the acutely dislocated knee: evaluation and management

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The Acutely Dislocated Knee:Evaluation and Management

Jeffrey A. Rihn, MD, Peter S. Cha, MD, Yram J. Groff, MD, and Christopher D. Harner, MD

Abstract

Traumatic knee dislocations are un-common, accounting for <0.02% of allorthopaedic injuries.1-3 These datalikely underestimate the true inci-dence because an unknown percent-age of knee dislocations spontaneous-ly reduce and thus are not diagnosedduring the initial evaluation. Mis-management of such injuries canhave devastating consequences, par-ticularly in dislocations that involvelimb-threatening vascular injuries.Therefore, despite the low reportedincidence of knee dislocation, a basicknowledge of current evaluation andmanagement concepts is essential.

Knee dislocation commonly in-volves injury to most of the soft-tissuestabilizing structures of the knee, re-sulting in multidirectional instabili-ty. Although knee dislocation can oc-cur involving injury isolated to theanterior cruciate ligament (ACL) orposterior cruciate ligament (PCL),both of the cruciate ligaments are usu-ally disrupted.4,5 Associated injuries

to the collateral ligaments, menisci,articular cartilage, and neurovascu-lar structures can complicate the eval-uation and treatment of the patientwith a traumatic knee dislocation.

Historically, traumatic dislocationof the knee has been managed withprolonged immobilization, which hasbeen associated with variable out-comes, including loss of motion, re-sidual instability, and poor kneefunction.6-8 The goal of surgical man-agement of acute dislocations is an-atomic repair and reconstruction ofall associated ligamentous and menis-cal injuries.9-13 Surgical timing, graftselection, and surgical technique re-main controversial. The use of al-lograft has become popular in mul-tiligament knee surgery because ofgraft availability, decreased operatingtime, and decreased donor site mor-bidity in an already traumatizedknee.9,12,13 Some advocate delayedsurgery, but many others recommendearly surgical repair or reconstruction

(within 3 weeks of injury).6,8,13,14 Mostof the principles of evaluation andmanagement of the patient with anacutely dislocated knee are well es-tablished;15 recent advances have cen-tered on improvements in surgicaltechnique.

Classification

Knee dislocation is temporally clas-sified as acute (<3 weeks) or chronic(≥3 weeks).16 Anatomic classificationis based on the position of the dis-placed tibia (ie, anterior, posterior,medial, or lateral) on the femur.2 A

Dr. Rihn is Resident Physician, Department ofOrthopaedic Surgery, University of PittsburghMedical Center, Pittsburgh, PA. Dr. Groff is Clin-ical Fellow, Center for Sports Medicine, Univer-sity of Pittsburgh, Pittsburgh. Dr. Harner is BlueCross of Western Pennsylvania Professor, and Di-rector, Section for Sports Medicine, Departmentof Orthopaedic Surgery, University of PittsburghMedical Center. Dr. Cha is Attending Surgeon,Beacon Orthopaedics and Sports Medicine, Cin-cinnati, OH.

None of the following authors or the departmentswith which they are affiliated has received anythingof value from or owns stock in a commercial com-pany or institution related directly or indirectlyto the subject of this article: Dr. Rihn, Dr. Groff,Dr. Harner, and Dr. Cha.

Reprint requests: Dr. Harner, Center for SportsMedicine, 3200 South Water Street, Pittsburgh,PA 15203.

Copyright 2004 by the American Academy ofOrthopaedic Surgeons.

Acute knee dislocations are uncommon orthopaedic injuries. Because they often spon-taneously reduce before initial evaluation, the true incidence is unknown. Dislo-cation involves injury to multiple ligaments of the knee, resulting in multidirec-tional instability. Associated meniscal, osteochondral, and neurovascular injuriesare often present and can complicate management. The substantial risk of associ-ated vascular injury mandates that vascular integrity be confirmed by angiographyin all suspected knee dislocations. Evaluation and initial management must be per-formed expeditiously to prevent limb-threatening complications. Definitive manage-ment of acute knee dislocation remains a matter of debate; however, surgical recon-struction or repair of all ligamentous injuries likely can help in achieving the returnof adequate knee function. Important considerations in surgical management in-clude surgical timing, graft selection, surgical technique, and postoperative rehabilitation.

J Am Acad Orthop Surg 2004;12:334-346

334 Journal of the American Academy of Orthopaedic Surgeons

rotatory knee dislocation involves acombination of these tibial displace-ment positions. Knee dislocations thatspontaneously reduce before evalu-ation are classified according to thedirection of instability.

Anterior dislocations are the mostcommon, accounting for approximate-ly 40% of all knee dislocations.17 Hy-perextension is typically the mecha-nism of injury. Posterior dislocationsrepresent 33% of all knee dislocations.17

The mechanism is usually high energy,such as the so-called dashboard in-jury sustained during a motor vehi-cle accident. Lateral and medial dis-locations are less common, estimatedat 18% and 4% incidence, respective-ly.17 The mechanism involves a vio-lent varus or valgus load. Associatedfractures are not uncommon. Rotatoryknee dislocations, caused by a twist-ing force to the knee, are the least com-mon type. Posterolateral dislocations,the most common type of rotatory kneedislocation, have a high incidence ofirreducibility, in which case the me-dial femoral condyle buttonholesthrough the medial soft-tissue struc-tures.18

Associated NeurovascularInjuries

Injuries to the popliteal artery canmake knee dislocation a limb-threat-ening emergency. The reported inci-dence of associated popliteal arteryinjury is between 32%17 and 45%,19

with severity ranging from an intimaltear to complete transection. Becauseamputation rates vary in direct rela-tion to the length of time to revascu-larization, immediate recognition ofarterial vascular compromise is cru-cial. An amputation rate of 86% aftera delay in revascularization of 6 to 8hours has been reported.17 Damageto the intimal portion of the artery canbe more insidious, with delayed vas-cular compromise presenting sever-al days after the injury. Vascular in-jury must be assumed in all patients

with knee dislocation until it is provedotherwise by angiography.

