Knee Dislocations: Whats My role? Do I put on the Ex Fix? William - - PowerPoint PPT Presentation

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Knee Dislocations: Whats My role? Do I put on the Ex Fix? William - - PowerPoint PPT Presentation

Mar 13, 2024 313 likes •630 views

Knee Dislocations: Whats My role? Do I put on the Ex Fix? William T Obremskey MD MPH Vanderbilt University Orthopedic Trauma Disclosures Board SEFC OTA EBQVS Chair No Industry Conflicts Whats My role? Role

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Knee Dislocations: What’s My role? Do I put on the Ex Fix?

William T Obremskey MD MPH Vanderbilt University Orthopedic Trauma

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Disclosures

  • Board SEFC
  • OTA EBQVS Chair
  • No Industry Conflicts
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What’s My role?

  • Role

– Reduce Joint – Assess Neuro/Vacular – Assist Vascular if needed – Release Compartments if needed – Stabilize - ?

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Do I put on the Ex Fix?

  • It depends
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OBJECTIVES

  • What knee injuries are likely to result in

vascular injury?

  • What is appropriate evaluation?
  • When Ex Fix?
  • Irreducible KD?
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JAAOS December 2015

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Schenck Classification KD I Multiligamentous injury with involvement of ACL or PCL KD II Injury to ACL and PCL only (2 ligaments) KD III Injury to ACL, PCL, and PMC or PLC (3 ligaments) KD IV Injury to ACL, PCL, PMC, and PLC (4 ligaments) KD V Multiligamentous injury with periarticular fracture

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What Injuries?

What knee injuries are likely to result in vascular compromise?

  • Fractures - distal femur and proximal

tibia

  • Dislocations
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INJURY KNEE DISLOCATIONS

10% - 60% rate of associated vascular injury (5% - 15% requiring surgery)

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High vs Low energy KNEE DISLOCATION

DeCoster JOT 1997 22 knee dislocations vs 28 “reduced” bicruciate ligament injuries

  • 14% popliteal artery disruptions in

each

  • Equal risk of vascular injury
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VASCULAR INJURY TIMING

Miller Arch Surg 1949 Extremity salvage repair 90% at 6 hours 50% at 12-18 hours 20% at > 24 hours

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DIAGNOSIS NONINVASIVE VASCULAR EXAM

Lynch, Johansen Ann Surg 1991 ABI < 0.9 95% sensitivity 97% specificity

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When to Ex Fix?

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When to Ex Fix?

  • Vascular injury

– To manage CPS release

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When to Ex Fix?

  • Obese – unable to hold reduced
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When to Ex Fix?

  • Severe Soft Tissue injury
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Nerve Injury

Peroneal most common

14% - 35%

One third will recover One half will remain as complete palsy

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Peroneal Nerve Contusion

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Nerve Avulsion

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Indications for immediate

  • perative treatment

Open dislocation Irreducible dislocation Popliteal artery disruption Compartment syndrome

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Open Dislocation

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Open Dislocation Ex Fix or Splint

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Posterolateral - irreducible

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Irreducible

Pucker Sign

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Evaluation: Radiographic Exam

AP/lat/oblique MRI helpful in defining torn structures Adds to both sensitivity and specificity (can still miss LCL and PLC) Aids preop planning by defining the location of tears

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Take Home

Knee dislocation is challenging

Not always obvious When obvious, not always reducible closed

On table or formal Angiogram only for hard signs/ ABI < 0.9X Initial stabilization, then MRI prior to repair

  • r reconstruction
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THANK YOU