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Knee Dislocation and Multiligament Injury for Orthopaedic Exams
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Knee Dislocation and Multiligament Injury for Orthopaedic Exams
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Language: EN.
Segment:0 .
Evening everybody once again, welcome to the FRCS mentor webinar session. As always, we have excellent talk for you. And we'll also have private sessions in the recorded part of the session. Today we have three them.
He is one of our new mentors. Join us in 2020. We're very proud of him and his work. He has an interest in the senior specialist with an interest in sports news and lowered numerous capacity. And we're looking to have to talk to us about knee dislocation, not his knee injury and for the interruption. Let me start off with the topic.
So as described with doing a knee dislocation presentation and multi ligaments knee injury, my talk is about is around 2025 minutes. This whole presentation is focused around. FRC is exam, hopefully, and I'm pretty hopeful. By the end of this presentation and discussion, you should be able to answer any questions that only dislocation and a confidential, OK, Uh, any dislocations.
As we are aware, it's a very rare injury, almost about 0.02% to zero 2% of all the orthopedic injuries. However, the true number may well be higher because about 50% to 60% of the cases, the knee spontaneously reduced. And that's why you don't have the true number knee dislocations. Why are they so serious? Because of the neurovascular structures around the knee?
It can have a limb threatening short term complications, which may end up in amputations and unable to use the knee because of the nerve injuries and things, and the long term consequences from the result of a multiligament knee injury and associated and neurology. So what is the mechanism involved? The most common mechanism is a high velocity injuries and the second most being sport injuries.
You see these in contact sports, rugby football and. Skiing in Greece. Ice skating and ice hockey. These are the injuries that you commonly see in these kind of contact sports. And interestingly, the low velocity injuries as well in high, morbid sorry in morbidly obese patients. And also, it is interesting that the neurovascular injury is no different from the high velocity or sports injuries and compared to low velocity injuries.
OK, coming to the clarification, what is the classification tell classification mainly guides, this classification gives us the nature of problem. If you see Kennedy classification, which basically tell us about the mechanism of injury where it is. A dislocation or posterior dislocation, medial, lateral and rotary dislocations.
It also tells you if you see the anterior and posterior, it's gone in the sagittal view. So basically tells it may be the crochets are gone, and it can tell you that likely that there may be an arterial injury or at least significant threatening threatening to the neuromuscular structures. Medial lateral undoubtedly gives us an information about the ligament rupture. Maybe the boat crew are gone, and the collective ligaments also would be involved in classification is more like a grading system.
It gives us an idea about how to manage this and guide us in the management, as well as to an extent it helps us in prognosis as it goes from top to bottom. We want to clarify it only worsens if you start with Katie one, it's only one of the groups that are gone. Katie, too, is by cruciate Katie. Three Katie 3 is more important because it constitutes about 65% of the dislocations.
So Katie, three where you have if! Katie three meaning there is medial collateral ligament being injured. Katie 3l, which is also ligament being injured. Katie for which has been cruciate and both collateral being gone. I'm Katie five that is very articular fracture dislocation. What are the immediate complications, as we expected, the vascular injury is most common.
Average about 30% to 40% popliteal artery is the most commonly injured. Why is probably the most commonly injured? Because it's relatively fixed and it is both due to the knee. Why is it fixed? It is fixed and after a hiatus, proximally and distally. It is relatively fixed at the soil's tendon injection and therefore it makes it relatively fixed and therefore it is subjected to shear forces when the knee dislocation happens.
As you can see, highest incidence of could more likely be in policy dislocation, and to be honest, anti dislocations are equally. You can equally cause injuries to the hospital artery. And the importance in detecting or diagnosing a vascular injury is crucial. Failure or delay in the diagnosis of vascular injury can lead to a significant rise of amputation rates, as you can.
The literature says that if it is beyond eight hours, the risk of amputation is about 86 percent, which is very high. OK, coming to the next injury, which is nerve injury, the common peritoneal nerve is the most common injury by comparing ulnar nerve. It is also relatively fixed because it is fixed approximately at the fibular neck and distally at the intramuscular septum, making it more rigid and therefore being subjected to shear forces during dislocation.
It it can most commonly occur in posture, laterally dislocations. However, you can't rule out a nerve injury based on a dislocation you, it only comes down to examination to rule out of injury. Studies have shown that 20 21% of the patients do recover fully, partially in 2009. About 50% of the people do not recover at all.
So for them, for the meeting and nerve repair grafting or in worst case scenario by if it doesn't recover by the end of the year, the many tendon transfers and the other most deadly complication is compartment syndrome, which we all aware of and we know that we act promptly. But the things that we miss is a vascular injury in case of a dislocation, which is reduced, so we don't really see that coming.
OK what do we do in the emergency department? This is something which is most important. I will go through this a little bit more in detail. You see on this slide on the left, the picture on the left. It is more or less widely used approach or algorithm in knee dislocations. Let's say a patient with a knee dislocation or a knee injury is in the emergency department.
How do you approach your approach with a TLS protocol? No different from any trauma injury you? You clear a bc and come to the deformity. If you see a deformity, check for the check for the neurology and get an urgent X-ray. If there is a dislocation, reduce a dislocation, splint the limb and then do the regular examination. What do we do? You just need to check the distal pulse, put the cuff before applying the splint so that you don't have to keep removing it.
Check the AVP ankle breaker pressure index. It is one of the most rapid, rapidly usable and unreliable method. Let's say you reduce the pulses, come back and you. You regularly monitor the ankle breaker pressure index for about 48 to 72 hours, up to 72 hours. And if there is any change, you will have to do any further imaging to see if there is any blockage of the artery or bleeding.
Let's say there is a pulse asymmetry or if there is an ankle brachial pressure index is less than zero point nine, then you have to involve the vascular surgeons. Get an urgent arterial. Graham prepared him for surgery for a new nerve repair or for the vascular repair or a reconstruction. Placement is fixed. They say there is no pulse at all after reduction.
You have no other option but to take him straight to the surge to the theater for exploration, you don't have to wait for a CT scan. I'll go through this again and by scenario based in the coming slides, if you go, if you just see the one picture which have put it in on a right at the lower end, which you see there is no dislocation. You know, the one which is below the X-ray.