Neurologic damage, ranging froma stretching of the nerve (neurapraxia)to complete transection (neuronotme-sis), occurs in 16% to 40% of all kneedislocations; it is most common afterposterolateral dislocations.6,20 The pe-roneal nerve is more often injured thanthe tibial nerve.21 Careful neurologicexamination before any manipulationof the knee is mandatory, although itis often difficult to obtain, particular-ly in a trauma patient.

Evaluation

Initial assessment of the patient be-gins with a brief history that reviewsthe mechanism of injury and a direct-ed physical examination that includesa thorough neurovascular evaluationof the injured extremity. The patientwith a dislocated knee usually has atremendous amount of pain, a largeknee effusion, and overall swelling ofthe extremity. A spontaneously re-duced knee dislocation can appeardeceptively benign and can be over-

looked when evaluating a multiplytraumatized patient. Thus, even withnormal-appearing radiographs, acomplete physical examination of theknee, including thorough neurovas-cular assessment, is essential for allvictims of high-energy trauma. Whensubstantial laxity of two or more ofthe major ligaments of the knee isfound, a presumptive diagnosis ofknee dislocation should be made.

The vascular examination includesmanual palpation of the dorsalis pe-dis and posterior tibialis pulses andcomparison with the uninvolved side.The ankle-brachial indices (ABI) de-termined with ultrasound is a moresensitive study that can help confirmthe vascular status of the extremity.An abnormal result from any of thesetests should prompt a vascular sur-gery consultation. However, a normalresult from any of these tests does notexclude arterial injury. Normal puls-es, a warm foot, and brisk capillaryrefill can be present with arterial in-jury. Therefore, any patient with ahigh suspicion of knee dislocationshould undergo arteriography of thelower extremity (Fig. 1). The routine

Figure 1 Anteroposterior arteriograms of an intact popliteal artery (A) and an injured poplitealartery (B) after acute knee dislocation and subsequent reduction. The artery shown in panelB was found to be transected at exploration.

Jeffrey A. Rihn, MD, et al

Vol 12, No 5, September/October 2004 335

use of arteriography in this setting isjustified by the relatively low morbid-ity of the test, the high incidence ofpopliteal artery injury, and the poten-tially devastating consequences of de-lay in diagnosis.20,22-24

A complete neurologic examina-tion also must be performed, includ-ing an evaluation of motor and sen-sory function in the distribution of thetibial and peroneal nerves. The por-tions of the examination requiringpatient cooperation are often difficultto obtain and should be accuratelydocumented. Progressive deteriora-tion of neurologic function raises thesuspicion of an impending compart-ment syndrome or ischemia.

The examination of knee stabilityshould be done only after survival ofthe limb is ensured. It should be doneas gently as possible to avoid iatro-genic injury. Thorough evaluation ofall ligaments can be difficult to obtainbecause of the associated pain. Themost sensitive test for determiningACL deficiency is the Lachman test,performed with the knee held in 20°to 30° of flexion.25 The most sensitivetest for detecting PCL injury is theposterior drawer test, performed withthe knee in 90° of flexion.26 To accu-rately assess the PCL, the normalstep-off of the medial tibial plateauin reference to the medial femoralcondyle must be determined. The col-lateral ligaments are assessed by ap-plying stress in the coronal plane atboth full extension and 30° of kneeflexion.

Standard radiographs are obtainedto evaluate the direction of disloca-tion, characterize associated osseousinjuries (ie, fracture or avulsion), andconfirm reduction (Fig. 2). Initial ra-diographs should be obtained imme-diately after a prompt evaluation ofthe patient. Magnetic resonance im-aging (MRI) can be used to charac-terize associated soft-tissue and occultosseous injuries only after the patienthas been acutely stabilized (Fig. 3).MRI is helpful in developing a sur-gical plan.

Initial Management

The vascular status of the limb mustbe determined quickly and managedappropriately. If the limb is obvious-ly ischemic, the knee should be re-

duced immediately through gentletraction-countertraction with the pa-tient under conscious sedation. Thelimb should then be stabilized in along leg splint. If pulses are restoredwith the reduction, postreduction ra-

Figure 2 Anteroposterior (A) and lateral (B) radiographs of a posterolateral knee disloca-tion in a patient who sustained a twisting injury to the left knee while playing basketball.Anteroposterior (C) and lateral (D) radiographs of the same knee after closed reduction un-der conscious sedation and placement in a long leg plaster splint.

The Acutely Dislocated Knee: Evaluation and Management


diographs and a formal angiogramshould be obtained. If the limb re-mains ischemic, the patient requiresemergent surgical exploration and re-vascularization in the operatingroom. More rigid stabilization can beapplied in the form of external fixa-tion that spans the knee joint, withpins in the femur and tibia. The ex-ternal fixator supplies sufficient rigid-ity to maintain reduction but allowsgood access to the knee and leg forserial neurovascular examinations.

When there is no vascular compro-mise, radiographs should be obtained

and the knee is promptly reduced. Agentle reduction maneuver is prefer-able, avoiding extreme deformity ofthe limb to minimize the likelihoodof iatrogenic vascular injury. Ade-quate sedation is important. The spe-cific reduction technique depends onthe direction of the dislocation, butthe most important element is distrac-tive force. After reduction, a repeatneurovascular examination is doneand radiographs are obtained. Aswith all cases of knee dislocation, an-giography should be done to rule outvascular injury.

