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Complex Knee Injuries

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Complex Knee Injuries Journal of Orthopaedic Education219 Original Article Volume 3 Number 2, July- December 2017 DOI:http://dx.doi.org/10.21088/joe.2454.7956.3217.16 Complex Knee Injuries R.B. Uppin1, S.K.Saidapur2, ChintanN. Patel3 Author Affiliation: 1Professor, Dept. of Orthopaedics, KLE Academy of Higher Education, J.N. Medical College &Dr.PrabhakarKoreHospitalandMedicalResearchCenter,Belgaum–590010,Karnataka,India. 2Assistant Professor 3Postgraduate Student, Dept. of Orthopaedics, J.N. Medical College, Belagavi, Karnataka 590010, India. CorrespondingAuthor: R.B. Uppin, Professor, Dept. of Orthopaedics, KLE Academy of Higher Education, J.N. MedicalCollege&Dr.PrabhakarKoreHospitalandMedicalResearchCenter,Belgaum–590010,Karnataka,India. E-mail: [email protected] Received: 05October2017, Accepted on: 12October2017 Abstract AsquotedbyReneDescartes[1]“Thehumanbodyisamachinewhosemovementsaredirectedbysoul”; andkneebeingacomplexjointwithmyriadligamentsandstabilityandmayleadtovaryingdegreeof impairments.Managementoffourcomplexkneejointinjuriesfollowingtraumaarediscussedinthisarticle. Keywords:Injuries;Myriadligaments. Introduction Greatstabilitymainlydependsontheintegrityofthe ligamentousstructures. Thekneejointisthelargestandmostcomplicated synovialjointinthebody.Kneejointisamodified- hingediarthrodialsynovialjoint[2]witharticulation betweenthefemurandtibiawhichisweightbearing andthearticulationbetweenthepatellaandfemur whichallowsthepullofquadricepsfemorismuscle tobedirectedanteriorlyoverthekneetothetibia withouttendonwear.Thefibro-cartilagenous menisci[2]areoneachside,betweenthefemoral condylesandtibiaaccommodatingchangesinthe slope of the articular surface during joint movements. Fig.1:Menisciofkneejoint Thedetailedmovementsofthekneearecomplex interactionofflexion,extension,rotation,gliding,and Biomechanics rolling.Likeallhingejoints,thekneejointis reinforcedbycollateralligamentswhichremainon Thekneejointisoneofthemostcommonlyinjured medialandlateralsidesofthejoint.Inadditiontwo jointinthehumanbody.Thecomplexityofthejoint very strong cruciate ligaments interconnect the is due myriad ofligamentousattachments, along adjacentendsofthefemurandtibiaandmaintain with numerous muscles crossing the joint. The theiropposedpositionsduringmovements.Asthe anatomiccomplexityisessentialtoallowfor kneejointisinvolvedinweightbearing,ithasan elaborateinterplaybetweenthejoint’sstability.The efficient‘locking’mechanismtoreducetheamount kneejointworksinconjugationwiththehipjoint andmuscleenergyrequiredtokeepthejointextended. andankletosupportthebody’sweightduringstatic ©RedFlowerJournal of Orthopaedic Publication Education Pvt. Ltd. / Volume 3Number 2 / July- December 2017 220 R.B. Uppin et. al. / Complex KneeInjuries erect posture. Dynamically, the complex is KneeJointKinematics responsible for moving and supporting the body Theprimaryangular(orrotator)motion ofthe duringvarietyofbothroutineanddifficultactivities. tibio-femoraljointisflexion-extension,althoughboth The fact that knee must fulfill major as well as medial-lateral(internal-external)rotationandvarus- mobilityrolesisreflectedinitsstructureandfunction. valgus(abduction-adduction)motionscanalsooccur toalesserextent.Thesemotionsoccuraboutchanging butdefinableaxis.Inadditiontotheangularmotions, onbothmedialandlateraltibialplateaustoalesser extent,medialandlateraltranslationscanoccurin responsetovarusandvalgusforces.Thesmall amountofantero-posteriorandmedial-lateral displacementsthatoccurinthenormalkneearethe resultofjointincongruenceandvariationsin ligamentouselasticity. Althoughthesetranslationsmaybeseen as undesirable,theyarenecessaryfornormalmotionto occur. Excessive translationalmotions however, shouldbeconsideredabnormalandgenerally indicatesomedegreeofligamentousincompetence. Wewillfocushereonthenormalkneejoint Fig. 2: Cruciates and collateral ligaments motionsincludingbothosteokinematicsand arthrokinematics. CaseReports 1. A38yearoldmalehadhistoryofRoadTraffic Accident–patientbeingtwowheelerridercollided withanothertwowheeler.Patientpresentedat EmergencyDepartment(ED)withcomplaintsof pain,swellingandinstabilityintherightknee. Onexamination,swellingandtendernesswere present over right knee with signs of instability.Anteriordrawer’stest,Lachmantest, Posteriordrawer’s test, Varus stress test were foundtobepositive.Patellortaptest,Sulcussign werealsonotedtobepositive.X-raysweredone Fig.3:Anatomy of anteriorof kneejoint whichshowedfibularheadavulsionfractureand nootherbonyinuries.Furtherevaluationofright knee with MRIscanning was donewhich was suggestive of – Grade 2 to 3 anterior cruciate ligamenttear at its tibial attachment, grade-3 midsubstancetearofposteriorcruciateligament withlateralcollateralligamentcomplexavulsion fromfibularattachmentwith1.5cmavulsed