There's no dislocation here, but you see extensive bruising and blistering. This should they should Ring Alarm bells. One must be very careful. It may be a spontaneous, maybe dislocation with spontaneous reduction. So this is something which you need to be aware of and you need to correlate your findings, like the mechanism of injury and then see subtle see the clinical examination like extensive bruising and see subtle signs of radiological signs of subluxation.
And then you will follow the protocol as a knee dislocation. OK OK. This is an ankle brachial pressure index, which why we need to do it. This is a very accurate, reliable and good sensitivity and specificity with a 100% positive predictive value. Less invasive. It's non-invasive, really. So which means you apply the ankle cuff traject after the ankle of the injured limb and upper uninjured arm and then check for it.
If the AVP is below zero point nine, then it is. It is a must that we need to get a CT angiogram and get the vascular surgeon input straight away. If you see a picture on the left of extreme left first extreme left slide, you see an angiogram which which shows completely a block of artery. But then if you see it there on the right picture where the patient has a collateral flow, this is why the patient can have a pulse within the completely occluded perpetual artery.
So doesn't mean if there is a pulse, you can avoid it. And clavicle president next is very important. And this will pick up API, which can which will be low, and therefore we can act accordingly. And urgently. OK, how do we reduce it when there is a dislocation? It must reduce it. We reduce it under sedation.
It should be gentle traction trying to reverse the deforming forces and not much and do not apply any pressure on the knee, especially on the back of the knee. You can aggravate or cause a vascular insult yourself, so it should be gentle traction. What if you don't get it? If you're not able to reduce it, you need to take him to the theater with the vascular support. Of course.
OK what do we see here? You can see a dimpled sign, you can see an arrow there, which is a postural or a lateral dislocation of knee, which means the middle from epicondyle has buttonhole to the capsule and has entrapped the ankle. So how much of pull it? You're not going to reduce it. In turn, you may cause more vascular damage by continuously trying to reduce it.
So don't attempt a closed reduction. This has to go to theater. Same is the case with open dislocations as well. Try not to reduce in the hospital. In the knee. Try to take to the theater as soon as possible. OK, here are the scenarios. I'll just go through it one by one.
So you can explain the knee. There are some surgeons splint the knee in extinction, which most surgeons do. Some surgeons try to flex the knee to about 10 degrees in the hinge brace so that you can avoid both of your subluxation. OK the first scenario is, let's say there's the chest X-rays of this satisfactory. There's a well, pulse, well, pulse.
What do you do? You don't need to do a CT angiogram. You you monitor the API. Check for pulse. EPA must be done every two hours for the next 48 hours to 72 hours. Check for the Science of compartment syndrome if there is compartment syndrome, you take in the theater for a face shortening.
OK, that's the next scenario. Check x-rays are OK. Czech x-rays are not OK with a bit of a subluxation that more or less tells that the knee dislocation knee is not stable. You may have an intact pulse doesn't mean that you should leave it at that. You should get an urgent CT angiogram and then take them to take the patient to the theater simply because there is a subluxation, which means it can push on the vessels.
So you need vascular surgeons help. It may not be. They may not be required, but they should be by the side. So you put an external fixator, reduce the knee. And if there is compartment syndrome, you can do fish shot me. Otherwise you don't need to. OK, next, let's come to another scenario. No pulse at all.
So there is no pulse. You just have to take to the page. Take the patient to the theater physiological exploration. Here are a few scenarios which I would like to mention. This is where I was confused during my exam. If I see it so, I thought I will just make it clear so it knee dislocation doesn't mean that every patient will have only knee dislocation.
They have multiple and they may have multiple injuries. Let's say the patient has a chest injury and a knee dislocation. So the he may not be amenable for a prone approach. He may not be able to put prone because of the chest problems during anesthesia. And therefore this the vascular surgeon can do an approach from the medial side. And can repair or revascularization and reconstruct the popliteal artery, and then you can do the external fixator, external fixator, whether you need to do it or not, which who comes first, the vascular or are the surgeons?
Ideally, if it is a very unstable knee to provide a strong bed, it is better to give better to do an external fixator first, followed by vascular repair. But but if the vascular surgeons think that they need to go first, they will go first and we should be able to work around putting an external fixator. Let's say, if it is an isolated knee dislocation and there's no other injuries, so the surgeon Vasquez will want to do it prone position.
So in that case, you will have to put a lateral external fixator. Of course, you want to put the lateral pins for your femur anyway, for the disc, for the proximal tibia or tibia. You may have to approach using the Shands pins from the lateral end and for the next space spanning 18 fixator like you see on the picture on the right, on the top. So once you do the external fixator, you position the patient prone and the vascular surgeons will repair or reconstruct the peripheral artery.
So hope this makes it clear. One more thing that you need to be aware of is will you need any compartment release when you have a vascular slap lesion? Well, the literature says that yes, you need, you may need or you may benefit with it simply because we can avoid a reperfusion syndrome and therefore relieving the compartment by 2 using one single incision or two incisions.
But the sutures generally do it with one single incision on the lateral side, right? OK, so prophylactic fascia to me, ratio to me. Why the results show that early 3 shot me has improved outcomes with patients with vascular injury, and it reduces the which reduce the amputation rates. So completely ulnar nerve injury, as we said, it is also one of the common injuries around 20 percent, ranging between 5 to 45.
We have an algorithm which you can follow in general. If you have an open, open dislocation, you will have the surgeons, especially surgeons, plastic surgeons available who will help you, who will help with nerve repair if is completely transacted. But if it is a closed injury, you will observe you can. You can follow this algorithm and by two weeks when you're are planning for multiple egawa test knee injury.
If it's you, you can plan for new releases if there is an intact nerve, but still with. No problems. You need to put uncle foot autopsies and closely observe him regularly do the nurse studies. Worst case scenario, you may have to go back and then do a tendon transfer if there is no recovery, then by the end of the year, normally it is about a year that we take a position to do it.
OK, now that we dealt with acute dislocations. We go with Michael egawa test injury. How do we deal with it? So we've dealt with the patient patient is comfortable in the brace. But we need to assess the need for a possible surgical intervention. What what are the requirements that we need to have for this, for assessing the need?