Emergent Surgery

Emergent surgery is indicated in pa-tients with vascular injury, compart-ment syndrome, open injury, or irre-ducible dislocation. Patients with apopliteal artery injury require emer-gent intervention by a vascular sur-geon. Input from the orthopaedic sur-geon concerning the location of futureincisions can help optimize recon-structive efforts. Saphenous veingrafting and fasciotomies are often re-quired after revascularization. Evenwithout vascular compromise, a com-partment syndrome is a surgicalemergency. Despite the presence of aknee dislocation, prompt diagnosisand management of a compartmentsyndrome is mandatory for success-ful resolution.

In open knee dislocation, the stan-dard principles of wound manage-ment prevail, including initial irriga-tion and débridement, with serialdébridements as needed as well as in-travenous antibiotics and adequatesoft-tissue coverage. Early ligamentreconstruction is contraindicated withan open wound. In some instances,soft-tissue coverage problems maydelay ligament reconstruction for sev-eral months.

Irreducible dislocations are un-common, but they require promptsurgical reduction to avoid prolongedtraction on the neurovascular struc-tures. Although ligament reconstruc-tion can be done at the time of openreduction, it is preferable to delay de-finitive reconstruction to allow forcomplete knee imaging, planning,and resource mobilization.

During emergent surgery on a dis-located knee, however, it is acceptableto perform simple repairs as they areencountered in the surgical exposure.Use of excessive foreign material, in-cluding suture, should be avoided inopen injuries, and additional inci-sions solely for reconstruction shouldnot be done. In almost all circum-stances, definitive ligament recon-struction should be delayed for sev-

Figure 3 T1-weighted (A) and T2-weighted (B) sagittal MRI scans of the left knee of a pa-tient who sustained a twisting injury from stepping in a hole during a softball game. Theimages show disruption of both the anterior (arrow) and posterior (arrowhead) cruciate lig-aments. C, T1-weighted sagittal image showing an injury to the lateral meniscus (asterisk),which appears to be elevated off the lateral tibial plateau. D, T2-weighted coronal image show-ing injuries to the lateral meniscus (asterisk) and posterolateral corner (solid circle). The fib-ular head appears comminuted, and there is no identifiable lateral collateral ligament, bi-ceps femoris tendon, or popliteus tendon.



eral days to allow limb swelling tosubside. With vascular injury, time isrequired to ensure that the vascularrepair is adequate.

Definitive Management

The management of multiligamen-tous knee injuries has not been wellstudied and remains controversial.Definitive conclusions are difficult tomake because of the relative infre-quency of these injuries, the manycombinations of ligamentous and me-niscal injury patterns, the varied treat-ment approaches, and the numerousmethods of outcomes assessment. Be-fore the mid 1970s, nonsurgical man-agement consisting of closed reduc-tion followed by immobilization wascommon.2,7,27,28 Results tended to varywith the duration of closed treatment:longer periods of immobilization re-sulted in stable but stiff knees, where-as brief periods led to excellent mo-tion but greater instability.6,7,29,30

Unfortunately, no prospective studycompares surgical with nonsurgicalmanagement options for this type ofinjury. With recent advances in kneeligament surgery, however, surgery isoften recommended for the patientwith knee dislocation.8,9,13,15,29-32 Thegoal of surgery is to improve stabil-ity, retain motion, and achieve kneefunction that allows the patient toperform daily activities.

Nonsurgical Management

Although used frequently in the past,closed reduction and cast immobili-zation is now indicated only for pa-tients who are elderly or sedentary orwho have debilitating medical or post-traumatic comorbidities.7,33 Those whoinitially undergo a trial of nonsurgi-cal management often require surgi-cal intervention later to address prob-lems with knee function, including lossof motion or persistent instability. Pooroutcome after nonsurgical manage-

ment of knee dislocation is well doc-umented.7,8,34

Nonsurgical management beginswith 6 weeks of immobilization in ex-tension. The form of immobilizationdepends on several clinical factors;choices include a cast, brace, externalfixator, or transarticular Steinmannpin. If vascular repair was done, a castor brace should not be used in orderto avoid circumferential pressure onthe limb. External fixation can pro-vide more protection to the vascula-ture. For the extremely obese patient,immobilization often is not possiblewith a cast or brace alone. Therefore,external fixation is a viable option forthe extremely obese patient.

The ideal flexion angle in which toimmobilize the dislocated knee hasnot been well studied. The ACL-deficient knee is more stable in flex-ion, and the PCL-deficient knee morestable in full extension. Knee flexionof 30° to 45° is usually sufficient. Ir-respective of the angle selected, main-taining a reduced tibiofemoral jointis essential. Nonsurgical managementdemands frequent radiographs, espe-cially in the first few weeks, to ensurethat the joint remains in the reducedposition. Immobilization is followedby rehabilitation with progressivemotion in a brace. Initiation of lightrunning is highly variable, with mostpatients reaching this point at 6 to 8months.

Surgical Management

Most authors currently recommendsurgery for acute knee disloca-tion.8,9,13,15,29-32 Controversies persistregarding surgical timing, surgicaltechnique (ie, which structures to re-construct or repair), graft selection,and rehabilitation. Generally, simul-taneously repairing both theACLandPCL as well as any grade III collat-eral or capsular injuries is the mostreliable method of restoring ligamen-tous stability, knee motion, and over-all knee function.

