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Björn Engström, M.D., Ph.D., Associate Professor

The Severely Injured Knee

Karolinska Institutet

IOC Advanced Team Physician

Course

First of all.....

Every knee injury

is unique !!!

Mechanism of Injury

High energy

Dashboard knee

Pedestrian vs Auto

MC

Fall from height

Low energy

Fall on flexed knee

Hyperextension

Forced flexion + internal rotation

Old ACL and/or PCL injury + new injury

ESSKA - 2002

The injury mechanism

Dashboard injury

F. Netter

Injury mechanism

Hyperextension injury

Flexion-Rotation

injury

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F. Netter

Flexion-Rotation

injury

Serious injury !

Remember when you examine a

severely injured knee(If possible) ask the patient: ”Exactly what

happened at the moment of injury?”

The distal part of the leg pointing in some

abnormal direction?

Spontaneous reduction or manual reduction?

Is the knee dislocated in anyway (when you

examine)

Is blood supply, motor function, sensory

normal - distal to the injured area?

Pulseless? Dropfoot? Sensory loss?

Knee Dislocation

Remember that many knees that have been

dislocated - are not dislocated at the time they

arrive at the hospital !!

The joint capsule is often ruptured i.e. The

effusion of the hemarthroses will not be

detected because the blood will be extra

articular !!

Classification

I. Direction of displacement

II. Open vs Closed

III. High energy vs Low energy

IV. Ligament Involved Classification

Anatomic Classification of

Knee Dislocation

KD-I. Single cruciate torn (ACL or PCL)

KD-II. Bicruciate disruption, MCL/LCL intact

KD-III. Bicruciate disruption, torn MCL or

LCL/PCL

KD-IV. ACL, PCL, MCL, LCL torn

KD-V. All ligaments torn with fracture

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Lachman test

Which stability tests are possible in

the acute phase?

(and/or Reversed Lachman test) Varus-Valgus test

Posterior sag

Posterior drawer

Tibia step off

Postero-lateral

instability

Reversed

Pivot shift

Dial test

X-ray

Dislocated

Anterior

Posterior

Postero-lateral

Avulsion fracture

Plateau fracture

Segond

fracture

Small

fractures can

tell you a

lot…

On the other hand big cartilage

lesions is sometimes ”hidden”…

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Severe knee injury

The risk of a possible knee dislocation

Be suspicious if you find ACL-PCL rupture

High- or low energy trauma ?

Damage to the nerves and/or the vessels!

Consider:

Severe knee injuryVascular lesions not

repaired within 6-8 hours

� Amputation rate is

> 85%

Amputation caseVascular grafting.

No amputation!

Timing – time since injury?

Do X-ray and MRI immediately !

i.e. X-ray acute and MRI within 1-2 days

The surgical technique is ”easier” in the acute stage and the best period for this injury is within 10-14 days!

i.e. Extraarticular injuries is more difficult to identify(and to repair) after this period.

In an acute injury, consider that all things

you have to do before surgery often take

more time than you think!

NeuroVascular Lesions

15% (n 41) neurovascular lesions

20 isolated nerve injuries (7.3%)

7 isolated vascular injuries (2.6%)

14 combined nerve&vasc injuries (5.1%)

ESSKA 1998: 273 knees in a Multicentre study

4.8 – 65% incidence of vascular injuries

20% nerve injuries (mostly peroneal part)

Skendzel J, Sekiya J, Wojtys E: J Orthopaedic & Sports Physical therapy 2012

Emergency CareClinical examination

Closed Reduction & Neurovascular & skin control!

Clinical examination

Immobilisation in Extension to prevent post sublux

Thromboembolic Prophylaxis

Cryotherapy

Preoperative screening: X-ray and MRI

Immediately preop check for DVT. Doppler.

ESSKA 1998: 273 knees in a Multicentre study

Emergency Care

Ankle brachial index (ABI) is very sensitive. If

<0.9 or if no pulses and/or Doppler showing

signs of vascular insufficiency � Angiography.

CT angiography (Less radiation, Less invasive)

ESSKA 1998: 273 knees in a Multicentre study

Vascular lesions

Check and describe all motor and sensory loss

(mark)

Nerve lesions

Levy et al The Journal of joint surgery 2012

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Other Pathology

Open dislocation 19-35%

Injury to tendons in at least 20% of the patients: Patellar tendon

Biceps femoris

Popliteus

Fascia lata

Concomitant fractures in at least 10-20 % of the patients: Especially of the tibial plateau

Generally associated with inferior outcomes.

Early correct treatment is very important

What to do?

How unstable is the knee?

Is it possible to get ”good” healing without surgery? Are there just a few structures that need surgery?

Are there any wounds that are contaminated?

Deep venous thrombosis

Timing - Time since injury?

