Multiple Ligament Knee Injuries: Does the Knee Dislocation Classification Predict the Type of Surgical Management?

This study aims to evaluate relationships among multiple ligament knee injury (MLKI) patterns as classified according to the knee dislocation (KD) classification and the types of surgical management pursued. We hypothesized that the KD classification would not be predictive of the types of surgical management, and that categorizing injuries according to additional injury features such as structure, chronicity, grade, and topographic location would be predictive of the types of surgical management. This is a Retrospective cohort study. This study was conducted at a level I trauma center with a 150-mile coverage radius. Query of our billing database was performed using combinations of 43 billing codes (International Classification of Diseases [ICD] 9, ICD-10, and Current Procedural Terminology) to identify patients from 2011 to 2015 who underwent operative management for MLKIs. There were operative or nonoperative treatment for individual ligamentous injuries, repair, or reconstruction of individual ligamentous injuries, and staging or nonstaging or nonstaging of each surgical procedure. The main outcome was the nature and timing of clinical management for specific ligamentous injury patterns. In total, 287 patients were included in this study; there were 199 males (69.3%), the mean age was 30.2 years (SD: 14.0), and the mean BMI was 28.8 kg/m2 (SD: 7.4). There were 212 injuries (73.9%) categorized as either KD-I or KD-V. The KD classification alone was not predictive of surgery timing, staging, or any type of intervention for any injured ligament (p > 0.05). Recategorization of injury patterns according to structure, chronicity, grade, and location revealed the following: partial non-ACL injuries were more frequently repaired primarily (p < 0.001), distal medial-sided injuries were more frequently treated operatively than proximal medial-sided injuries (odds ratio [OR] = 24.7; p <0.0001), and staging was more frequent for combined PCL-lateral injuries (OR = 1.3; p = 0.003) and nonavulsive fractures (OR = 1.2; p = 0.0009). The KD classification in isolation was not predictive of any surgical management strategy. Surgical management was predictable when specifying the grade and topographic location of each ligamentous injury. This is a Level IV, retrospective cohort study.

Initial Evaluation and Classification of Knee Dislocations.

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.

Development of heterotopic ossification after multiple-ligament reconstruction of the knee joint: Incidence and explanatory factor analysis.

BACKGROUND: The development of heterotopic ossification (HO) might nullify any benefit of multiple-ligament reconstruction of the knee joint. The purpose of this study was to investigate the incidence and the specific explanatory factors for the development of HO after multiple-ligament reconstruction of the knee joint. METHODS: From January 2011 to June 2016, 72 consecutive patients with knee dislocations received multiple-ligament reconstructions, of which 57 (79%) were available for a minimum follow up of 12 months and were included in this study. Anteroposterior (AP) and lateral radiographs were reviewed for all patients. This knee dislocation cohort was separated into two groups based on the presence or absence of HO for comparisons. In addition, the HO group was divided into three subgroups based on a modified quadrant grading system introduced by the senior author for further evaluation. Multivariate logistic regression analysis was then performed to identify specific explanatory factors predicting development of HO in patients after multiple-ligament reconstructions of the knee joint. RESULTS: Among the 72 consecutive patients, 57 (79%) were available for the clinical evaluations with an average period of 28.4 months (range, 12-51 months). Twenty-one patients (37%) showed radiological evidence of HO. The HO group (n = 21) showed significantly inferior results of knee flexion angle compared with the non-HO group (n = 36) (HO group vs. non-HO group: 124 ± 13° vs. 132 ± 5°; P<0.01). According to the quadrant grading system, there were seven patients with grade I, nine with grade II, and five with grade III HO. Subgroup analysis further revealed that higher HO grade would lead to lower knee flexion angle. In addition, multivariate regression analysis showed that concomitant posterior cruciate ligament reconstruction was the only independent explanatory factor predicting the development of HO after multiple-ligament reconstruction of the knee joint (P=0.018; odds ratio, 8.75; 95% confidence interval, 1.69-39.7). CONCLUSION: In this cohort of knee dislocations, the incidence of HO development following multiple-ligament reconstruction was 37%, with grade III HO showing the most inferior range of motion outcome. Moreover, concomitant posterior cruciate ligament reconstruction was the only independent predictor for the development of HO.

Multiple Ligament Knee Injuries: Current State and Proposed Classification.

Classification systems should enhance communication between providers, facilitate accurate and consistent reporting in the literature, and guide management. However, current classification systems for MLKIs lack sufficient detail to guide clinical management which limit their prognostic value. The purpose of this chapter is to revisit and consider important features of some of the most impactful classification systems developed in the orthopaedic literature and to propose a classification system for MLKIs that may improve communication among providers, facilitate consistent reporting in the literature, and ultimately foster publication of meaningful clinical data.

Knee Ligament Instability Patterns: What Is Clinically Important.

The knee dislocation is a severe, complex injury that can be difficult to treat and is fraught with complications. The first step in a successful reconstruction of a multiple ligamentous knee injury is gaining an accurate and thorough understanding of the pattern of instability imparted by the injury. Evaluation begins with a detailed review of radiographic and advanced imaging studies followed by a thorough physical examination, often done under anesthesia, in conjunction with dynamic fluoroscopy. Failure to identify and reconstruct a damaged ligament may place undue stress on adjacent structures, resulting in complications and potential failure of the surgical procedure.

