Transcript
12/06/2013
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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
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