuvo más de 70 y 82 puntos IKDC y Lysholm, respectivamente, con funcionalidad aceptable y disminución de la actividad física (Tegner de 7 a 5). Todos presentaron algún grado de inestabilidad residual anteroposterior según la lesión, en 4 casos inestabilidad medial leve y en 2, flexión limitada. Discusión El manejo quirúrgico de las lesiones mediales acompañadas de lesión del LCA o el LCP restaura la estabilidad en valgo con persistencia de leve inestabilidad anteroposterior y rotacional. Nivel de evidencia clínica Nivel IV.

Background To evaluate current functional results in patients operated by medial corner injury of the knee KD I we compared the results obtained in patients with anteromedial involvement (LCA) with those of posteromedial involvement (LCP) Materials & methods Case series study where patients were assessed with posteromedial corner injuries knees KD I operated on between 2008 and 2013. The current clinical and functional assessment was performed with the IKDC, Lysholm, Tegner and EVA scales, and mobility and stability tests. Results Nine patients were included with a 21/2 years follow-up, the average age was 36 years. There were 6 cases of traffic accidents, 4 LCP injuries and 5 LCA injuries. During the clinical evaluation, we found 7 asymptomatic patients during daily activities, half of patients get more than 70 and 82 points on IKDC and Lysholm scales respectively, with acceptable functionality and decreased physical activity (Tegner from 7 to 5). All had some degree of residual anteroposterior instability, in 4 cases mild medial instability and limited flexion 2. Discussion The surgical management of medial injury with ACL or LCP lesions restores valgus stability with persistent mild anterior-posterior and rotational instability. Evidence leve IV.

Luxación congénita de rodilla bilateral. Reporte de caso / Bilateral congenital dislocation of the knee (BDK). Case report

Introducción La luxación congénita de rodilla (LCR) es una patología muy poco habitual, pues se estima una incidencia de 0,017 por cada mil nacidos vivos o, aproximadamente, del 1% de la incidencia de la displasia de la cadera en desarrollo (DCD). Debido a su baja incidencia existe controversia respecto al tratamiento definitivo. Presentamos el caso de un paciente con un cuadro sindrómico, con luxación congénita bilateral de rodillas, tratadas satisfactoriamente mediante manejo quirúrgico. El propósito de la publicación es describir el caso clínico de un paciente con LCR bilateral asociado con un cuadro sindrómico no clasificado genéticamente, sin la existencia de otras luxaciones articulares. Materiales y métodos Se describe el caso clínico de un niño de 2 años y 6 meses, a quien se le realizó tratamiento quirúrgico de LCR bilateral mediante reducción abierta y asociada con cuadriceplastia selectiva (distal en una de las rodillas y proximal en la otra) en Colombia. Se intervino primero la rodilla derecha y luego la rodilla izquierda con un intervalo de tiempo de 1 mes entre una cirugía y la otra. El manejo postoperatorio consistió en inmovilización con yesos cerrados inguinopédicos con rodilla a 90° de flexión durante 2 meses, luego tubo de yeso con rodilla en flexión de 45° y posteriormente férulas anteriores de yeso con flexión de 60° en cada rodilla de uso intermitente. Se realizó valoración funcional de los resultados postoperatorios mediante arcos de movilidad de las rodillas (activa y pasiva), posición cuadrúpeda, posición de rodillas, gateo y extensión de rodillas contra gravedad ya que el paciente aún no camina. Resultados En el seguimiento, los padres del paciente reportaron estar «muy satisfechos¼ con los resultados obtenidos. Los arcos pasivos de movilidad de ambas rodillas fueron: flexión de 125° (promedio de las dos rodillas) y extensión de -5°. No se reportó inestabilidad ni recurrencia de la luxación. Los controles fueron realizados después de 5 meses del tratamiento quirúrgico para la rodilla derecha y después de 4 meses para la rodilla izquierda. Discusión Se indicó manejo quirúrgico de las deformidades por edad del paciente, falla en los tratamientos ortopédicos no quirúrgicos previos en otras instituciones y por tratarse de una asociación con cuadro sindrómico, mediante la realización de cuadriceplastia selectiva bilateral, en la cual se realizó solo un abordaje anterior, suprarrotuliano e infrarrotuliano medial, cuadriceplastia en Z proximal para la rodilla izquierda y cuadriceplastia distal para la rodilla derecha, lo cual disminuyo las comorbilidades por número de abordajes y permitió una recuperación más rápida. El tratamiento quirúrgico de la LCR mediante la técnica de cuadriceplastia selectiva en pacientes mayores, cuya patología se asocia con síndromes genéticos que empobrecen los resultados de manejo y dificultan los tratamientos no quirúrgicos, hasta la fecha ha ofrecido buenos resultados en términos de funcionalidad, satisfacción de los padres y ausencia de recurrencia de la luxación a los 5 meses de seguimiento en el caso descrito. Nivel de evidencia clínica Nivel IV.

