2/1/2017

Knee Dislocation Dislocations

John D. Adams, Jr. MD University of South Carolina- Greenville Greenville Health System Greenville, SC TraumaSports

Don’t Forget

As high as 66% of knee dislocations self reduce ?

May have been this 30 minutes earlier

Can a Knee Dislocation be treated like an Dislocation?

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Is it the same as treating an How is the Knee Similar to Elbow dislocation? the Elbow? • A stiff stable elbow ≠ Successful Treatment – The same as with the Knee YES • Goals of treatment are the same – Provide Stability and – Prevent Stiffness NO X

How is the knee different So what does that mean? than the elbow? • Knee is not as inherently stable as the • How do we maintain reduction/stability and elbow when reduced provide motion of the joint?? • Lower Extremity vs Upper Extremity • Most all need surgery – Levy 2009: Systematic Review of Surgical versus • Anatomy is different Nonsurgical Management • Better outcomes in surgical group – Peskun 2011: meta-analysis Surgery versus Nonsurgical • Surgery = better outcomes, less instability, contracture, and earlier return to activity

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So when is surgery? So when is the surgery?

Early (3-4 weeks) Delayed (> 4 weeks) • Early seems to be better than late – Less surgery – Harner et al. 2004 JBJS – Possibility of repair – 31 patients, 19 reconstructed early because some » Early group had better outcomes – Identification of have healed?? anatomy » 4 knee manipulations in early group – Allows time for soft – Liow et al. 2003 – Avoid injury to joint tissues • 21 patients associated with (Arthroscopy) – Early group had higher scores but not statistically significant – But delayed surgery also has benefits chronic instability – Downsides • Karataglis et al. 2006 – Downsides • Is chronic instability – 35 patients reconstructed for chronic multiple deficiency » Most patients had good to excellent results (60%) • Fixing everything bad?? • Delay in return to » 31% fair results • arthrofibrosis work/activity » 9% failure rate

So when is surgery?

Current Recommendation: So we need to operate and we Early treatment is preferred, but depending on the need to do it early most of the overall status of the patient, delayed treatment is time… acceptable. HOW???

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What about Static Repair vs Reconstruction- Exfix? Cruciates • Most are stable after reduction – 1999 Mariani and Static Exfix is not • functional outcomes are similar for both necessary • Repair group was stiffer • When to apply a static exfix? • Return to activity not as good in repair group – Knee Dislocation in setting – 2007 Owens of Vascular Injury/Repair • 25 dislocations all repaired – Open Injuries- soft tissue – Similar outcome scores compared to Fanelli’s work in 2002 for management paramount reconstruction importance – So what to do? – Inability to maintain • What have we learned with isolated ACL injuries? reduction in brace

Repair vs Reconstruction- Compass Hinge ExFix Collaterals • PLC – 2005 Stannard • 57 patients repair vs reconstruction – Failure rate: Repair: 37%; Reconstruction 9% – Replicated by Levy 2010 – Failure rate: Repair: 40%; Reconstruction 6% • PMC

– 2012 Stannard

• Failure Rate: Repair: 20%, Reconstruction: 4% • Interestingly: • When to use it? – Functional outcome scores are similar – Severely Unstable (KDIII or KDIV) – Return to activity seems better with Reconstruction – When a Staged Reconstruction is utilized – Polytrauma patients • Help with mobilization while protecting the reconstructions

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Common Complications to Hinged Exfix: Results Consider • Infection Rate: • Stannard et al. – reported to be as high as 12.5% – Prospective Randomized Study- Hinged Exfix vs • Arthrofibrosis: Brace (103 patients) – nearly 40% need treatment • Brace group= 21% ligament failure rate • Continued Instability: 40% • Hinge= 7% ligament failure rate • Similar outcome scores Would a Staged Treatment Protocol Potentially Help????

Our Typical Protocol Our Typical Staged Protocol

• Early Stage- ~3 weeks post injury • Late Stage- 6-8 weeks later – Reconstruct PCL and Corners – Removal of Hinge – Menisci – MUA – Hinged Ex-Fix?? – ACL

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Why Consider a Staged Summary Approach? • Infection Rate: • Most all need surgery – Allow soft tissues to recover – Shortens surgical time • Early surgery seems to be better than late • Arthrofibrosis • Most do not need an exfix, but follow them – MUA at 6 weeks carefully – Less of an initial hit to the knee • Reconstruction seems better but controversial • Instability – Dedicated rehab for PCL/ACL – Hinged Ex-Fix

THANK YOU • I use A LOT of allografts in these cases, so I do like to think that the goal for these patients is for them to be called…

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