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Hinged-Knee External Fixator Used to Reduce and Maintain Subacute Tibiofemoral Coronal Subluxation

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Hinged-Knee External Fixator Used to Reduce and Maintain Subacute Tibiofemoral Coronal Subluxation A Case Report & Literature Review Hinged-Knee External Fixator Used to Reduce and Maintain Subacute Tibiofemoral Coronal Subluxation Erik J. Geiger, MD, Alexander H. Arzeno, MD, and Michael J. Medvecky, MD Abstract Dislocation of the knee is a rare phenomenon dislocation with lateral ligament injury sec- that is becoming increasingly recognized with ondary to a motor vehicle accident. At 5-year the expansion of its definition to include knees follow-up, the patient treated with hinged presenting with multiligament compromise. external fixation had a stable joint, was able Hinged external fixators are now considered a to tolerate regular aerobic exercise, was viable supplementary treatment option in the minimally symptomatic, and did not require management of acute ligament repair or re- more extensive ligament reconstruction. construction but their use in the management Although there are reports on postopera- of subacute or chronic tibiofemoral disloca- tive use of hinged external fixation to main- tions or subluxations is less well defined. tain the reduction of chronic or subacute We report a case of a hinged-knee external knee dislocations in the sagittal plane after fixator used to facilitate and maintain reduc- cruciate ligament repair, there are no reports tion of a chronic coronal tibial subluxation on management of subacute tibiofemoral that presented after repair of an acute knee subluxation in the coronal plane. islocation of the knee is a severe injury that external fixation originally across the ankle and elbow usually results from high-energy blunt trau- inspired interest in its use for the knee.10-12 Richter D ma.1 Recognition of knee dislocations has and Lobenhoffer13 and Simonian and colleagues14 increased with expansion of the definition beyond were the first to report on the postoperative use of a radiographically confirmed loss of tibiofemoral artic- hinged external fixation device to help maintain the ulation to include injury of multiple knee ligaments reduction of chronic fixed posterior knee disloca- with multidirectional joint instability, or the rupture tions. The literature has even supported nonoperative of the anterior and posterior cruciate ligaments reduction of small fixed anterior or posterior (sagittal) (ACL, PCL) when no gross dislocation can be iden- subluxations with knee bracing alone.15,16 However, tified2 (though knee dislocations without rupture of there are no reports on treatment of chronic tibial either ligament have been reported3,4). Knee dislo- subluxation in the coronal plane. cations account for 0.02% to 0.2% of orthopedic We report a case of a hinged-knee external fixator injuries.5 These multiligamentous injuries are rare, (HEF) used alone to reduce a chronic medial tibia but their clinical outcomes are often complicated subluxation that presented after initial repair of a by arthrofibrosis, pain, and instability, as surgeons knee dislocation sustained in a motor vehicle acci- contend with the competing interests of long-term dent. The patient provided written informed consent joint stability and range of motion (ROM).6-9 for print and electronic publication of this case report. Whereas treatment standards for acute knee dislocations are becoming clearer, treatment of sub- Case Report acute and chronic tibiofemoral dislocations and sub- A 51-year-old healthy woman who was traveling luxations is less defined.5 Success with articulated out of state sustained multiple orthopedic injuries Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com November/December 2016 The American Journal of Orthopedics ® E497 Hinged-Knee External Fixator Used to Reduce and Maintain Subacute Tibiofemoral Coronal Subluxation in a motor vehicle accident. She had a pelvic frac- ture, a contralateral femoral shaft fracture, signifi- cant multiligamentous damage to the right knee, and a cavitary impaction fracture of the tibial emi- nence with resultant coronal tibial subluxation. Ini- tial magnetic resonance imaging (MRI) showed the tibia injury likely was the result of varus translation, as the medial femoral condyle impacted the tibial spine, disrupting the ACL (Figures 1A, 1B). The patient also had disruption of the posterolateral A B corner (PLC), including a lateral collateral ligament (LCL) fibular avulsion, an iliotibial band avulsion, Figure 1. Initial injury. (A) Coronal fast spin echo T2-weighted fat-saturated magnetic resonance imaging showing edema of medial femoral condyle and intercondylar and a popliteus myotendinous junction tear with eminence of tibia suggests subluxation in response to varus force. Lateral