Knee Dislocations: Lessons Learned From 20-Year Follow-up

Abstract

Background: Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking.

Purpose: To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee.

Study design: Review and case reports.

Methods: Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form-36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability.

Results: The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject's IKDC score to "C."

Conclusion: Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

Keywords: knee dislocation; ligament reconstruction; long-term clinical outcome; multiligamentous knee injury.

Figure 1.

Lateral (and only) radiograph of injured knee for patient 1. Radiograph was not classifiable by position system and led the authors to classify by what is torn, or anatomically. Reprinted with permission from Muscat et al.

Figure 2.

Open posteromedial approach for reverse saphenous vein grafting of a popliteal artery injury in patient 1. The sartorius, semimembranosus, semitendinosus, and gracilis tendons are incised approximately 2 cm proximal to their distal bony insertions and are reflected distally and proximally (stay sutures shown). The medial head of the gastrocnemius is incised along its proximal tendinous portion to expose the popliteal artery. Reprinted with permission from Muscat et al.

Figure 3.

(A) Arthroscopic image of the medial compartment at 6 years after injury in patient 1. (B) Bilateral, standing, weightbearing images at 6 years after injury showing early medial compartment narrowing.

Figure 4.

(A) Prone extension of the affected knee with 2° of flexion contracture compared with normal side in patient 1 at 22-year follow-up. (B) Supine knee flexion with 10° of flexion loss compared with normal. (C) Bilateral, standing, weightbearing images with tricompartmental degenerative changes. (D) Magnetic resonance image of anterior cruciate ligament graft demonstrating some graft attenuation.

Figure 5.

Bilateral, standing, weightbearing images with mild medial joint space narrowing in patient 2 at 22-year follow-up. The broken drill bit below the Gerdy tubercle and surgical staple in the tibia are from a previous failed attempt of posterolateral corner repair at an outside hospital. The anterior cruciate ligament was repaired using a bone–patellar tendon–bone allograft with interference screw fixation (femur and tibia) and back up sutures around a screw/washer on the tibia. The posterior cruciate ligament was repaired using Achilles allograft with press fit of the bone block on the femur and sutures around a screw/washer on the tibia. The soft tissue screw and spiked washer represents the biceps tenodesis for the posterolateral corner reconstruction.

Figure 6.

Photograph of patient 2 after completing a hike of the Grand Canyon.

Figure 7.

Standard protocol for selective arteriography.