First is first and foremost is a physical examination. You need to assess the ligaments, see which is gone. It may be difficult when somebody's a patient. For a patient who is two weeks old, he may not cooperate as much because he may be in pain. And what I can gives a lot of information in terms of what ligaments have been ruptured, if it's please check the image on the right. It is a published stress radiograph for multiligament knee injuries, comparing amount of opening on the medial side or lateral side.
Um, suggesting if it is a partial complete or involvement of posterolateral and post-traumatic corners as well. So emperor intraoperatively radiographs are extremely useful, reliable and post-reconstruction. We can always check and then document as well if you have achieved the stability. OK imagine if there is a fracture that you suspect, you will need X rays, if not, you will need MRI scan, which is a gold standard.
You definitely will require what ligaments are going to plan your surgery. Non-operating management, the literature says there is no role for non-operated management as they have significantly poorer results and poor functional outcome from non-operated management, and it should only be reserved to people with poor general health condition and elderly patients who doesn't have the reserves or may not be able to do an extensive, rigorous post-operative physiotherapy.
OK, coming to the surgical management, what do we do? We it depends on the timing of surgery. When do we do the surgery? Is it soon or sooner or later? Two schools of thought. Some surgeons tried to do this in as early as possible, around three weeks time. Some surgeons do it in six weeks time. Why three weeks?
Three weeks is what they call an early intervention where you have a possibility, there is a possibility of ligament repair, as well as needing reconstruction it in 3 Allen three weeks time, you will have all the systemic inflammatory process subsides and the anesthetic risk also reduces. But the downside is going around three weeks time operating the risk of ultrafine growth is slightly higher compared to operating after six weeks.
However, the recent literature says you have higher functional outcome from early intervention than a late intervention. So late surgeries. Uh, generally around six weeks is where you tend to take up, you can't repair because the ligaments would have scarred up retracted. So you have no other option, but a reconstruction is the only way out.
OK do we do all at one go or how do we do it? Staged procedure again, two schools of thought as some surgeons do it a single stage. Some surgeons do it. A staged approach. So single stage, which means repairing and reconstructing, reconstructing all the ligaments around three weeks time. What are the advantages of it? It it restores the knee kinematics and decrease the risk of meniscal or damage due to instability, which you may have if you reconstruct only a few ligaments.
OK it is, however, suitable for a young, individual motivated individual who is open and capable of taking an aggressive physiotherapy because also fibrosis is something which is relatively at higher risk. If you do all single stage in three weeks time. Staged approach where you can repair the ligaments, the collateral ligament, the extra articular, mainly that's what the first stage is. You repair or reconstruct the extra articular structures and then rehabilitate.
Get full range of movement and then try to do a second stage by reconstructing the cruciate ligaments. Repaired with this reconstruction repair is only possible in the first three weeks after three weeks is it becomes difficult. Why reconstruction of the ligaments after three weeks is preferred?
Sorry, the repair has got probably a slightly poorer outcome and failure rates compared to reconstruction. And that is and that's why reconstruction of the ligaments are preferred in the first three weeks. Although the soft tissue planes are not very distinct, we can still be able to do better at the time. A PCL, lc, injuries and the literature say, is that both slap lesion reconstructions are.
Better than repairs, and they have a much better outcome from reconstructions. However, there are some religions who are saying the cruciate ligaments repairs or have equal functional outcome. To a reconstruction. OK what are the graph that we need to use? We have photographs, autographs, we know autographs. We can use quadriceps, tendon, hamstring, tendon, bone, collarbone, tendon, but with a multiligament is the injury.
You require a lot of crabs for which most of the surgeons would prefer to use polygraphs because you have a greater selection on top. On top of those tendons that are mentioned, you can have Achilles tendon breath and the tendon, both to your tibial exposed tendon that can be used. What are the advantages? Because it reduces the surgical time, a multiligament reconstruction does take time, so any time that can reduce it, we can take it.
So reduce the surgical time, reduce the donor site morbidity, as well as the post-operative pain. What are the disadvantages? Holograms don't come cheap. They are expensive. There, there is a small risk of disease transmission as the Allen grafts, and the incorporation is definitely slower compared to autographs.
Let's go to the principles of multiple injury. What is the aim of the surgery is to provide a stable knee and improve the range of movement with physiotherapy and bring him back to as normal as possible with regards to the knee. However, we need to prepare the patient about the expectations, which we must have a true expectations ligament as injuries are not that straightforward.
You, you wouldn't. You wouldn't. You wouldn't be able to get a perfect knee straight away. It's a long process. The principles involved, first of all, identification of all the ligaments by stress radiographs assessment and MRI scans then decide whether we then plan, whether it is going to be a single stage or a staged approach.
Um, awarding tunnel convergence, which I'm going to discuss in the coming slides. And tension sequence. These two are very important in multiple egawa test knee injury. If it is a single stage approach and a supervised rehab program, which which is half the job. Surgery is off the job and I think rehabilitation is half the job.
See, avoiding tunnel convergence, let's say, if you have all the ligaments that are damaged, if you have all the ligament damage, you may need all at least four tunnels on the medial side in 3 tons in the lateral side. Then you can expect how difficult it is to have individual tunnels and to avoid convergence risk. So for an ACL and FCL, the convergence risk about 70% and for tibia, the number of tunnels you may need to do is about five.
So the risk of convergence is very high. And if there is any convergence, the risk of graft failure is also very high. So it should be an experience. Hands anatomical alignments are very important. You need to have operatively recipe for to help in better placement and orientation. Pension sequins, again, different surgeons follow different protocols.
This is this is tension frequency, but a single stage l'approvisionnement. Doctor slap is one of the very famous soft tissue knee surgeons. You follow. You can follow this. He follows this protocol generally, most of the surgeons follow. Starting with the PCL as it restores the central pivot and then they work around it.
Laporte starts with an two lateral bundle, the PCL, with 90 degrees, followed by postal mail bundle. And then he goes to FCL, followed by the posterior corner ACL. And last is the de corner. You can see the number of. An indifferent cruise that went in and it's a complex surgery, so you can expect risks, and the rehabilitation process also can take longer.
The rehab process may take up to 12 to 18 months for the grafts to incorporate. It does take about three to four months. The rehab process is very important. The surgeon must liaise with the physiotherapist and on the rehab process, must be patient specific based on the surgery performed, and the patient must also have realistic expectations, and he should have the patience to undergo the rehab process for at least a year.
