European Journal of Orthopaedic Surgery & Traumatology https://doi.org/10.1007/s00590-018-2148-4 GENERAL REVIEW • KNEE - BIOMECHANICS Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm Alexander Maslaris1 · Olaf Brinkmann1 · Matthias Bungartz1 · Christian Krettek2 · Michael Jagodzinski2 · Emmanouil Liodakis2 Received: 25 August 2017 / Accepted: 3 February 2018 © Springer-Verlag France SAS, part of Springer Nature 2018 Abstract Traumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation. Keywords Knee dislocation · MLKI · Initial management · Protocol · Vascular injury · Nerve injury · Immobilization · Fixator · Brace · Cast Introduction Traumatic knee dislocation (KD) is a rare injury, reach- ing incidences between 0.001% of general population and 0.072% of orthopaedic traumata [1–6]. It can become very challenging, and even more, limb threatening [7–13]. 5–17% * Alexander Maslaris [email protected] of all knee dislocations are open injuries [14], 14–44% appear in the context of a polytrauma, and in 5%, they occur Olaf Brinkmann [email protected] bilaterally [15–19]. They can occur after high or low veloc- ity traumata in the almost equal rates of 53 and 47%, respec- Matthias Bungartz [email protected] tively [20]. Knee dislocation is widely accepted as a term to define Christian Krettek [email protected] the integrity disruption of the tibiofemoral junction, while multiple ligament knee injury (MLKI) illustrates the rup- Michael Jagodzinski [email protected] ture of at least two of the main four knee ligament stabilizer groups [2–4, 17]. Emmanouil Liodakis [email protected] In most cases of knee dislocations, it is both cruciate liga- ments and one peripheral collateral group which are injured 1 Department of Orthopaedics, Rudolf-Elle-Hospital, [3, 17, 21–24]. However, rare cases with only one disrupted Friedrich-Schiller-University of Jena, Campus Eisenberg, cruciate ligament have also been reported [23, 25–27]. Klostersnitzer Straße 81, 07607 Eisenberg, Germany 2 Approximately 50% of all knee dislocations reduce Trauma Department, Hannover Medical School, spontaneously before the physician’s arrival. Thus, high Carl-Neuberg-Str. 1, 30625 Hannover, Germany Vol.:(0123456789)1 3 European Journal of Orthopaedic Surgery & Traumatology suspicion must be held, and literally every MLKI must be 3. Immobilization: Fixator or brace? Hinged or fixed? Indi- treated immediately as a true knee dislocation until proven cations, differences, pros and cons. otherwise [22, 28]. Failing to recognize the whole injury pattern around the We present here an up-to-date comprehensive treatment knee can lead to disastrous consequences. Thus, an initial algorithm for the initial management of acute knee disloca- interdisciplinary systematic approach obtains top priority tion up to the time of a definitive ligament reconstruction. [22, 29–33]. Even though diagnostic image instruments become more and more reliable, physical examination still remains a fundamental element in any accurate assessment of KD. Methods Several authors describe their own experiences and related treatment strategies of knee dislocation [21, 22, 29, For the purpose of this study, literature resources from Pub- 32, 34–46]. But although a large number of studies about Med, MEDLINE, Cochrane Library, Web of Science, and KD and MLKI do exist in medical databases, the complexity Google Scholar were used. We included all clinical studies, of this injury, the inhomogeneity of literature, and the perse- randomized and non-randomized clinical trials, multicen- vering controversies in their treatment still make it difficult tre studies, case reports, reviews, systematic reviews, and to draw reliable general conclusions. meta-analysis. There were no limitations chosen in regard to publication date, study population, or cultural/language criteria (1958–2017). Purpose Publications associated with congenital, paediatric cases, arthroplasties, systematic diseases, poliomyelitis, rheuma- We here review the following aspects in the acute manage- toid arthritis, osteochondral or patellofemoral diseases, ment of knee dislocation: biomechanical or cadaver studies, surgical techniques and rehabilitations were excluded. Injuries of less than two of 1. Vascular injuries: Which approach provides at once the the main knee ligament stabilizers were also not taken into highest sensitivity and practicability? consideration. Inclusion criteria involved the management of 2. Nerve injuries: Incidence, injury pattern and treatment acute traumatic knee dislocation or MLKI and their compli- algorithm. cations before ligament reconstruction. Relevant treatment Fig. 1 Flow chart of study Total identified items (n=1593) selection procedure PubMed/MEDLINE (n=530) Cochrane Library (n=111) Google Scholar (n=507) Web of Science (n=445) VI after KD (n=92) Items after title and NI after KD (n=31) duplicates exclusion Immobilization (n=31) (n=279) Initial management (n=42) Associated injuries (n=44) Irreducible KD (n=39) Items afterabstractand full-text exclusion Items identifiied by hand search (n=29) (n=120) VI (n=8) NI (n=7) Immobilization (n=4) Imaging (n=2) Total number of itemsincluded Associated injuries (n=4) (n=149) Ligament examination (n=4) 1 3 European Journal of Orthopaedic Surgery & Traumatology 35 35 30 30 IIIL 25 25 IIIM 20 20 15 15 IV evalence (%) evalence (%) 10 10 III Pr Pr 5 III V 5 Posterior Anterior Lateral Medial Rotatory 0 0 (a) (b) Fig. 2 a–b Prevalence of vascular injuries adapted to a the Anatomic Classification of Schenck [82] and b the Directional Classification of Ken- nedy [13] protocols associated with neurovascular injuries, fractures, Results and immobilization techniques after KD were reviewed. Two investigators (AM, MB) performed the study selec- Vascular injuries: Which approach provides tion and reviewed all relevant published items independently at once the highest sensitivity and practicability? without considering limitations or guidelines for systematic reviews and meta-analysis. A series of keywords (knee dislo- Vascular injuries after knee dislocation pose a potential limb cation, MLKI, initial management, protocol, vascular injury, threat for the patient. Their overall incidence documented nerve injury, immobilization, fixator, brace, cast) were com- in the literature varies widely between 1.6 and 64% [16, bined in a logical way to search the electronic database. 75–80]. In a recent systematic review which included 862 Through the initial search and under the previously men- patients with KD, the reported prevalence of vascular inju- tioned terms, 1593 items were found. After title exclusions ries was 18%, out of which 80% underwent surgery and 12% and removal of duplicates, a total number of 279 studies ended in amputation [13]. resulted. Subsequent to the abstracts and full text reviews Posterior knee dislocations cause direct vessel compres- finally sorted out, 120 publications were retained (Fig. 1). sion and usually lead to full-thickness tears, whereas anterior Further studies concerning specific aspects of our subject dislocations induce traction to the popliteal soft tissues caus- or individual treatment proposals were selectively added by ing partial wall thickness defects (intimal or intimal media hand (n = 29) to establish higher rationale and clarity of tears) [81]. statements [11, 47–74]. Fig. 3 Diagnostic algorithm for Knee dislocation or MLKI vascular injury in the context of knee dislocation, as described by Nicandri et al. [38] Immidate reduction Physical examination Ankle Brachial Index Periph. pulse present Periph. pulse asymmetry Periph. pulse absent Normal reperfusion Normal reperfusion Hard signsofvascular injury ABI >0.9 ABI <0.9 24h indoor observation Arteriography Immidiate OR Arterial & venous Surgicalexploration Duplex prior to surgery ± intraop. arteriography 1 3 European Journal of Orthopaedic Surgery & Traumatology Table 1 Vascular injury treatment protocol with selective arteriography after knee dislocation Findings, checklist Indicated procedure ✓ Normal peripheral pulse 24–48-h indoor observation, ✓ Normal reperfusion arterial and venous duplex sonography ✓ ABI > 0.9 prior to surgery ✓SSVI: 1. Trauma proximity to major limb vessel (popliteal fossa)