Background Congenital dislocation of the knee (CDK) is a very rare condition, with an incidence of 0.017 per thousand live births and approximately 1 percent incidence in patients diagnosed with developing hip dysplasia (DHD). Due to its low incidence, there is controversy regarding definitive treatment. We present the case of a syndromic patient with bilateral congenital dislocation of the knees, satisfactorily treated by surgical management. The purpose of the publication is to describe the clinical case of a patient with bilateral CDK associated with non-genetically classified syndromic syndrome, without the presence of other joint dislocations. Materials and methods We describe the clinical case of a 2-year and 6-month-old child who underwent bilateral CDK surgical treatment through open reduction and associated selective quadriceplasty (Distal in one knee and Proximal in the other knee). The right knee was first intervened and then the left knee with a time interval of one month between one surgery and another. Postoperative management consisted of immobilization with closed inguinopedic casts with knee at 90° flexion for two months, then plaster tube with knee at 45° flexion and then anterior gypsum ferrules with 60° flexion at each knee of intermittent use. Functional assessment of the postoperative results was performed by knee mobility arches (active and passive), quadruped position, knee position, crawling and knee extension against gravity, because the patient still does not walk. Results At follow-up, the patient's parents reported being "very satisfied" with the obtained results. The passive arches of mobility of both knees were: flexion of 125° (on average for the two knees), extension of - 5°. No instability or recurrence of dislocation was reported. Controls were performed after 5 months of surgical treatment for the right knee and 4 months after for the left knee. Discussion Due to age, failure in previous non-surgical orthopedic treatments in other institutions, and a syndromic association, surgical management of the patient's deformities were indicated, performing bilateral selective quadriceplasty. A single restricted anterior medial suprapatellar and infrapatellar approach was performed accordingly to each knee, proximal "Z" quadriceplasty for the left knee and distal quadriceplasty for the right knee were also performed, a decreased in co-morbidities was observed by avoiding several approaches as well as a faster postsurgical recovery for the patient. After 5 months follow-up, this approach has provided good results in terms of functionality, satisfaction of the parents and absence of recurrence of dislocation. Evidence level IV.

Luxación de una prótesis abisagrada de rodilla: Reporte de un caso / Posterior dislocation of a hinged knee prosthesis. Case report

Las prótesis abisagradas de rodilla tienen índices de complicaciones que pueden llegar al 44% en 15 años. La luxación protésica secundaria a una ruptura del mecanismo abisagrado resulta ser la complicación alejada más frecuente luego del aflojamiento mecánico. Presentamos un caso de luxación protésica posterior, en un implante abisagrado rotatorio de tercera generación (Rotax, FII SA®, Saint Just Malmont, Francia), implantado originalmente en una paciente de 69 años, con artritis reumatoide y en terapia prolongada con metilprednisona y metotrexato a altas dosis. El tratamiento se realizó en ambas rodillas, en dos tiempos para corregir una deformidad en ráfaga altamente invalidante. Nuestra hipótesis postula que la luxación se debió a la ruptura del buje de polietileno del implante, este es el eslabón más débil del mecanismo abisagrado. Existen escasos reportes bibliográficos sobre esta particular complicación. Sin embargo, encontramos homogeneidad en las conclusiones, que consideran el ensamble entre el componente tibial y femoral, como el punto más frágil del sistema. Recomendamos, en estos complejos escenarios, efectuar la revisión protésica solo ante la presencia de episodios clínicos evidenciables, como luxaciones o inestabilidad persistente. Nivel de Evidencia: IV

Hinged knee prosthesis has a complication rate up to 44% at 15 years. Prosthetic dislocation secondary to a breakage of the hinged mechanism turns to be the second most frequent late complication after mechanical loosening. We present a patient with a posterior dislocation of a third generation rotating hinged total knee replacement (Rotax, FII SA®, Saint Just Malmont, France), implanted originally in a 69-year-old woman with rheumatoid arthritis and history of treatment with metilprednisone and methotrexate at high doses. The bilateral arthroplasty was performed in two times to correct a highly disabling deformity. We hypothesize the dislocation is due to the breakage of the polyethylene yoke of the prosthesis, being the weakest link of the hinged mechanism. There are rare bibliographic reports about this complication. However, we found similar conclusions, considering the engage of the tibial and femoral components as the weakest link of the system. We recommend in these complex scenarios to perform revision surgery only in cases with high repercussion in daily life presenting persistent instability or multiple dislocations. Level of Evidence: IV

Diagnóstico y tratamiento de luxación tibioperonea proximal de rodilla. Reporte de caso en un deportista / Proximal tibiofibular dislocation. Diagnosis and treatment. Case report in athlete

La luxación traumática es una entidad infrecuente. El tratamiento de elección en el estadio agudo es la reducción cerrada, mientras que en el caso de inestabilidad crónica se opta por reducción y fijación interna. No habiendo reportes de luxaciones subagudas se presenta un caso de 20 días de evolución tratado mediante reducción cerrada y artroscopia el cual evolucionó favorablemente luego de la cirugía.

Traumatic dislocation is an infrequent entity. The treatment of choice in the acute stage is closed reduction, whereas in the case of chronic instability, reduction and internal fixation is the treatment of choice. In absence of subacute dislocation reports we present a case with 20 days of evolution treated by closed reduction and arthroscopy which evolved favorably after surgery.