TimingWhen there is no need for emer-

gent surgery, surgical interventionshould be delayed until adequate per-fusion of the limb is ensured and allfactors have been optimized to allowsafe surgical repair. Delaying surgeryfor 10 to 14 days offers several advan-tages. It allows for a period of vas-cular monitoring and the resolutionof acute inflammation and soft-tissueswelling. Range of motion (ROM) andquadriceps muscle tone will partial-ly return, potentially reducing the riskof postoperative arthrofibrosis.10 Var-ious degrees of healing occur. Thecapsule heals quickly and may allowan arthroscopically assisted approachthat minimizes the extent of dissec-tion.

Delaying surgery beyond 3 weeks,however, results in excessive scarringof the collateral ligaments and pos-terolateral structures that may pre-clude their repair. If surgery must bedelayed beyond 3 weeks, it may beprudent to wait until full ROM is es-tablished and to consider late recon-struction only if the patient developsresidual laxity and functional insta-bility.

ProcedureThe patient is positioned supine on

the operating table with a well-padded tourniquet applied to theupper thigh; the tourniquet is not in-flated during the procedure unlessnecessary. A sandbag, on which thefoot is rested when the injured kneeis flexed, is secured to the operatingtable at the level of the midthigh. Alateral post is placed at the level ofthe tourniquet to prevent lateralmovement of the flexed leg. The set-up should permit the knee to be tak-en through a full ROM. A Doppler ul-trasound is used to confirm the distalpulses at the beginning and end ofsurgery.

After appropriate patient position-ing, an examination under anesthe-sia is performed. It is important tocompletely define all ligamentous in-



juries and ROM. Special attention ispaid to the collateral ligaments becauseinjuries to these structures generallydetermine which surgical incisions areused. The contralateral knee is usedfor comparison. Proposed skin inci-sions are marked and injected with0.5% bupivacaine with epinephrine.

To decrease the amount of sur-gical dissection, arthroscopic tech-niques are used as much as possible.However, it is not always possible orsafe to use arthroscopy in the acutesetting because of capsular disrup-tion. Sufficient capsular healing (ap-proximately 2 weeks) is needed tomaintain joint distension and avoidiatrogenic compartment syndrome.The procedure is begun using grav-ity inflow. The thigh and calf must bepalpated intermittently throughoutthe procedure to monitor fluid ex-travasation. If extravasation is noted,the arthroscopic technique is aban-doned and the remainder of the sur-gery is done with an open technique.In this situation, the arthroscope canstill be valuable in a dry field becauseit can improve visualization as theprocedure is done through miniar-throtomies.

ApproachThe pattern of injury dictates the

surgical approach. The two mostcommon combined injury patterns in-clude either the ACL, PCL, and me-dial collateral ligament (MCL), or theACL, PCL, lateral collateral ligament(LCL), and posterolateral structures.Less commonly, the PCL is intact oris only partially disrupted and doesnot require reconstruction.5,35 The pat-tern of injury determines placementof the skin incisions. Some authorsadvocate the use of a midline incision,which provides limited access to thecollateral ligaments and can be com-plicated by skin sloughing over thepatella. The medial and lateral hock-ey stick incisions described by Hugh-ston and Jacobson36 and Muller,37

when separated by at least 10 cm,minimize the risk of skin necrosis and

wound breakdown while providingsatisfactory exposure.

Repair Versus ReconstructionThe decision to repair or reconstruct

a torn ligament depends on severalfactors. Most cruciate injuries in kneedislocations are midsubstance tearsthat are not amenable to successfulsurgical repair.37,38 Some surgeonsreconstruct midsubstance tears of thecruciate ligaments with allograft. Suc-cessful repairs can be done in casesof bony avulsion,39,40 either by usingnonabsorbable sutures passed throughsmall drill holes tied over a corticalbridge of bone or by achieving screwfixation, depending on the size of theassociated bone fragment.

For the MCL and posterolateralstructures, primary surgical repair inthe acute setting (<3 weeks) yieldssatisfactory results. During this time,avulsions or intrasubstance tears ofthe MCL may be directly repaired.Similar intrasubstance tears of theLCL also can be repaired but mayneed to be supplemented with al-lograft tissue. Beyond 3 weeks, scarformation and soft-tissue contracturelimit the success of primary ligamen-tous repair, often making reconstruc-tive procedures necessary.

The articular cartilage and menis-ci should be inspected arthroscopicallyto define pathology not appreciatedon physical examination or in imag-ing studies. Peripheral meniscal tearsare repaired directly; central or irrep-arable meniscal lesions are débridedto a stable rim while preserving asmuch meniscus as possible.

Graft Selection and PreparationSeveral different grafts may be used

for reconstruction. Depending on theextent of injury, autograft tissue maybe obtained from the ipsilateral or con-tralateral extremity. However, allografttissue has advantages over autograftsin knees with multiple ligament in-juries. The use of allograft tissue elim-inates graft site morbidity, decreasesdissection time, and reduces the num-

ber and extent of incisions in an al-ready traumatized knee.12,41,42Allograftuse also decreases intraoperative tour-niquet time, postoperative pain, andpostoperative knee stiffness.41 Disad-vantages of allograft tissue comparedwith autograft tissue include greatercost, risk of disease transmission, anddelay in graft incorporation and re-modeling.43,44