fracturefragmentoffibularhead.Arthroscopic evaluationofrightkneewasdonetoconfirmMRI findings,whichwassuggestiveofpartialtearof anteriorcruciateligament,completetearof posteriorcruciateligamentwithlateralcollateral ligamentcompleteavulsionfromfibularheadwith avulsion fracture of fibular head. Decision to operateforposteriorcruciateligamentandlateral Fig.4: Anatomy of posterior ofkneejoint collateralligamentandnottooperateforanterior Journal of Orthopaedic Education / Volume 3Number 2 / July- December 2017 R.B. Uppin et. al. / Complex KneeInjuries 221 cruciateligamentwasmadeafterdiscussionwith achievedbetweenweeks4and8.After8week,the patientandattenders.Posteriorcruciateligament patientswasstartedwithpartialweightbearing reconstructionwasperformedwithBPTB(Bone followedbyfullweightbearingandat6month patellortendonbone)graftharvestedfromsame followuppatientcouldwalkcomfortablykeeping lowerextremity.Inviewoflongtourniquettime, thebalanceonbothlimbswithnosignsof lateralcollateralligamentavulsionrepairwithS.S. instabilityand110° ofkneebending.Patientis wire(Stainlesssteelwire)wasperformedin2nd satisfiedwithhisfunctionandstability,andfeels stagesurgery.Patientwasstartedwithphysical adequateto perform job relatedactivities and therapyforkneebending0°to90°withinthefirst activitiesofdailyliving. 2weeksaftersurgery.Furtherrangeofmotionwas Fig.5:Pre-OpMRIofRight Knee 2. A39yearoldmalehadhistoryoffallfrombike, scanning was done which wassuggestive of– patient being a rider, 1 month back. Patient Grade3anteriorcruciateligamenttear,bucket consultedatout-patientclinicwithcomplaintsof handletearofmedialmeniscuswithmedial pain,swellingandinstabilityintheleftknee.On collateralligamentcompletetear(alsoknownas examination,swellingandtenderness were unhappytriadofkneejoint).Arthroscopic present over rightknee with instability signs evaluationofrightkneewasdonetoconfirmMRI present. Anteriordrawer’s test,Lachman test, findingsfollowedbyAnteriorcruciateligament Valgusstresstest,Mc-murray’stestwerepositive. reconstructionwithQuadrupleHamstringsgraft Patellortaptestwasalsopositive.X-rayswere (semitendinosus and gracilis) harvested from done which showed no obvious bony samelowerextremitywithpartialmeniscectomy injuries.FurtherevaluationofrightkneewithMRI ofmedialmeniscuswithmedialcollateral Fig. 6: Post-operative X-ray Fig.7: Pre-Operative MRI of Left Knee Journal of Orthopaedic Education / Volume 3Number 2 / July- December 2017 222 R.B. Uppin et. al. / Complex KneeInjuries ligament repair.Post-operatively, patient was confirmedtobe‘type-3c’compoundinjuryofleft startedwithphysicaltherapyforkneebending0° lowerlimbwithinjurytoleftpoplitealarterywith to90°withinthefirst2weeksandfurtherrangeof multiplefracturesofproximaltibiaandfibula. motionwasachievedbetweenweeks2and6.After Patientwastakenforsurgeryonemergencybasis week6,thepatientswasstartedwithpartialweight andembolectomywasperformedforleftpopliteal bearingfollowedbyfullweightbearingandat6 arteryandposteriortibialarteryalongwith monthfollowuppatientcouldwalkcomfortably fasciotomybymicro-vascularsurgeryteam.Open keepingthebalanceonbothlimbswithnosigns reductionandinternalfixationwith3.5mmnon- ofinstabilityand120°ofkneebending.Patient locking4-holebuttressplateand4inter- couldperformactivitiesofdailylivingand fragmentalscrews of4.5mmforproximaltibia occupationalactivitiessatisfactorily. fracture,withposteriorcapsulerepairandfixation ofheadoffibulawithsutureswasperformed.Post- operativelyafterstabilizationofthepatientfor1 week,2ndstagedefinitivefixationofproximal tibiafracturewasperformedbyopenreduction andinternalfixationwith5-holehockeyplateand screws.ClosureoffasciotomywoundswithSTSG (splitthicknessskingrafting)wasundertakenin samesitting.Giventhecomplexityofhisinjury, thepatientremainednon-weightbearingfor12 weekbutcontinuedwithhiskneerangeofmotion exercisesandkneebracewear.Thepatient Fig. 8: Post-operative x-ray progressedtofullweightbearingwithoutassisted deviceby4thmonthpostinjurywithalmost90°of kneebendingwithactivephysiotherapysessions. 3. A38yearoldmalehadhistoryoffallfrombullock- cart presented at emergencydepartment with complaintsofpain,swellingandinstabilityinthe leftknee.Onexamination,swellingandtenderness werepresentoverrightkneeandproximallegwith crepituspresentandrestrictedrangeofmovements atrightkneejoint.Single2*3cmpuncturewound waspresentoveranterioraspectofproximalof leg. Distal pulses (dorsalispedisandposterior tibial)werenotpalpableandSpO2wasnot recordableinrightlowerlimb.Moreover,patient wasunabletomovethetoeswithalteredsensation overthedorsumoffoot.X-raysweredonewhich showedleftkneeposteriorsubluxationwith comminutedfractureofproximaltibia,avulsion fractureofheadof fibulawithproximal1/3rd Fig. 6: Post-operative X-ray after Initialemergency fixation fibula fracture, tibialtuberosity fracture.Blood
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