Jump to content
We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Multiligament Injury

From WikiSM
(Redirected from Multiligament Knee Injury)

Other Names

  • Multiligament knee injuries (MLKI)
  • Multiligament Knee Injury

Background

History

Epidemiology

  • Estimated to represent 0.02% to 0.20% of all orthopedic injuries[1]
  • Likely underestimated as a high proportion are missed on initial evaluation

Pathophysiology

Etiology

  • High energy trauma
    • Examples include motor vehicle crash, ATV accident
    • Often associated with other injuries
  • Lower energy trauma
    • Sports-related trauma
    • Fall from standing

Associated Injuries

Risk Factors

  • Needs to be updated

Differential Diagnosis

Clinical Features

  • History
    • High energy or low energy trauma
    • If ambulation attempted, likely instability or buckling
  • Physical Exam: Physical Exam Knee
    • Dimple Sign: buttonholing of of medial femoral condyle through medial capsule
    • Very important to document a thorough vascular exam
    • Presence of peripheral pulses does not exclude vascular injury
    • Abnormal pedal pulse is only 79% sensitive, 91% specific for arterial injury[2]
    • Serial vascular exam is mandatory
    • Assess Peroneal Nerve, Tibial Nerve
    • Carefully examine compartments
  • Special Tests
    • Ankle Brachial Index: can be used to compare vascular flow to contralateral limb
    • Need to perform structural exam assessing ACL, PCL, MCL and LCL

Evaluation

Load video
YouTube
Multiligament Knee Injury with Popliteal Artery Injury
Knee dislocation algorithim proposed by Ng et al[3]

Ankle Brachial Index

  • Excellent screening tool since arteriography is impractical in all patients
    • If ABI < 0.9, must pursue further vascular workup
  • Mills et al: ABI <0.9 has 100% sensitivity, specificity and PPD for vascular injuries in knee dislocations[4]

Radiographs

MRI

  • Indicated in most cases
    • After reduction, prior to surgical intervention if possible
  • Helpful to identify degree of soft tissue injury
    • Especially in the multi-ligament knee injury
  • Consider angiography

CT

  • Useful to evaluate for fracture patterns
  • Findings
    • Tibial eminence fracture
    • Tibial tubercle fracture
    • Tibial Plateau fracture
  • Consider angiography

Ultrasound

  • Duplex arterial sonography may be useful to evaluate arterial supply

Classification

Schenck Anatomic Knee Dislocation (KD) Classification

  • KD I: Knee dislocation with either cruciate intact
  • KD II: Bicruciate with collateral intact
  • KD III: Bicruciate injury with one collateral ligament injury
    • KD IIIM: Bicruciate + MCL injury
    • KD IIIL: Bicruciate + LCL injury
  • KD IV: Bicruciate with both colateral ligaments injured
  • KD V: Periarticular fracture dislocation

Management

Prognosis

  • Levy et al systematic review compared operative to nonoperative management[5]
    • Overall, operative treatment results in better functional outcome as compared to nonoperative treatment
    • Higher rates of return to work and pre-injury sports activities
    • International Knee Documentation Committee [IKDC] excellent/good results 58% operative vs 20% nonoperative
    • Return to sport is 29% in operative group vs 10% in nonoperative group
    • Range of motion (126° vs. 123°) and flexion (4° vs. 3°) loss were similar among groups
  • Timing of surgery
    • Levy looked at timing of surgery[6]
      • More likely to return to sport if surgery done within 3 weeks
      • No difference in functional outcomes between early and late surgery
  • Staged vs acute reconstruction/repair
    • Jiang et al: staged treatment yield best clinical results for KD III, with no difference between acute and chronic reconstruction[7]
    • Mook et al: staged procedures produced better outcomes, acute timeline was superior[8]

Acute

  • Follow ATLS protocol when appropriate, based on mechanism
  • Examination
    • Thorough structural examination
    • Examine soft tissue compartments
    • Confirm palpable dorsalis pedis, posterior tibia and popliteal artery pulses
  • Immobilization
  • Imaging
    • Pre and post-reduction radiographs
    • Consider CT (with angiography), emergent MRI
    • Vascular- consider ABI, duplex arterial sonography
  • Emergent surgery
    • Irreducible knee dislocation
    • Open knee dislocation
    • Vascular injury