Bone–patellar tendon–bone (BPTB)allograft is recommendedtoreconstructthe ACL. The BPTB graft provides ad-equate strength and rigid bony fixa-tion at both the tibial and femoral at-tachment sites. Use of cylindrical boneplugs 11 mm in diameter × 25 mm inlength with an 11-mm tendon widthis preferred. To facilitate graft passage,two no. 5 nonabsorbable sutures areplaced in both the patellar and tibialplugs through drill holes. For PCL re-construction,Achilles tendon allograftcan be used alone or in combinationwith an ipsilateral hamstring tendonas an autograft for a single-bundle ordouble-bundle technique, respectively.Achilles tendon allograft is effectivefor PCL reconstruction because of itscross-sectional area and calcaneal boneplug that allows rigid bony fixationat the femoral attachment site. Com-paction pliers and a rongeur are usedto size the central portion of the cal-caneal bone plug to a diameter of 11mm and a length of 25 mm. Two no.5 nonabsorbable sutures are placed inthe bone plug. The tendinous end ofthe graft is tubularized with a double-armed no. 5 nonabsorbable suture us-ing a baseball whipstitch, which pre-vents the graft from “balling up”during graft passage. The LCL is re-constructed with an Achilles tendonallograft with a 7- or 8-mm–diame-ter calcaneal bone plug. Alternatively,the BPTB allograft remaining from theACL graft may be used for the LCLreconstruction. Either tibialis anteriortendon allograft or ipsilateral ham-string tendon autograft can be usedto reconstruct the popliteofibular lig-ament. These grafts are prepared toa diameter of 7 mm and secured with



a no. 2 nonabsorbable suture using awhipstitch on both ends.

Cruciate LigamentReconstruction

The details of reconstructing theACL and PCL have been welldescribed.45-48 The femoral and tibialinsertions of the cruciate ligamentsare identified arthroscopically. Thefemoral PCL tunnels are placed to re-produce the anterolateral bundle ofthe native PCL, whereas the ACL tun-nels are placed in the center of its an-atomic insertions (Fig. 4). In the set-ting of acute knee dislocation, atranstibial tunnel technique for PCLreconstruction is safer than the tibialinlay technique; the tibial inlay tech-nique requires extensive soft-tissuedissection, and there is increased riskof vascular injury associated with theposterior approach. Some techniquemodifications are helpful for multi-ligament reconstruction after kneedislocation. One order of bicruciatereconstruction is outlined in Table 1.

Tibial and Femoral TunnelsThe PCL tibial tunnel is drilled

first, with placement of a 15-mm off-set PCL guide set at 50° through theanteromedial portal. The tip of thePCL guide is positioned in the distaland lateral third of the tibial PCL in-sertion site. A 1.8-mm guidewire isstarted 4 cm distal to the joint line and2 cm medial to the tibial tubercle andplaced under arthroscopic guidanceusing the PCL guide. The guidewireshould exit through the tibial PCLfootprint approximately 1 cm belowthe tibial plateau. Caution must betaken when passing the guidewirethrough the PCL tibial insertion sitebecause of the close proximity of theneurovascular structures.

The ACL tibial guide is set to 47.5°and introduced through the antero-medial portal. A 1.8-mm guidewire isplaced through the center of the ACLtibial footprint. It exits at least 2 to 3cm proximal to the PCL guidewire toensure that an adequate medial tib-

ial cortical bridge remains after drill-ing. Because the PCL is absent, theposterior edge of the anterior horn ofthe lateral meniscus is used as a guideto the center of the tibial footprint ofthe ACL. The guidewire should be di-rected posterior to Blumenstaat’s lineon the full extension lateral projection

to ensure proper placement of theACL tibial tunnel. Intraoperative ra-diographs or fluoroscopy images areobtained to monitor guidewire place-ment (Fig. 5).

The PCL tunnel is drilled using a10-mm compaction drill bit under di-rect arthroscopic control. A30° arthro-

Figure 4 Anteroposterior (A) and lateral (B) views showing tunnel placement in combinedPCL and ACL reconstruction.

Table 1Order of Bicruciate Ligament Reconstruction in the Dislocated Knee

Step 1 Drill tibial tunnels PCL, then ACLStep 2 Drill femoral tunnels ACL, then PCLStep 3 Graft passage and

femoral fixationPass and fix PCL bone block into femoral

tunnel through the anterolateral portalPass tendinous portion of PCL graft into

tibial tunnelPass ACL graft through tibial tunnel and

fix in femoral tunnelStep 4 Collateral ligament

repairSecure extra-articular repairs or recon-

structionsStep 5 PCL fixation: Tibia Fix PCL graft on tibia at 90° of flexion with

reproduction of anteromedial step-offStep 6 ACL fixation: Tibia Fix ACL graft on tibial side at full extension

ACL = anterior cruciate ligament, PCL = posterior cruciate ligament

(Adapted with permission from Cole BJ, Harner CD: The multiple ligament injured knee.Clin Sports Med 1999;18:241-262.)



scope is placed through the postero-medial portal, and a curette is usedto stabilize the Kirschner wire duringdrilling. The initial drilling is startedby power and completed by hand tominimize the risk of plunging throughthe posterior tibial cortex. Althoughintraoperative fluoroscopy can beused, direct visualization provides bet-ter control. The PCL tibial tunnel isexpanded to a diameter of 11 mm us-ing dilators in 0.5-mm increments. TheACL tibial tunnel is then drilled us-ing a 9-mm compaction drill bit andis expanded to a diameter of 10 mmusing dilators in 0.5-mm increments.

The femoral tunnels are created inthe opposite order: ACL, then PCL.The ACL femoral tunnel is drilledthrough the anteromedial portal withthe knee in full flexion.49 This is pref-erable to the more traditional transtib-ial technique because the location ofthe femoral tunnel is not constrainedby the position or angulation of thetibial tunnel. The femoral tunnel canbe placed more easily toward the wall

of the notch in the center of the an-atomic insertion of the ACL, located6 mm anterior to the posterior wallof the femur at the 10 o’clock posi-tion (right knee) or 2 o’clock position(left knee).50 The guidewire is over-drilled with a 9-mm compaction drillto a depth of 25 to 35 mm, and dila-tors in 0.5-mm increments are usedto expand the tunnel to a diameter of10 mm. This technique can be de-manding because visibility is limitedwith the knee in full flexion.

