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

Schenck RC, Richter DL, Wascher DC - Orthop J Sports Med (2014)

Bottom Line: Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.Both patients had radiographic signs of arthritis, which lowered 1 subject's IKDC score to "C." Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results.Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.

ABSTRACT

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

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

Study design: Review and case reports.

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

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

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

No MeSH data available.


Related in: MedlinePlus

Standard protocol for selective arteriography.
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fig7-2325967114534387: Standard protocol for selective arteriography.

Mentions: In 1993, Kendall et al24 published their study of a small cohort of 35 patients where clinical examination was reliable and the presence of a normal vascular examination (normal and symmetrical pulses, capillary refill, neurological examination) proved to be reliable to screen patients with knee dislocations for “selective” arteriography. Stannard et al56 then developed a prospective protocol where clinical examination was utilized to safely follow knee dislocation patients with a normal vascular examination without utilizing arteriography. It is critical that the orthopaedic surgeon follow the protocol by Stannard et al56 carefully when utilizing selective arteriography (Figure 7). Importantly, the clinical neurovascular examination must be normal without any evidence of neurologic injury or extremity asymmetry in the vascular examination throughout the prehospital course (ie, time of injury and triage) and at initial evaluation in the emergency department. The protocol requires both nursing evaluations every 2 to 4 hours and physician examinations at time zero, at 4 to 6 hours, 24 hours, and 48 hours after presentation. On a busy trauma service or at a community hospital where the orthopaedic surgeon has multiple call responsibilities, these repeated clinical examinations by the physician can be difficult to properly follow. We cannot emphasize enough that if utilizing the selective arteriography approach, subtle changes in serial examinations must prompt urgent vascular imaging. We have seen cases where failure to act on mild abnormalities (eg, mottling, present but unequal pulses, discrepancies between nursing and physician examination, etc) has led to a delayed diagnosis of complete popliteal artery disruption and loss of limb. We feel that it is critical to have a treatment algorithm at each institution for the dislocated knee centered around the vascular examination. This can be based on the protocol by Stannard et al,56 as described above, or institution specific, such as that described at the University of Pittsburgh by Seroyer et al.52


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

Schenck RC, Richter DL, Wascher DC - Orthop J Sports Med (2014)

Standard protocol for selective arteriography.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC4555540&req=5

fig7-2325967114534387: Standard protocol for selective arteriography.
Mentions: In 1993, Kendall et al24 published their study of a small cohort of 35 patients where clinical examination was reliable and the presence of a normal vascular examination (normal and symmetrical pulses, capillary refill, neurological examination) proved to be reliable to screen patients with knee dislocations for “selective” arteriography. Stannard et al56 then developed a prospective protocol where clinical examination was utilized to safely follow knee dislocation patients with a normal vascular examination without utilizing arteriography. It is critical that the orthopaedic surgeon follow the protocol by Stannard et al56 carefully when utilizing selective arteriography (Figure 7). Importantly, the clinical neurovascular examination must be normal without any evidence of neurologic injury or extremity asymmetry in the vascular examination throughout the prehospital course (ie, time of injury and triage) and at initial evaluation in the emergency department. The protocol requires both nursing evaluations every 2 to 4 hours and physician examinations at time zero, at 4 to 6 hours, 24 hours, and 48 hours after presentation. On a busy trauma service or at a community hospital where the orthopaedic surgeon has multiple call responsibilities, these repeated clinical examinations by the physician can be difficult to properly follow. We cannot emphasize enough that if utilizing the selective arteriography approach, subtle changes in serial examinations must prompt urgent vascular imaging. We have seen cases where failure to act on mild abnormalities (eg, mottling, present but unequal pulses, discrepancies between nursing and physician examination, etc) has led to a delayed diagnosis of complete popliteal artery disruption and loss of limb. We feel that it is critical to have a treatment algorithm at each institution for the dislocated knee centered around the vascular examination. This can be based on the protocol by Stannard et al,56 as described above, or institution specific, such as that described at the University of Pittsburgh by Seroyer et al.52

Bottom Line: Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.Both patients had radiographic signs of arthritis, which lowered 1 subject's IKDC score to "C." Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results.Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.

ABSTRACT

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

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

Study design: Review and case reports.

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

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

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

No MeSH data available.


Related in: MedlinePlus