Vascular Injury in the Multiligament Injured Knee.

In this review, we explore the epidemiology and mechanism of multiligament knee injuries (knee dislocation) and their complications, focusing on the morbidity and mortality associated with concomitant vascular injuries. We discuss the various diagnostic and treatment algorithms in use today and finish the report with a brief case example to outline these principles.

Multiligament Knee Injury: Injury Patterns, Outcomes, and Gait Analysis.

Multiligament knee injuries remain a challenge for the treating surgeon and little is known about the injury patterns and factors determining clinical and gait outcomes after multiligament knee reconstruction (MLKR). This article aims to identify specificities of this complex injury, in terms of demographics, mechanisms of injury, injury pattern, and associated lesions. The time frame between injury and surgery and distribution of repair versus reconstruction procedures have been analyzed. This study reports functional and clinical outcomes, providing an overview of expected results. Using motion capture gait analysis, knee kinematics and gait characteristics of MLKR patients have been assessed.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment.

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Knee Dislocation (KD) IV Injuries of the Knee: Presentation, Treatment, and Outcomes.

"KDIV ligamentous injuries of the knee are frequently high-energy injuries with significant soft tissue disruption, gross knee instability, and rarely are treated nonoperatively. KDIVs frequently require external fixation, but when presenting in an isolated fashion can be reconstructed in one setting. Five presentations of KDIV injury are described: closed with multitrauma/closed head injury requiring external fixation, irreducible KDIV requiring semi-emergent open reduction and repair, isolated KDIV without arterial injury undergoing 4-ligament reconstruction after regaining motion, KDIV with varus and slight thrust undergoing medial opening osteotomy before ligament reconstruction, and KDIV with failed ligaments requiring revision and posterior tibial tendon transfer."

Incidence of Concurrent Peroneal Nerve Injury in Multiligament Knee Injuries and Outcomes after Knee Reconstruction.

The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty (p = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity (p = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p = 0.17), Lysholm score (mean 88.6 vs. 88.8; p = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower (p = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity.

A rare variant of knee dislocation.

Knee dislocation is a rare injury. It represents less than 0.2% of orthopaedic injuries. This case reports a rare form of knee dislocation caused by the impact of a high-energy trauma. In these cases the appropriate assessment and management is needed to ensure that patient receives the proper treatment.

Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Traumatic Knee Dislocations: Evaluation, Management, and Surgical Treatment.

Knee dislocations are catastrophic injuries that demand emergent evaluation and often require a multidisciplinary approach. Long-term outcome studies are relatively scarce secondary to the variability in any given study population and the wide variety of injury patterns between knee dislocations. Multiple controversies exist with regard to outcomes using various treatment methods (early vs late intervention, graft selection, repair vs reconstruction of medial and lateral structures, rehabilitation regimens). Careful clinical evaluation is essential when knee dislocation is suspected.

Staged management of knee dislocation in polytrauma injured patients.

INTRODUCTION: Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution. PATIENTS AND METHODS: From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months). RESULTS: Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant. CONCLUSION: The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.

Radiologic review of knee dislocation: from diagnosis to repair.

OBJECTIVE: This imaging-based article systematically reviews traumatic knee dislocations. After completion, the reader should be familiar with the definition, epidemiology, cause, and classification schemes associated with these injuries, as well as the importance of timely diagnostic imaging and an accurate, detailed description of findings, particularly as it relates to MRI interpretation. Finally, information our orthopedic surgical colleagues consider critical for the preoperative planning and reconstruction of the multiple ligament knee injury will be discussed. CONCLUSION: Although uncommon, traumatic knee dislocations are an important potentially limb-threatening injury, which if not emergently recognized and appropriately managed, can result in significant patient morbidity, joint dysfunction, chronic pain, and long-term disability. A radiologist familiar with the imaging appearance and potential neurovascular complications associated with these injuries can play an integral role in the multidisciplinary team that manages this increasingly recognized clinical entity.

Initial evaluation of the acute and chronic multiple ligament injured knee.

Multiple ligament injuries of the knee are rare, and severe injuries are often present following a knee dislocation. Appropriate initial evaluation and management is of critical importance for maximizing the potential outcome and avoiding disastrous consequences associated with these difficult injuries. While many of these injuries present acutely in an emergency department or clinic, presentation on a delayed basis is not uncommon. Injuries can present in a variety of situations, such as an isolated knee injury in an athlete or as part of a multisystem-injured trauma patient. In this publication, we review the etiology, classification, and comprehensive initial evaluation of the acute and chronic multiple-ligament injured knee.

Treatment of PCL, ACL, and lateral-side knee injuries: acute and chronic.

Combined posterior cruciate ligament, anterior cruciate ligament, and lateral-side disruption is one of the more common patterns of multiligament knee injury. This is a devastating injury with significant long-term functional sequelae, making accurate diagnosis and management extremely important. While surgical intervention is necessary to restore function, the specific management strategies remain controversial. This article will review the current literature and the authors' preferred approach including physical examination, imaging, timing of surgery, surgical technique, and postoperative rehabilitation.