A two-incision technique for PCLgraft tunnel placement with a sepa-rate femoral incision for outside-indrilling of the femoral tunnel can beused, but it is preferable to drill thefemoral PCL tunnel through the an-terolateral portal. With the scope inthe anteromedial portal, the footprintof the anterolateral bundle of the PCLis easily visualized on the medial fem-oral condyle. A guidewire is thenplaced 7 to 10 mm from the articularsurface within this footprint. A 10-mm compaction drill bit is used todrill the tunnel to a depth of 25 to 30mm. Bone debris is removed, and thetunnel is dilated to a diameter of 11mm using dilators in 0.5-mm incre-ments. Double-bundle PCL recon-struction is not routinely done inacute knee dislocations.

Graft Passage and Femoral FixationThe PCL graft is passed first. Us-

ing the two-incision transtibial tun-nel technique for PCL reconstruction,the graft is passed from the femur tothe tibia, and the calcaneal bone plugis secured on the femoral side withan interference screw (Fig. 6). Usingthe one-incision transtibial tunneltechnique for PCL reconstruction, along looped 18-gauge wire is passedretrograde into the PCL tibial tunneland retrieved from the anterolateralportal with a pituitary rongeur. Theno. 5 suture secured to the tendinousportion of the graft is passed into thejoint using the looped 18-gauge wirethrough the anterolateral portal, thenpassed antegrade down the PCL tib-

ial tunnel to exit on the anteromedialtibia. The calcaneal bone plug ispassed through the anteromedial fe-mur using a Beath needle placedthrough the PCL femoral tunnel toexit in the anteromedial thigh. Aprobe is used under arthroscopicguidance to facilitate passage of thecalcaneal bone plug. The calcanealbone plug is secured within the fem-oral tunnel using an interferencescrew. If interference screw fixationis not possible, a separate femoral in-cision is made, and the no. 5 nonab-sorbable suture attached to the calca-neal bone plug is tied over a plasticbutton. The ACL graft is then passedretrograde from the tibial to femoraltunnel using a Beath needle and issecured on the femoral side with a7 × 25-mm interference screw.

Final FixationThe tibial sides of the grafts are not

secured until after the collateral lig-ament injuries are addressed. Extra-

Figure 5 Intraoperative lateral radiographtaken after placement of ACL (top wire) andPCL (bottom wire) tibial tunnel guidewires.

Figure 6 Passage of the Achilles tendon al-lograft for PCL reconstruction using the two-incision technique. The Achilles tendon al-lograft is passed from the femur to the tibiato position the calcaneal bone plug in the fem-oral tunnel.



articular repairs or reconstructionsare secured with slight internal rota-tion for posterolateral structures andwith valgus force on the tibia for lat-eral collateral ligament repairs. Oncecollateral surgery is completed, thecruciate grafts are fixed to their re-spective tibial attachment sites. Incontrast to isolated cruciate ligamentreconstruction, cyclic loading of thegrafts is not performed before finalfixation. The tenuous repair or recon-struction of other injured structuresof the knee precludes rigorous pre-tensioning of the cruciate grafts. Rath-er, the knee is taken through gentleROM before final fixation to ensurethat the reconstructed knee has notbeen captured. The PCL graft is ten-sioned and fixed to the tibia while re-producing the normal step-off of themedial tibial plateau in relation to thefemoral condyle. The graft is fixedwith a 10 × 30-mm bioabsorbable in-terference screw and/or a 4.5-mmAOscrew with a soft-tissue washer withthe knee held in 90° of flexion to re-create the anterolateral bundle. Thisreestablishes the central pivot of theknee. With the knee in full extension,the ACL graft is then secured with a7 × 25-mm interference screw.

Medial Side InjuryFor combined ACL-PCL-MCL in-

juries in which the medial side opensin full extension, a combined cruci-ate ligament reconstruction and MCLrepair is performed. The MCL doesnot require repair if the knee does notexhibit a grade III MCL injury in fullextension during the examination un-der anesthesia. In patients with gradeIII MCL injury, the cruciate tunnelsare created arthroscopically before themedial side repair is done. In theacute setting with marked MCL in-sufficiency and extreme valgus laxity,arthroscopy may be impossible be-cause of fluid extravasation. In suchcases, a medial hockey stick incisionand the arthroscope (without fluid)are used to guide tunnel placement.

For MCL repairs, a medial hockey

stick incision is made at the level ofthe vastus medialis muscle and isbrought over the femoral epicondyleto the anteromedial tibia just medialto the patellar tendon (Fig. 7). The sar-torius fascia is split and reflected toexpose the MCL and capsule. Periph-eral tears of the medial meniscus arerepaired through this approach usingnonabsorbable sutures; the MCLis re-paired with nonabsorbable suturesand suture anchors. MCL and capsu-lar avulsions are repaired anatomical-ly with suture anchors, whereas in-trasubstance MCL tears are repairedwith no. 2 nonabsorbable sutures us-ing a modified Kessler stitch.37 In thechronic setting, reconstruction with asemitendinosus tendon or Achillestendon allograft may be required inaddition to repair. The repair or re-construction is done with the knee in30° of flexion. The knee is flexed andextended during repair to ensure thatknee motion is not constrained. Thecruciate ligaments are then fixed onthe tibial side, as described, and theknee is braced in full extension.