ligament an intact biceps femoris tendon. Three weeks after complex has sustained substantial injury. (B) Sagittal T2-weighted magnetic resonance imaging shows intact posterior cruciate ligament. the accident and after the associated polytrauma injuries were stabilized, the patient underwent “en masse” repair of the PLC, at an outside institution, as described by Shelbourne and colleagues17 with tibial spine and ACL débridement. On initial presentation to our clinic 5 weeks after injury, x-rays showed progressive medial sublux- ation of the tibia in relation to the femur with trans- lation of about a third of the tibial width medially (Figures 2A, 2B). The central tibial defect nearly ap- posed the medial femoral condyle, consistent with the initial impaction injury with translation in the coronal rather than anteroposterior plane. Addition- al MRI and computed tomography were performed to better define the bony and ligamentous anatomy (Figures 3A-3C). They showed an intact en masse A B lateral repair, an intact superficial medial collateral ligament, a bucket-handle lateral meniscus tear, and Figure 2. First presentation. (A) Anteroposterior and (B) lateral radiographs show sub- stantial tibial subluxation in coronal plane but not sagittal plane. absence of the ACL and tibial eminence. A B C Figure 3. First presentation. (A) Coronal T1-weighted magnetic resonance imaging, (B) coronal computed tomography, and (C) sagittal computed tomog- raphy show intact “en masse” lateral repair, anterolateral tibial plateau fracture, and central defect in posterior tibia E498 The American Journal of Orthopedics ® November/December 2016 www.amjorthopedics.com E. J. Geiger et al Figure 4. Postoperative radiograph shows A B application of hinged-knee external fixator Figure 5. (A) Anteroposterior and (B) lateral radiographs obtained on removal of hinged- after tibiofemoral reduction. knee external fixator 6 weeks after application show tibiofemoral alignment. Given the worsening tibial subluxation and maintaining coronal alignment. resultant instability, the patient was taken to the After HEF placement, the patient spent a short operating room for examination under anesthesia, time recovering at an inpatient rehabilitation facility and planned closed reduction and spanning exter- before starting aggressive twice-a-week outpatient nal fixation. Fluoroscopy of the lateral translation physical therapy. Initially after HEF placement, she and external rotation of the tibia allowed us to could not actively flex the knee to about 40° or reduce the joint, with the lateral tibial plateau and fully extend it concentrically. Given these limita- lateral femoral condyle relatively but not complete- tions and concern about interval development of ly concentric. A rigid spanning multiplanar external arthrofibrosis, manipulation under anesthesia was fixator was then placed to maintain the knee joint performed, 3 weeks after surgery, and 90° of flex- in a more reduced position. ion was obtained. When the HEF was removed, 6 A week later, the patient was taken back to the weeks after placement, fluoroscopy and radio- operating room for arthroscopic evaluation of the graphs showed maintained tibiofemoral alignment knee joint. At the time of her index operation at the (Figures 5A, 5B). outside institution, she had undergone arthroscop- Six weeks after HEF removal, the patient was ic débridement of intra-articular loose bodies and ambulating well with a cane, pain was minimal, lateral meniscus repair. Now it was found that and knee ROM was up to 110° of flexion. Tibiofem- the meniscus was not healed but had displaced. oral stability remained constant—no change in A bucket-handle lateral meniscus tear appeared medial or lateral joint space opening. Full-extension to be blocking lateral translation of the tibia, thus radiographs showed medial translation of about impeding complete reduction. 5 mm, which decreased to 1 mm on Rosenberg Given the meniscus deformity that resulted view. This represents marked improvement over from the chronicity of the injury and the resultant the severe subluxation on initial presentation. subluxation, a sub-total lateral meniscectomy was Follow-up over the next months revealed con- performed. As the patient was now noted to have tinued improvement in the right lower extremity an intact medial collateral ligament and an intact strength, increased tolerance for physical activity, en masse lateral repair, we converted the spanning and stable right medial tibial translation. A year external fixator to a Compass Universal Hinge after HEF removal, imaging showed adequate (Smith & Nephew) to maintain reduction without tibiofemoral alignment (Figures 6A-6C). There was further ligamentous reconstruction (Figure 4). As mild to moderate joint space narrowing, lateral we were able to maintain reduction, we
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