Complications, yes, you do have complication, the risk of iatrogenic vascular injury, nerve injury, meniscal root injuries, if you're placing the tunnels. The risk of compartment syndrome, of course. Painful hardware, this is relatively more common in all in the multilingualism injury. It can range between 30% to 40% risk of oral fibrosis, as it is more likely in an if you do act, if you do operate early.
However, it can be negated by. Rehab process and the residual instability aim is to achieve full instability. That is a possibility that you may have some instability still remaining. Right, that's the end of my talk. I will take the questions from here. I would stop sharing the screen.
Thank you. Sorry that's an excellent talk. Very comprehensive. The discussions for reconstruction guys, if you're reaching that level, it means you're doing really well. Get your basics right. The very beginning of this talk is the key points here. Once you have that correct, you'll smooth goes smoothly into the reconstruction talks.
Is there any questions from anyone? Yes, there is a few questions, thank you for the excellent talk. First question, what about if there is an internal terror? Would you do anything different or you would rely on the Vosper input for that? Yeah, thank you. Good question. So if you have intimate, you will identify because you need to do the API.
I will pick up if the blood pressure is going down, if it is going less and less. So if you do a CT angiogram, if it is an evolving into tear likely that it is, it can lead to occlusion. So a careful monitoring vascular input vascular surgeons will likely to take up this case and then go ahead and repair it if it is a small, intimate tear. If it is not evolving, they tend to leave it, but most likely for an injury like this with an internal tear, it is like most likely to evolve and occlude the artery.
OK, thank you. And for this laxity, how would you assess of 2.1 of opening? Because if it's two point two, it will be great too. So how can you specifically and accurately measure? Yeah again, it is. It is difficult. It is difficult, you have to say on one or two point two, whatever the published picture that I just put in, it is for.
Oh, for our purpose. And you very assess a free assessment and instability, or you don't go by. Go everything, go on everything on the stress radiographs alone. If you have an MRI scan, which is a complete rupture and you don't need to do it if it is a partial rupture and if it is 2.1 and if it is 2.1 to 2.2, and you may consider it, you know, it's based on how many other ligaments are injured you may tend to leave it, or if it again, it comes down to the surgeon who assist him at the time and things that look after reconstructing the other ligaments.
If he thinks that you OK, there is some instability, he may have further problems, then he'll end up reconstructing. That is well. Thank you. And if there is a vascular injury that's requiring repair, how would you tie your ligament injury repair in relation to that? Yes, so it's no different.
So you do the vascular reconstruction or repair and you wait for early intervention if the patient is recovering, doing very well. You go ahead and say around the time of based on which surgeons, somebody are early, somebody are late. Some people may take it late. They just say, take it easy. I'm not going to put a tourniquet.
So of course, after a vascular injury, you're not going to put a tourniquet by operating on it. You do a staged approach or you do you do a single approach based on discussing discussion with the vascular solutions in general after the vascular repair after three weeks, you still go ahead. OK and where if the vascular surgeon is to operate posterior approach and the patient is positioned prone?
Where are the lateral pins put in the tibia? The position of the location of the lateral pins in the tibia. It's you have to identify the safe zones, go to the safe zones. You can put the lateral just behind the anti shin, the lateral side. You go through it one on the proximal. You can go approximately or make sure you're more likely to get away without any injury if you go slightly more proximal on the lateral side.
OK, thank you. And for if you have a after deduction, of course, if you have a distant pulse, a good diesel pulse and an FBI of more than 0.9, would you still go for a engine? More or less sorry. Would you would you still go for a city Ngo, even if you have a good digital pulse and maybe I of more than open mind after the action?
No, it is not necessary that you need to if the app is maintained or 0.9 or above, you don't need to. It is not an indication, an absolute indication to do a CT angiogram and you could rely completely on a BPI. Some institutions routinely do it. Let's say let's take a scenario you have a digital pulse during the dislocation at the date. There's no pulse and then you reduce it and you got the pulse back.
We say, OK, there that is an injury, there was a policy because occluded, maybe there was an tear, there it may be evolving. I would like to get a CT angiogram, get this Vaseline involved early. That's an argument people some institutions make. So do you say the safest answer is to do the city you in the exam? Not necessarily, it is not routinely recommended because it is, as I said, AVP is less invasive, rapid and it is so accurate that it can pick up.
It's got 100% predictive value, excellent sensitivity and specificity. You don't have to go over, can you? But if I don't think you would go wrong if you say, OK, I'd like to, I'd like to get an angiogram. And I don't think you'll be, Uh, you will have any points minus on that. So I would from how she explains it, from experience, from the drivers, both teaching wise and on the course of being an exam, I do suggest that you do mention you would consider doing ACT or at least an MRA, an MRI angiogram while you're doing your so depending on your access in terms of which hospital and so on.
But CT would be the safest answer. I do appreciate what you're saying. So you write the paper is due say a b, but remember we didn't. With all respect to my consultant colleagues, we are dealing with guys that defer to the vascular surgeons. And in a lot of hospitals, especially the major trauma centers, the vascular surgeons will ask for an MRI or a CT angiogram to assess the vascular, even in a patient that has returned pulse.
Absolutely some institutions do it irrespective of it. They just do whatever it is, the safer answer, for example, it's also safer for the patient. I do. But I do appreciate these can be dependent on a lot of other things. But then the flip conversation is a CT angiogram in a patient who's got renal dysfunction is a risk as well for a patient.
So it's not. It's not the easy answer, but it is OK. Is there any role of velocity in multiligament injury in older than in patients older than 50 years of age? Like, of course, a constraint implant or something? Yes very good question. Somebody who's 50 years and older and you probably would like to create at least the collateral ligament instead of the knee.
Again, it depends on the surgeon who is doing it rather than going for a completely hinged, a complex knee. You can make the knee more primary and simpler and then reconstruct the only extra articular ligament medial and lateral collateral ligament and then rehabilitate the knee. See how we get on and somebody who's 50 years and then take it from there.
If if he's only 50 years and if he's doing reasonably well from the rehab process. And if he does not have any stability, we can wait as long as he develops the arthritis and then go for a primary neoplastic. OK, thank you. That's the end of.