Lateral Side InjuryAfter the cruciate ligament graft

passage, a 12- to 18-cm curvilinear in-

cision is made over the lateral epi-condyle. It begins midway betweenthe fibular head and Gerdy’s tuber-cle and then continues proximallyover the lateral epicondyle, parallel-ing the posterior border of the iliotib-ial band (ITB) (Fig. 8). The peronealnerve is identified and tagged witha vessel loop. It is easiest to locate thenerve proximally, posterior to the bi-ceps femoris tendon, and trace it dis-tally to its entrance into the anteriorcompartment of the leg. The nerve iscarefully evaluated and is usually re-leased as it passes around the fibu-lar neck. If a nerve injury is presentpreoperatively, the extent of damageis noted. A formal neurolysis is usu-ally not done, but the fascial bandsat the entrance to the anterior com-partment of the leg are released if aneurologic deficit is present at thetime of surgery.

All of the posterolateral structuresare then systematically evaluated. Inacute injuries, there may be signifi-cant stripping and detachment ofboth ligaments and tendons. The in-terval between the posterior edge ofthe ITB and the biceps femoris ten-don is developed. The ITB insertionalso can be partially released subper-

Figure 7 Medial approach to a knee dislocation involving injury of the ACL, PCL, and MCL.This patient also had an associated injury to the medial meniscus that required repair.A, Incisions for medial approach. B, Medial approach with guidewires present for drillingACL and PCL tunnels and exposure of medial joint line for meniscus repair.



iosteally from Gerdy’s tubercle to in-crease exposure to the LCL and popli-teus tendon insertions.All repairs andreconstructions are performed withthe knee in 30° of flexion.

Peripheral tears of the lateral me-niscus are repaired with nonabsorb-able sutures, and capsular avulsionsare fixed with suture anchors. Bonyavulsions of the LCL or popliteus ten-don are anatomically repaired. Achil-les tendon allograft can be used forLCL reconstruction; a 7- to 8-mmbone block is fixed to the fibular headwith a metal interference screw. TheAchilles tendon allograft is securedto the lateral femoral epicondyle withsuture anchors. The remaining LCLis meticulously dissected to preserveits proximal and distal remnants.These remnants are tensioned and su-tured to the Achilles tendon allograftthat has been secured to the lateralfemoral condyle (Fig. 9).

If there is increased posterolateralrotation on the preoperative exami-nation, the popliteus tendon and itsvarious attachments are addressed.The location of injury determines thetreatment method; femoral avulsionsare repaired directly. A popliteofibu-lar reconstruction is performed for

midsubstance injuries using ham-string autograft or tibialis anteriortendon allograft. A tunnel is createdin the proximal fibula. The graft ispassed deep to the LCL and placedinto a closed-end tunnel at the ana-

tomic femoral insertion site of thepopliteus tendon (Fig. 10). Its femo-ral attachment is then tied over a plas-tic button on the medial femoral cor-tex. The distal end is pulled throughthe tunnel created in the fibular headand tensioned with the knee in 30° offlexion. Fixation is achieved with abioabsorbable interference screwplaced in the fibular head tunnel. Inpatients who require combined LCLand popliteofibular ligament recon-struction, the distal end of the popli-teofibular graft is brought posteriorto anterior through a soft-tissue tun-nel created at the insertion of the bi-ceps femoris tendon.

Rehabilitation

Postoperative rehabilitation is criticalto patient outcome. For the first 6 to8 weeks, the primary goal is to de-crease swelling and maximize quad-riceps muscle firing.51 With primaryrepair, the initial fixation may be ten-uous and vulnerable to failure if

Figure 8 Lateral approach to a knee dislocation involving injury of the ACL, PCL, and LCLas well as the posterolateral structures. A, Incisions for combined ACL-PCL-posterolateralcorner injury. B, Lateral exposure for repair of the posterolateral corner and LCL injuries.(Reproduced with permission from Cole BJ, Harner CD: The multiple ligament injured knee.Clin Sports Med 1999;18:241-262.)

Figure 9 Reconstruction of the LCL. A, Calcaneal bone block of the Achilles tendon allograftis secured to the fibular head using an interference screw. The tendinous portion of the Achil-les tendon allograft is sutured to the insertion of the native LCL. B, The tendinous portionof the Achilles tendon allograft is oversewn to the native LCL remnant. (Adapted with per-mission from Cole BJ, Harner CD: The multiple ligament injured knee. Clin Sports Med 1999;18:241-262.)



stressed too early. Therefore, the kneeshould remain in a brace locked in fullextension for the first 4 weeks to pro-vide maximum protection. Initial re-habilitation should focus on restoringfull passive extension symmetric tothat of the uninjured knee and restor-ing quadriceps muscle function suchthat the patient can perform a straightleg raise without a quadriceps lag. Ex-ercises immediately after surgery in-clude passive knee extension (avoid-ing hyperextension in patients withrepair or reconstruction of the poster-olateral structures), isometric quad-riceps sets, and straight leg raises.High-intensity electrical stimulationmay be used to improve quadricepsfunction.

Passive ROM is begun 2 to 3 weekspostoperatively with a physical ther-apist, preventing posterior tibial sub-luxation during flexion by applyingan anterior force to the proximal tib-

ia. Active flexion is avoided for thefirst 6 weeks to prevent posterior tib-ial translation resulting from ham-string contraction. During this peri-od, motion is limited to 90° of flexion.After 6 weeks, passive and active-assisted ROM and stretching exercis-es are begun to increase knee flexion.Knee flexion symmetric to that of theuninjured knee should be achievedwithin 12 weeks.