Nonoperative

Operative

  • Indications
    • Virtually all cases
  • Technique
    • Repair
    • Reconstruction

Rehab and Return to Play

Rehabilitation

  • Overall, there is a paucity of evidence guiding rehabilitation of repaired MLKI
  • General consensus is protected non-weight bearing for 4-6 weeks
    • Followed by active mobilization, progressive weight bearing, avoid passive stretching[9]
  • Mook et al showed early mobilization resulted in better range of motion, stability[8]

Return to Play

  • Needs to be updated

Complications

  • Popliteal Artery injury
    • Reported in 18 to 64% of knee dislocations[10]
    • Approximately 80% are repaired, 12% require amputation
    • Lower risk in sports-related injuries than high-velocity injuries[11]
    • Early interventions within 8 hours (11%) is associated with lower rates of amputation than beyond (86%)[12]
    • Highest risk with KD IV injuries
    • McDonough case series on popliteal artery injuries following MLKI[13]
      • 4/12 identified by physical exam, 5/12 identified with arteriography and 3/12 identified in OR with vascular exam and arteriography
  • Peroneal Nerve Injury
    • Most commonly the Common Peroneal Nerve, however Superficial Peroneal Nerve, Deep Peroneal Nerve also affected
    • Injured in between 25% and 33% of dislocations, particular posterior and lateral[14][15]
    • As high as 41% in posterlateral corner injuries[16]
    • Among sports, skiing and football are most commonly associated[17]
    • Approximately 30% have a complete palsy, with only 38.4% of them having a functional recovery
    • Approximately 70% have an incomplete palsy, 87.3% of them have a functional recovery[18]
  • Inability to return to sport
  • Chronic instability
  • Chronic pain

See Also

References

  1. ↑ Howells NR , Brunton LR , Robinson J , Porteus AJ , Eldridge JD , Murray JR . Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury 2011;42:1198–1204.
  2. ↑ Barnes CJ , Pietrobon R , Higgins LD . Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis. J Trauma 2002;53:1109–1114
  3. ↑ Ng, Jimmy Wui Guan, Yulanda Myint, and Fazal M. Ali. "Management of multiligament knee injuries." EFORT Open Reviews 5.3 (2020): 145-155.
  4. ↑ Mills WJ , Barei DP , McNair P . The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004;56:1261–1265.
  5. ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
  6. ↑ Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy. 2009;25:430–8.
  7. ↑ Jiang W , Yao J , He Y , Sun W , Huang Y , Kong D . The timing of surgical treatment of knee dislocations: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015;23:3108–3113
  8. ↑ 8.0 8.1 Mook WR , Miller MD , Diduch DR , Hertel J , Boachie-Adjei Y , Hart JM . Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg Am 2009;91:2946–2957.
  9. ↑ Lynch AD , Chmielewski T , Bailey L , et al.; STaR Trial Investigators. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr Rev Musculoskelet Med 2017;10:328–345
  10. ↑ Medina, Omar, et al. "Vascular and nerve injury after knee dislocation: a systematic review." Clinical Orthopaedics and Related Research® 472.9 (2014): 2621-2629.
  11. ↑ Shelbourne KD, Klootwyk TE. Low-velocity knee dislocation with sports injuries. Treatment principles. Clin Sports Med. 2000;19:443–56
  12. ↑ Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–9.
  13. ↑ McDonough EB Jr , Wojtys EM . Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med 2009;37:156–159
  14. ↑ Meyers MH, Harvey JP. Traumatic dislocation of the knee joint: a study of eighteen cases. J Bone Joint Surg Am 1971;53:16-29.
  15. ↑ Samson D , Ng CY , Power D . An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2017;1:362–367
  16. ↑ Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87:664–7.
  17. ↑ Cho D, Saetia K, Lee S, Kline DG, Kim DH. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus. 2011;31:E11.
  18. ↑ Woodmass JM, Romatowski NP, Esposito JG, Mohtadi NG, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2015;23:2992–3002.
Created by:
John Kiel on 18 December 2020 22:31:21
Authors:
Last edited:
30 January 2025 17:46:02
Retrieved from "https://wikism.org/w/index.php?title=Multiligament_Injury&oldid=28340"