Segment:0 .
Evening everybody once again, welcome to the FRCS mentor webinar session. As always, we have excellent talk for you. And we'll also have private sessions in the recorded part of the session. Today we have three them.
He is one of our new mentors. Join us in 2020. We're very proud of him and his work. He has an interest in the senior specialist with an interest in sports news and lowered numerous capacity. And we're looking to have to talk to us about knee dislocation, not his knee injury and for the interruption. Let me start off with the topic.
So as described with doing a knee dislocation presentation and multi ligaments knee injury, my talk is about is around 2025 minutes. This whole presentation is focused around. FRC is exam, hopefully, and I'm pretty hopeful. By the end of this presentation and discussion, you should be able to answer any questions that only dislocation and a confidential, OK, Uh, any dislocations.
As we are aware, it's a very rare injury, almost about 0.02% to zero 2% of all the orthopedic injuries. However, the true number may well be higher because about 50% to 60% of the cases, the knee spontaneously reduced. And that's why you don't have the true number knee dislocations. Why are they so serious? Because of the neurovascular structures around the knee?
It can have a limb threatening short term complications, which may end up in amputations and unable to use the knee because of the nerve injuries and things, and the long term consequences from the result of a multiligament knee injury and associated and neurology. So what is the mechanism involved? The most common mechanism is a high velocity injuries and the second most being sport injuries.
You see these in contact sports, rugby football and. Skiing in Greece. Ice skating and ice hockey. These are the injuries that you commonly see in these kind of contact sports. And interestingly, the low velocity injuries as well in high, morbid sorry in morbidly obese patients. And also, it is interesting that the neurovascular injury is no different from the high velocity or sports injuries and compared to low velocity injuries.
OK, coming to the clarification, what is the classification tell classification mainly guides, this classification gives us the nature of problem. If you see Kennedy classification, which basically tell us about the mechanism of injury where it is. A dislocation or posterior dislocation, medial, lateral and rotary dislocations.
It also tells you if you see the anterior and posterior, it's gone in the sagittal view. So basically tells it may be the crochets are gone, and it can tell you that likely that there may be an arterial injury or at least significant threatening threatening to the neuromuscular structures. Medial lateral undoubtedly gives us an information about the ligament rupture. Maybe the boat crew are gone, and the collective ligaments also would be involved in classification is more like a grading system.
It gives us an idea about how to manage this and guide us in the management, as well as to an extent it helps us in prognosis as it goes from top to bottom. We want to clarify it only worsens if you start with Katie one, it's only one of the groups that are gone. Katie, too, is by cruciate Katie. Three Katie 3 is more important because it constitutes about 65% of the dislocations.
So Katie, three where you have if! Katie three meaning there is medial collateral ligament being injured. Katie 3l, which is also ligament being injured. Katie for which has been cruciate and both collateral being gone. I'm Katie five that is very articular fracture dislocation. What are the immediate complications, as we expected, the vascular injury is most common.
Average about 30% to 40% popliteal artery is the most commonly injured. Why is probably the most commonly injured? Because it's relatively fixed and it is both due to the knee. Why is it fixed? It is fixed and after a hiatus, proximally and distally. It is relatively fixed at the soil's tendon injection and therefore it makes it relatively fixed and therefore it is subjected to shear forces when the knee dislocation happens.
As you can see, highest incidence of could more likely be in policy dislocation, and to be honest, anti dislocations are equally. You can equally cause injuries to the hospital artery. And the importance in detecting or diagnosing a vascular injury is crucial. Failure or delay in the diagnosis of vascular injury can lead to a significant rise of amputation rates, as you can.
The literature says that if it is beyond eight hours, the risk of amputation is about 86 percent, which is very high. OK, coming to the next injury, which is nerve injury, the common peritoneal nerve is the most common injury by comparing ulnar nerve. It is also relatively fixed because it is fixed approximately at the fibular neck and distally at the intramuscular septum, making it more rigid and therefore being subjected to shear forces during dislocation.
It it can most commonly occur in posture, laterally dislocations. However, you can't rule out a nerve injury based on a dislocation you, it only comes down to examination to rule out of injury. Studies have shown that 20 21% of the patients do recover fully, partially in 2009. About 50% of the people do not recover at all.
So for them, for the meeting and nerve repair grafting or in worst case scenario by if it doesn't recover by the end of the year, the many tendon transfers and the other most deadly complication is compartment syndrome, which we all aware of and we know that we act promptly. But the things that we miss is a vascular injury in case of a dislocation, which is reduced, so we don't really see that coming.
OK what do we do in the emergency department? This is something which is most important. I will go through this a little bit more in detail. You see on this slide on the left, the picture on the left. It is more or less widely used approach or algorithm in knee dislocations. Let's say a patient with a knee dislocation or a knee injury is in the emergency department.
How do you approach your approach with a TLS protocol? No different from any trauma injury you? You clear a bc and come to the deformity. If you see a deformity, check for the check for the neurology and get an urgent X-ray. If there is a dislocation, reduce a dislocation, splint the limb and then do the regular examination. What do we do? You just need to check the distal pulse, put the cuff before applying the splint so that you don't have to keep removing it.
Check the AVP ankle breaker pressure index. It is one of the most rapid, rapidly usable and unreliable method. Let's say you reduce the pulses, come back and you. You regularly monitor the ankle breaker pressure index for about 48 to 72 hours, up to 72 hours. And if there is any change, you will have to do any further imaging to see if there is any blockage of the artery or bleeding.
Let's say there is a pulse asymmetry or if there is an ankle brachial pressure index is less than zero point nine, then you have to involve the vascular surgeons. Get an urgent arterial. Graham prepared him for surgery for a new nerve repair or for the vascular repair or a reconstruction. Placement is fixed. They say there is no pulse at all after reduction.
You have no other option but to take him straight to the surge to the theater for exploration, you don't have to wait for a CT scan. I'll go through this again and by scenario based in the coming slides, if you go, if you just see the one picture which have put it in on a right at the lower end, which you see there is no dislocation. You know, the one which is below the X-ray.