Quadriceps exercises are pro-gressed to limited-arc, open-chainknee extension exercises as toleratedafter 4 weeks. These exercises are per-formed only from 75° to 60° of kneeflexion to prevent excessive stress onthe reconstructed grafts. Open kinet-ic chain knee flexion is avoided forat least 3 months to prevent posteri-or tibial translation resulting fromhamstring contraction. Closed-chainhamstring exercises should be avoid-ed for the first 6 weeks after surgery.

Progression from partial to fullweight bearing as tolerated is doneover the first 4 weeks unless a lateralrepair or reconstruction was per-formed. In those cases, patients mustremain partial weight bearing andlocked in extension for 8 weeks toprotect the lateral structures. Once pa-tients have regained good quadricepscontrol (approximately 4 weeks), thebrace may be unlocked for controlledgait training. Patients generally re-quire crutches for 6 to 8 weeks de-pending on ROM, strength, and am-bulatory ability. The brace is usuallydiscontinued at approximately 6 to 8weeks after 90° to 100° of knee flex-ion is achieved. Gentle manipulationis required in patients who struggleto regain flexion (<90°) beyond 8 to12 weeks. Running is permitted at 6months if 80% of quadriceps strengthhas been achieved. Return to sportsaverages between 9 and 12 months.Patients may return to sedentarywork in approximately 2 weeks andto heavy labor in 6 to 9 months.

Results

Studies that evaluate the results of sur-gical management of knee dislocationare limited in number and vary inregard to the involved ligamentousinjuries, surgical technique, graft se-lection, outcomes assessment, and post-operative rehabilitation.9-12,42 Thus, itis difficult to draw conclusions regard-ing the efficacy of surgical treatment.

Harner et al52 recently reviewedthe results of the protocol describedabove for surgical and postoperativemanagement of knee dislocation withassociated multiple-ligament injury.Forty-seven consecutive patients whopresented with a spontaneously re-duced or grossly dislocated knee be-tween 1990 and 1995 were reviewed.Fourteen of these patients were notincluded in the study because of con-founding variables that altered thetreatment protocol: four open kneedislocations, five vascular injuries,

Figure 10 Lateral (A) and anteroposterior (B) views after reconstruction of the popliteofib-ular ligament. (Adapted with permission from Cole BJ, Harner CD: The multiple ligamentinjured knee. Clin Sports Med 1999;18:241-262.)



three patients treated with externalfixation, one patient with a severehead injury, and one with a contralat-eral, below-the-knee amputation. Theremaining 33 patients underwenttreatment according to the protocol.Thirty-one of 33 patients were avail-able for evaluation at a mean of 44months after surgery. Nineteen pa-tients underwent surgery <3 weeksafter the initial injury (acute treat-ment). Twelve patients underwentsurgery ≥3 weeks (average, 6.5months) after the initial injury (chron-ic treatment). Three of four patientswith injury to the common peronealnerve had transient symptoms thatresolved within 3 months after sur-gery; one had permanent symptomsnecessitating a tendon transfer 9months after surgery.

Clinical results were determinedwith a questionnaire and physical ex-amination. The mean score on the Ac-tivities of Daily Living Scale of theKnee Outcome Survey was 91 pointsfor patients with acute treatment and84 points for patients with chronictreatment (P = 0.07).52 Patients in theacute group had a mean Knee Out-come Survey Sports Activities Scalescore of 89, compared to a mean scoreof 69 in the chronic group (P = 0.04).52

Sixteen of the 19 acutely treated kneesand 7 of the 12 chronically treatedknees had an excellent or good Mey-

ers score. Improved stability wasfound in all patients on physical ex-amination, with more predictable re-sults in the acute group. No statisti-cal difference in ROM was evidentbetween patients treated acutely ver-sus chronically. Four patients, all ofwhom were treated acutely, requiredmanipulation under anesthesia be-cause of postoperative stiffness.

These results are consistent withother reports of surgical managementof knee dislocation with allograft re-construction of the cruciate liga-ments.9,11,12,42 The protocol used byHarner et al52 for the treatment of theknee with multiple ligament injuriesseems to offer good functional out-come, ROM, and stability for most pa-tients, particularly those treated with-in 3 weeks of initial injury. Mostpatients are able to perform daily ac-tivities without difficulty; however,return to high-demand sports activ-ity is less predictable. Patients treat-ed for a chronic injury are more like-ly to have functional limitations thanare those treated within 3 weeks ofinitial injury.

Summary

Traumatic knee dislocation is relative-ly uncommon. Because of the sever-ity of this injury and the potential for

devastating complications, however,it is necessary to understand the prin-ciples of evaluation and managementof knee dislocation. Evaluation con-sists of a brief history, thorough neu-rovascular evaluation, ligamentous ex-amination, and radiographic studies.Angiography should be used when-ever knee dislocation is suspected toevaluate for the presence of a poplitealartery injury. Initial management in-cludes prompt reduction and stabi-lization followed by reassessment ofthe neurovascular status of the limband postreduction radiographs. Emer-gent surgery is indicated in patientswith open dislocation, compartmentsyndrome, vascular injury, and irre-ducible dislocation.

Definitive management of theknee with multiple ligament injuriesremains a controversial topic. Satis-factory results can be achieved withearly reconstruction of both the ACLand PCL using allograft tissue alongwith allograft reconstruction of com-plete LCL injuries, repair or allograftreconstruction of injured posterolat-eral structures, and early repair ofcomplete MCL injuries. Althoughtechnically challenging, adequateknee stability, ROM, and knee func-tion can be obtained after anatomicrepair or reconstruction and appro-priate postoperative rehabilitation ofthe dislocated knee.

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the acutely dislocated knee: evaluation and management

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