Reconstrucción del ligamento patelofemoral medial. descripción de técnica quirúrgica. estudio retrospectivo / Medial patellofemoral ligament reconstruction. surgical technique

Introducción: la luxación de la patela es una patología relativamente frecuente sin embargo, su manejo es controversial. En los últimos años la tendencia a realizar reconstrucciones que asemejen más la anatomía nativa, ha generado un renovado interés por las reconstrucciones del ligamento patelofemoral medial (LPFM). De las estructuras que permiten mantener la patela en adecuada posición, el LPFM es la estructura más importante y su lesión es reconocida como esencial para que se origine una luxación de patela. Objetivo: La reconstrucción del LPFM con la técnica de doble haz fijada anatómicamente y verificada por artroscopia pretende acercarse a los parámetros actuales de reconstrucción. Este estudio busca describir los resultados del tratamiento quirúrgico con esta técnica en pacientes con luxación de patela tratados entre mayo de 2010 y mayo de 2016 mediante la aplicación de escalas funcionales establecidas en la literatura, para identificar la mejoría de los síntomas y la no recidiva un año posterior a finalizar el período de rehabilitación. Resultados: Se intervinieron 16 rodillas en 15 pacientes (una de las pacientes con compromiso bilateral), de las cuales el 81,2% fueron de sexo femenino. El tiempo entre la primera luxación y la intervención quirúrgica fue en promedio 11,81 meses. Al año se encontraron diferencias estadísticamente significativas para las escalas funcionales Lisholm, Tegner, y Kujala y no se realizaron reintervenciones durante el seguimiento. Conclusión: La reconstrucción del LPFM, con doble fijación en patela y fijación asistida por artroscopia, es una variación a la técnica abierta tradicional que, teniendo en cuenta parámetros anatómicos, se puede realizar de forma segura. La evolución clínica de los pacientes es satisfactoria teniendo en cuenta que las escalas funcionales medidas en estos pacientes mejoraron estadísticamente significativo con respecto a los puntajes iniciales.

Introduction: dislocation of the patella is a relatively frequent pathology, however, its handling is controversial. In the recent years the tendency to perform reconstructions that more closely resemble native anatomy has generated a renewed interest in reconstructions of the medial patellofemoral ligament (LPFM).1,2 Of the structures that maintain the patella in a suitable position, LPFM is the most important one and its lesion is recognized as essential for the origin of a patella dislocation.3 Objective: The reconstruction of the LPFM with the anatomically fixed and double-beam technique, which was verified by arthroscopy, aims to approach the current reconstruction parameters. This study looks at the results of the surgical treatment with this technique in patients with patellar dislocation treated between May 2010 and May 2016, through the application of functional scales established in the literature to identify the improvement of symptoms and non-recurrence, one year after the end of the rehabilitation period. Results: 16 knees were involved in 15 patients (one of the patients with bilateral involvement), of whom 81.2% were female. The time between the first dislocation and the surgery had an average of 11.81 months. There were found statistically significant differences for the Lisholm, Tegner, and Kujala functional scales and there were no interventions performed during the year of follow-up. Conclusion: The reconstruction of LPFM, with double fixation in patella and fixation assisted by arthroscopy is a variation to the traditional open technique, taking into account anatomical parameters can be performed safely. The clinical evolution of the patients is satisfactory considering that the functional scales measured in these patients improved compared to their initial scores.

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

La luxación congénita de rodilla (LCR) 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. Presentamos un caso observado en nuestro hospital con seguimiento por cinco meses, en donde un diagnóstico y manejo terapéutico precoz, brindo una buena evolución clínica.

Congenital dislocation of the knee (CSF) is one of the very rare anatomical alterations, that its diagnosis is based on the clinical findings obtained at birth and corroborated with radiological examinations. The evolution and complications that can lead to this pathology will depend on the degree of severity and timing of treatment, since timely treatment will lead to adequate mobility and proper psychomotor development. We present a case observed in our hospital with a five-month follow-up, where a diagnosis and early therapeutic management, leading to a good clinical evolution.

Luxación congénita de rodilla: a propósito de un caso / Congenital knee dislocation: case report

Resumen: La luxación congénita de rodilla es una patología poco frecuente con una etiología desconocida. En algunos casos se le considera una patología aislada mientras que en otros pueden observarse patologías asociadas o síndromes. El tratamiento de la luxación congénita de rodilla depende de la gravedad y flexibilidad de la deformidad y en la bibliografía pueden encontrarse desde enyesados seriados o arnés de Pavlik hasta plastías del tendón cuadricipital u osteotomías femorales. Presentamos un caso de una luxación congénita que se trató mediante enyesado seriado y que evolucionó favorablemente.

Abstract: Congenital knee dislocation is an infrequent condition with unknown etiology. In some cases it occurs as an isolated condition, while in others it coexists with associated conditions or syndromes. The treatment of congenital knee dislocation is driven by the severity and flexibility of the deformity. The literature includes from serial casting or the Pavlik harness to quadriceps tendon plasty or femoral osteotomies. We report herein the case of a congenital dislocation treated with serial casting with a good outcome.