There's no dislocation here, but you see extensive bruising and blistering. This should they should Ring Alarm bells. One must be very careful. It may be a spontaneous, maybe dislocation with spontaneous reduction. So this is something which you need to be aware of and you need to correlate your findings, like the mechanism of injury and then see subtle see the clinical examination like extensive bruising and see subtle signs of radiological signs of subluxation.
And then you will follow the protocol as a knee dislocation. OK OK. This is an ankle brachial pressure index, which why we need to do it. This is a very accurate, reliable and good sensitivity and specificity with a 100% positive predictive value. Less invasive. It's non-invasive, really. So which means you apply the ankle cuff traject after the ankle of the injured limb and upper uninjured arm and then check for it.
If the AVP is below zero point nine, then it is. It is a must that we need to get a CT angiogram and get the vascular surgeon input straight away. If you see a picture on the left of extreme left first extreme left slide, you see an angiogram which which shows completely a block of artery. But then if you see it there on the right picture where the patient has a collateral flow, this is why the patient can have a pulse within the completely occluded perpetual artery.
So doesn't mean if there is a pulse, you can avoid it. And clavicle president next is very important. And this will pick up API, which can which will be low, and therefore we can act accordingly. And urgently. OK, how do we reduce it when there is a dislocation? It must reduce it. We reduce it under sedation.
It should be gentle traction trying to reverse the deforming forces and not much and do not apply any pressure on the knee, especially on the back of the knee. You can aggravate or cause a vascular insult yourself, so it should be gentle traction. What if you don't get it? If you're not able to reduce it, you need to take him to the theater with the vascular support. Of course.
OK what do we see here? You can see a dimpled sign, you can see an arrow there, which is a postural or a lateral dislocation of knee, which means the middle from epicondyle has buttonhole to the capsule and has entrapped the ankle. So how much of pull it? You're not going to reduce it. In turn, you may cause more vascular damage by continuously trying to reduce it.
So don't attempt a closed reduction. This has to go to theater. Same is the case with open dislocations as well. Try not to reduce in the hospital. In the knee. Try to take to the theater as soon as possible. OK, here are the scenarios. I'll just go through it one by one.
So you can explain the knee. There are some surgeons splint the knee in extinction, which most surgeons do. Some surgeons try to flex the knee to about 10 degrees in the hinge brace so that you can avoid both of your subluxation. OK the first scenario is, let's say there's the chest X-rays of this satisfactory. There's a well, pulse, well, pulse.
What do you do? You don't need to do a CT angiogram. You you monitor the API. Check for pulse. EPA must be done every two hours for the next 48 hours to 72 hours. Check for the Science of compartment syndrome if there is compartment syndrome, you take in the theater for a face shortening.
OK, that's the next scenario. Check x-rays are OK. Czech x-rays are not OK with a bit of a subluxation that more or less tells that the knee dislocation knee is not stable. You may have an intact pulse doesn't mean that you should leave it at that. You should get an urgent CT angiogram and then take them to take the patient to the theater simply because there is a subluxation, which means it can push on the vessels.
So you need vascular surgeons help. It may not be. They may not be required, but they should be by the side. So you put an external fixator, reduce the knee. And if there is compartment syndrome, you can do fish shot me. Otherwise you don't need to. OK, next, let's come to another scenario. No pulse at all.
So there is no pulse. You just have to take to the page. Take the patient to the theater physiological exploration. Here are a few scenarios which I would like to mention. This is where I was confused during my exam. If I see it so, I thought I will just make it clear so it knee dislocation doesn't mean that every patient will have only knee dislocation.
They have multiple and they may have multiple injuries. Let's say the patient has a chest injury and a knee dislocation. So the he may not be amenable for a prone approach. He may not be able to put prone because of the chest problems during anesthesia. And therefore this the vascular surgeon can do an approach from the medial side. And can repair or revascularization and reconstruct the popliteal artery, and then you can do the external fixator, external fixator, whether you need to do it or not, which who comes first, the vascular or are the surgeons?
Ideally, if it is a very unstable knee to provide a strong bed, it is better to give better to do an external fixator first, followed by vascular repair. But but if the vascular surgeons think that they need to go first, they will go first and we should be able to work around putting an external fixator. Let's say, if it is an isolated knee dislocation and there's no other injuries, so the surgeon Vasquez will want to do it prone position.
So in that case, you will have to put a lateral external fixator. Of course, you want to put the lateral pins for your femur anyway, for the disc, for the proximal tibia or tibia. You may have to approach using the Shands pins from the lateral end and for the next space spanning 18 fixator like you see on the picture on the right, on the top. So once you do the external fixator, you position the patient prone and the vascular surgeons will repair or reconstruct the peripheral artery.
So hope this makes it clear. One more thing that you need to be aware of is will you need any compartment release when you have a vascular slap lesion? Well, the literature says that yes, you need, you may need or you may benefit with it simply because we can avoid a reperfusion syndrome and therefore relieving the compartment by 2 using one single incision or two incisions.
But the sutures generally do it with one single incision on the lateral side, right? OK, so prophylactic fascia to me, ratio to me. Why the results show that early 3 shot me has improved outcomes with patients with vascular injury, and it reduces the which reduce the amputation rates. So completely ulnar nerve injury, as we said, it is also one of the common injuries around 20 percent, ranging between 5 to 45.
We have an algorithm which you can follow in general. If you have an open, open dislocation, you will have the surgeons, especially surgeons, plastic surgeons available who will help you, who will help with nerve repair if is completely transacted. But if it is a closed injury, you will observe you can. You can follow this algorithm and by two weeks when you're are planning for multiple egawa test knee injury.
If it's you, you can plan for new releases if there is an intact nerve, but still with. No problems. You need to put uncle foot autopsies and closely observe him regularly do the nurse studies. Worst case scenario, you may have to go back and then do a tendon transfer if there is no recovery, then by the end of the year, normally it is about a year that we take a position to do it.
OK, now that we dealt with acute dislocations. We go with Michael egawa test injury. How do we deal with it? So we've dealt with the patient patient is comfortable in the brace. But we need to assess the need for a possible surgical intervention. What what are the requirements that we need to have for this, for assessing the need?