Acute (within 2-3 w) - Subacute – Chronic (> 3 months)

To take into consideration

Brace

The Jack PCL-Brace has for

example an additional spring

tension that cause an anterior

directed translation force. Be

careful if the ACL is ruptured!

Treatment with

Brace in full

extension is

sometimes a

good option

Healing without surgery?

Acute PCL rupture 8 month later

Operative vs Nonoperative

Out of 413 articles found in PubMed there were 4

studies that compared operative with nonoperative

treatment.

Totally 227 operatively and 107 nonoperatively

treated patients in these 4 studies.

IKDC and Lysholm score was in favour for the

operatively treated patients

But injury pattern differ etc. etc.

Levy B et al. Arthroscopy 2009

If surgery:

Experienced team – Two surgeons

Sufficient equipment

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Is it possible to return

to high level of sports???

Gould: Slalom, Giant slalom, Combination

Silver: Super-G

Olympic Games in Salt Lake City

But the long term result

is not always superior

Chronic PCL-posterolateral injury

including a

Tibial Plateau Fracture

Case 1

Patient & Injury mechanism

• Female elite gymnast

• Age 15

• Hyperextension when running

to jump off the jumpboard

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X-ray – Report:

”A small fracture fragment on the

medial side of the Tibia plateau;

slight displacement”.

Angiogram

Normal

MRI…

Day 2

One week after injury

Open surgery was performed (“Hospital Elsewhere”)

Additional findings – the Biceps tendons were ruptured

Open repair of the lateral structures using suture

anchors:

Biceps femoris

LCL

Fixation of the small medial fragment with

bioabsorbable Smart nail®.

The Decision

Was that decision

right?

Here is the result

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Posterior instability

Fracture dislocation

Why did it fail?Our Decision

Step 1 - Bone

Restore Tibial plateau with bone graft

from iliac crest

Refixation of the medial meniscus

anterior horn

JACK-brace to keep tibia in position

5 months later

Step 2 – Ligaments

Hardware removal

Arthroscopic PCL (4xHamstrings –

single bundle)

Postero-lateral reconstruction

(Larson) (contralateral ST)

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10 weeks after reconstruction…

(Feb 2006)

2 years after ligament reconstruction. The

Patient put this video on YouTube

Acute ACL-MCL-Patellatendon-

Medial+Lateral meniscal rupture

injury

Case 2

Patient & Injury mechanism

• Male Snowborder from USA

• Age 27

• Decceleration-Hypervalgus

after ”big air” in Norway

• Injury date Febr 2008

• Surgery 10 days later

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Acute Clinical findings (in GA)

Pos Lachman ++ (Soft endpoint)

Posterior drawer: neg

Pivot shift + (++)

Valgus instability ++ (in 25 degree of flexion)

Posteromedial and Posterolateral rotational

stability OK (ROM 25-90 degrees)

Injury pattern

Medial injury from post.med. corner to PT

Total patellartendon rupture

Rupture of IT-band insertion at the Gerdy’s tubercle

Lateral meniscus had a longitudinal tear and a deep

radial tear to the capsule in the posterior horn

Most part of medial meniscus was detached

Total ACL rupture

Medial Surgery Medial surgery

10 weeks postop

Acute ACL-PCL-MCL injury

Case 3

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Patient & Injury mechanism

• Male

• Age 30

• Hypervalgus after falling from an

offshore boat in a race in 150 km/h

Acute Clinical findings

Pos Lachman ++ (Soft endpoint)

Posterior drawer: ++ (could only be tested in GA)

Pivot shift: neg (could only be tested in GA)

Valgus instability ++ (in 25 degree of flexion)

Posteromedial rotational instability (ROM 25-90 degrees)

(could only be tested in GA)

ACL

PCL

Medial ruptur

Müller: The Knee

Ivar Palmer 1897-1985

On the injuries to the

ligaments of the knee

joint. A clinical

study, Thesis.

Karolinska Institutet,

1938

Early postop rehab phaseEarly postop rehab phase

Brace in 0 degree 4 weeks with partial weight bearing

Week 1 - 2: No ROM training

Week 3 - 4: ROM 0 - 30 degree

Week 5 - 6: Brace and ROM 0 - 60 degree

Week 7 - 8: Brace and ROM 0 - 90 degree

Week 9 - 12: Brace and ROM without limit

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Take home message

KD and trauma with more than one rupturedligament involved. Make a thorough analysis and useMRI (within a few days). ”Overlooked” injuries is not uncommen!

Never forget to check nerve function and vacularisation distal to the injury (several times)!

Get a second opinion from experts, to decide ifsurgery should be performed in the acute phase i.e. tomake it possible to do surgery within 7-10 days.

Giro d’Italia it perhaps more safe!

Thank you!

and welcome to