First is first and foremost is a physical examination. You need to assess the ligaments, see which is gone. It may be difficult when somebody's a patient. For a patient who is two weeks old, he may not cooperate as much because he may be in pain. And what I can gives a lot of information in terms of what ligaments have been ruptured, if it's please check the image on the right. It is a published stress radiograph for multiligament knee injuries, comparing amount of opening on the medial side or lateral side.
Um, suggesting if it is a partial complete or involvement of posterolateral and post-traumatic corners as well. So emperor intraoperatively radiographs are extremely useful, reliable and post-reconstruction. We can always check and then document as well if you have achieved the stability. OK imagine if there is a fracture that you suspect, you will need X rays, if not, you will need MRI scan, which is a gold standard.
You definitely will require what ligaments are going to plan your surgery. Non-operating management, the literature says there is no role for non-operated management as they have significantly poorer results and poor functional outcome from non-operated management, and it should only be reserved to people with poor general health condition and elderly patients who doesn't have the reserves or may not be able to do an extensive, rigorous post-operative physiotherapy.
OK, coming to the surgical management, what do we do? We it depends on the timing of surgery. When do we do the surgery? Is it soon or sooner or later? Two schools of thought. Some surgeons tried to do this in as early as possible, around three weeks time. Some surgeons do it in six weeks time. Why three weeks?
Three weeks is what they call an early intervention where you have a possibility, there is a possibility of ligament repair, as well as needing reconstruction it in 3 Allen three weeks time, you will have all the systemic inflammatory process subsides and the anesthetic risk also reduces. But the downside is going around three weeks time operating the risk of ultrafine growth is slightly higher compared to operating after six weeks.
However, the recent literature says you have higher functional outcome from early intervention than a late intervention. So late surgeries. Uh, generally around six weeks is where you tend to take up, you can't repair because the ligaments would have scarred up retracted. So you have no other option, but a reconstruction is the only way out.
OK do we do all at one go or how do we do it? Staged procedure again, two schools of thought as some surgeons do it a single stage. Some surgeons do it. A staged approach. So single stage, which means repairing and reconstructing, reconstructing all the ligaments around three weeks time. What are the advantages of it? It it restores the knee kinematics and decrease the risk of meniscal or damage due to instability, which you may have if you reconstruct only a few ligaments.
OK it is, however, suitable for a young, individual motivated individual who is open and capable of taking an aggressive physiotherapy because also fibrosis is something which is relatively at higher risk. If you do all single stage in three weeks time. Staged approach where you can repair the ligaments, the collateral ligament, the extra articular, mainly that's what the first stage is. You repair or reconstruct the extra articular structures and then rehabilitate.
Get full range of movement and then try to do a second stage by reconstructing the cruciate ligaments. Repaired with this reconstruction repair is only possible in the first three weeks after three weeks is it becomes difficult. Why reconstruction of the ligaments after three weeks is preferred?
Sorry, the repair has got probably a slightly poorer outcome and failure rates compared to reconstruction. And that is and that's why reconstruction of the ligaments are preferred in the first three weeks. Although the soft tissue planes are not very distinct, we can still be able to do better at the time. A PCL, lc, injuries and the literature say, is that both slap lesion reconstructions are.
Better than repairs, and they have a much better outcome from reconstructions. However, there are some religions who are saying the cruciate ligaments repairs or have equal functional outcome. To a reconstruction. OK what are the graph that we need to use? We have photographs, autographs, we know autographs. We can use quadriceps, tendon, hamstring, tendon, bone, collarbone, tendon, but with a multiligament is the injury.
You require a lot of crabs for which most of the surgeons would prefer to use polygraphs because you have a greater selection on top. On top of those tendons that are mentioned, you can have Achilles tendon breath and the tendon, both to your tibial exposed tendon that can be used. What are the advantages? Because it reduces the surgical time, a multiligament reconstruction does take time, so any time that can reduce it, we can take it.
So reduce the surgical time, reduce the donor site morbidity, as well as the post-operative pain. What are the disadvantages? Holograms don't come cheap. They are expensive. There, there is a small risk of disease transmission as the Allen grafts, and the incorporation is definitely slower compared to autographs.
Let's go to the principles of multiple injury. What is the aim of the surgery is to provide a stable knee and improve the range of movement with physiotherapy and bring him back to as normal as possible with regards to the knee. However, we need to prepare the patient about the expectations, which we must have a true expectations ligament as injuries are not that straightforward.
You, you wouldn't. You wouldn't. You wouldn't be able to get a perfect knee straight away. It's a long process. The principles involved, first of all, identification of all the ligaments by stress radiographs assessment and MRI scans then decide whether we then plan, whether it is going to be a single stage or a staged approach.
Um, awarding tunnel convergence, which I'm going to discuss in the coming slides. And tension sequence. These two are very important in multiple egawa test knee injury. If it is a single stage approach and a supervised rehab program, which which is half the job. Surgery is off the job and I think rehabilitation is half the job.
See, avoiding tunnel convergence, let's say, if you have all the ligaments that are damaged, if you have all the ligament damage, you may need all at least four tunnels on the medial side in 3 tons in the lateral side. Then you can expect how difficult it is to have individual tunnels and to avoid convergence risk. So for an ACL and FCL, the convergence risk about 70% and for tibia, the number of tunnels you may need to do is about five.
So the risk of convergence is very high. And if there is any convergence, the risk of graft failure is also very high. So it should be an experience. Hands anatomical alignments are very important. You need to have operatively recipe for to help in better placement and orientation. Pension sequins, again, different surgeons follow different protocols.
This is this is tension frequency, but a single stage l'approvisionnement. Doctor slap is one of the very famous soft tissue knee surgeons. You follow. You can follow this. He follows this protocol generally, most of the surgeons follow. Starting with the PCL as it restores the central pivot and then they work around it.
Laporte starts with an two lateral bundle, the PCL, with 90 degrees, followed by postal mail bundle. And then he goes to FCL, followed by the posterior corner ACL. And last is the de corner. You can see the number of. An indifferent cruise that went in and it's a complex surgery, so you can expect risks, and the rehabilitation process also can take longer.
The rehab process may take up to 12 to 18 months for the grafts to incorporate. It does take about three to four months. The rehab process is very important. The surgeon must liaise with the physiotherapist and on the rehab process, must be patient specific based on the surgery performed, and the patient must also have realistic expectations, and he should have the patience to undergo the rehab process for at least a year.
Complications, yes, you do have complication, the risk of iatrogenic vascular injury, nerve injury, meniscal root injuries, if you're placing the tunnels. The risk of compartment syndrome, of course. Painful hardware, this is relatively more common in all in the multilingualism injury. It can range between 30% to 40% risk of oral fibrosis, as it is more likely in an if you do act, if you do operate early.
However, it can be negated by. Rehab process and the residual instability aim is to achieve full instability. That is a possibility that you may have some instability still remaining. Right, that's the end of my talk. I will take the questions from here. I would stop sharing the screen.
Thank you. Sorry that's an excellent talk. Very comprehensive. The discussions for reconstruction guys, if you're reaching that level, it means you're doing really well. Get your basics right. The very beginning of this talk is the key points here. Once you have that correct, you'll smooth goes smoothly into the reconstruction talks.
Is there any questions from anyone? Yes, there is a few questions, thank you for the excellent talk. First question, what about if there is an internal terror? Would you do anything different or you would rely on the Vosper input for that? Yeah, thank you. Good question. So if you have intimate, you will identify because you need to do the API.
I will pick up if the blood pressure is going down, if it is going less and less. So if you do a CT angiogram, if it is an evolving into tear likely that it is, it can lead to occlusion. So a careful monitoring vascular input vascular surgeons will likely to take up this case and then go ahead and repair it if it is a small, intimate tear. If it is not evolving, they tend to leave it, but most likely for an injury like this with an internal tear, it is like most likely to evolve and occlude the artery.
OK, thank you. And for this laxity, how would you assess of 2.1 of opening? Because if it's two point two, it will be great too. So how can you specifically and accurately measure? Yeah again, it is. It is difficult. It is difficult, you have to say on one or two point two, whatever the published picture that I just put in, it is for.
Oh, for our purpose. And you very assess a free assessment and instability, or you don't go by. Go everything, go on everything on the stress radiographs alone. If you have an MRI scan, which is a complete rupture and you don't need to do it if it is a partial rupture and if it is 2.1 and if it is 2.1 to 2.2, and you may consider it, you know, it's based on how many other ligaments are injured you may tend to leave it, or if it again, it comes down to the surgeon who assist him at the time and things that look after reconstructing the other ligaments.
If he thinks that you OK, there is some instability, he may have further problems, then he'll end up reconstructing. That is well. Thank you. And if there is a vascular injury that's requiring repair, how would you tie your ligament injury repair in relation to that? Yes, so it's no different.
So you do the vascular reconstruction or repair and you wait for early intervention if the patient is recovering, doing very well. You go ahead and say around the time of based on which surgeons, somebody are early, somebody are late. Some people may take it late. They just say, take it easy. I'm not going to put a tourniquet.
So of course, after a vascular injury, you're not going to put a tourniquet by operating on it. You do a staged approach or you do you do a single approach based on discussing discussion with the vascular solutions in general after the vascular repair after three weeks, you still go ahead. OK and where if the vascular surgeon is to operate posterior approach and the patient is positioned prone?
Where are the lateral pins put in the tibia? The position of the location of the lateral pins in the tibia. It's you have to identify the safe zones, go to the safe zones. You can put the lateral just behind the anti shin, the lateral side. You go through it one on the proximal. You can go approximately or make sure you're more likely to get away without any injury if you go slightly more proximal on the lateral side.
OK, thank you. And for if you have a after deduction, of course, if you have a distant pulse, a good diesel pulse and an FBI of more than 0.9, would you still go for a engine? More or less sorry. Would you would you still go for a city Ngo, even if you have a good digital pulse and maybe I of more than open mind after the action?
No, it is not necessary that you need to if the app is maintained or 0.9 or above, you don't need to. It is not an indication, an absolute indication to do a CT angiogram and you could rely completely on a BPI. Some institutions routinely do it. Let's say let's take a scenario you have a digital pulse during the dislocation at the date. There's no pulse and then you reduce it and you got the pulse back.
We say, OK, there that is an injury, there was a policy because occluded, maybe there was an tear, there it may be evolving. I would like to get a CT angiogram, get this Vaseline involved early. That's an argument people some institutions make. So do you say the safest answer is to do the city you in the exam? Not necessarily, it is not routinely recommended because it is, as I said, AVP is less invasive, rapid and it is so accurate that it can pick up.
It's got 100% predictive value, excellent sensitivity and specificity. You don't have to go over, can you? But if I don't think you would go wrong if you say, OK, I'd like to, I'd like to get an angiogram. And I don't think you'll be, Uh, you will have any points minus on that. So I would from how she explains it, from experience, from the drivers, both teaching wise and on the course of being an exam, I do suggest that you do mention you would consider doing ACT or at least an MRA, an MRI angiogram while you're doing your so depending on your access in terms of which hospital and so on.
But CT would be the safest answer. I do appreciate what you're saying. So you write the paper is due say a b, but remember we didn't. With all respect to my consultant colleagues, we are dealing with guys that defer to the vascular surgeons. And in a lot of hospitals, especially the major trauma centers, the vascular surgeons will ask for an MRI or a CT angiogram to assess the vascular, even in a patient that has returned pulse.
Absolutely some institutions do it irrespective of it. They just do whatever it is, the safer answer, for example, it's also safer for the patient. I do. But I do appreciate these can be dependent on a lot of other things. But then the flip conversation is a CT angiogram in a patient who's got renal dysfunction is a risk as well for a patient.
So it's not. It's not the easy answer, but it is OK. Is there any role of velocity in multiligament injury in older than in patients older than 50 years of age? Like, of course, a constraint implant or something? Yes very good question. Somebody who's 50 years and older and you probably would like to create at least the collateral ligament instead of the knee.
Again, it depends on the surgeon who is doing it rather than going for a completely hinged, a complex knee. You can make the knee more primary and simpler and then reconstruct the only extra articular ligament medial and lateral collateral ligament and then rehabilitate the knee. See how we get on and somebody who's 50 years and then take it from there.
If if he's only 50 years and if he's doing reasonably well from the rehab process. And if he does not have any stability, we can wait as long as he develops the arthritis and then go for a primary neoplastic. OK, thank you. That's the end of.
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