DISLOCATION OF THE KNEE
DOCTOR CHRISTOPHE BURES *
PROFESSOR G. VERSIER * - PH. ** NEYRET - F. RONGIER *** - - T. AIT SI SELMI **
CORRESPONDENTS:
Dr. Christophe BURES
Clinique Internationale du Parc Monceau
21, rue de Chazelles - 75 017 - Paris
Appointment every Tuesday and Friday mornings
Telephone (33) 01.48.88.25.25
Email: @ christophe.bures clinic monceau.com
Introduction
The concern that grabs the surgeon faced with a dislocated knee is legitimate.These lesions account for the reported difficulties in surgery of the anterior cruciate ligament and that observed in the surgery of the posterior cruciate ligament. Our efforts must focus on understanding the mechanisms wounds.We are still therapeutic principles. Quite surprisingly these severe injuries areoften accompanied by relatively good healing of peripheral structures as long as this scar is properly oriented.
The result, often assumed, announced catastrophic finally functionally acceptable and accepted by the patient who was mourning the performance of certain sports. The progress expected in the years ahead are immense, and the teams experienced in knee surgery have to work. For many of us recognize complications including stroke, and know properly reduce and stop is still the main objective.
Keywords: Knee / Luxation / Injury bicroisée / pentad
Abstract
Knee dislocation
Knee dislocation is a surgical challenge for all surgeons. The treatment of these lesions Associates the difficulty of both cruciate ligament surgery. It is necessary to enderstand injury mechanism to know porpose associated lesions and a consensual surgical treatment. Soft tissue healing is the rule, particularly when articular rotaional center takes place after a good correction of posterior tibial translation. Function is satisfactory outcome for patients who have resigned themselves to give up high-demand sports.
Diagnosis of vascular trauma, and an appropriate reduction and immobilization are essential. Surgical procedure must be performed after testing under anesthesia and angio-MRI.
Keywords: Knee / knee dislocation / Bicruciate lesion
Anatomo-clinical form lesions bicroisées, the dislocation of the knee results in a complete loss of contact between the two surfaces induced by the kinetic energy of the trauma of a major source movement. They are rare, as evidenced by the low number of publications on this subject, focused mostly on complications vasculo-nerve apanage dislocations (1, 2, 3). The lesions observed changes or results arthrogène treatments implemented were never studied in detail, there is no therapeutic consensus.
The multicenter study that we conducted at the symposium of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) in 1998, although questionable in terms of methodology, helped to collect 273 cases out of 10 specialized centers, constituting a fundamental database. It allowed us to establish a new classification and to draw practical therapeutic applications.
Frequency
The incidence of knee dislocations is low, HOOVER (4) the estimated between 0.001% and 0.013%. It appears that this impact is underestimated at the number of dislocations spontaneously reduced at the scene of an accident or neglected in the presence of a vital urgency that goes first.
Epidemiology
The age of onset most often interested in the 4th decade and, in the series, patients have an activity or an active lifestyle.
The sex ratio was 4 males to 1 female, predominantly common to all series.
The etiology is mainly represented by road accidents (1 out of 2), especially motorcycle accidents, injuries violent high-energy, the frequency of associated lesions and the difficulty of identifying the precise mechanisms lesional ( 2).
We need insite on the possibility of injury mechanisms for bicroisée less violent (13% for KENDALL (5), 5% DENNIS (6), similar to those of the triads. Accidents sports low power are not uncommon (7 ). Accidents at work (farmers, woodcutters ...) generate larger skin lesions, secondary to trauma or sometimes supported the windings, but also with severe vascular lesions hémoragie externalised. The frequency of complications encountered at low arterial energy reaches 4.5% (8.9)
Ligament injuries and classification
The names and classifications of injuries bicroisées do not respond to an international consensus and we propose here a new classification Essous (Fig. No. 19) which is the result of the study of lesional this series. Bicroisées The lesions do not always dislocation and a dislocation can occur with injury toa single cruciate ligament (8.9), what remains to be demonstrated.
Peripheral ligament injuries are inconsistent and variable (abruptio capsulopérosté or transligamentaire rupture, or avulsion), and we shall see, it will determine the routes first.
Ligament testing under anesthesia and performing MRI for diagnosis of injury-capsulo ligament damage (10, 11, 12) and vascular when combined with angiography, are systematic in our daily practice, and can classify the dislocation as a result of injury assessment.
If the lesions are focal point of the rule, there are several types of peripheral lesions of the potential healing also very different.
- Yawning is a snap with ligament healing in the right place requires at least the preservation or restoration of the instantaneous center of rotation, ie the correction of posterior tibial translation caused by the rupture of the posterior cruciate ligament (CCL ).
- The detachment (Figure No. 20) reflects a disinsertion capsulo-périostée of the metaphysis to the diaphysis, while respecting continuity capsuloligamentaire. Healing, after reduction, is to rule without residual laxity front, but could fix a posterior drawer uncorrected.
Thus there are:
The lesions bicroisées simple (old pentad) bicroisée involving an attack and an attack by a yawn alone device: simple bicroisée medial yawn if the plan medial (internal pentad), bicroisée simple case of lateral yawn of laterally ( pentad external), bicroisée simple posterior (Figure 3) if the plan yawn after (post pendate with hyper extension).
The lesions bicroisées combined peripheral lesions that contain at least one injury yawn.
- Internal injuries with external disbonding (external dislocation)
- External with internal delamination injury (dislocated internal)
- Complex (Figure 4) with internal and external injury by yawn bicroisée involving an attack with an attack plans peripheral ligament and medial létéral (dislocation rotation)
Pure bicroisées lesions (Figures 1 and 2) where the damage internal and external devices are made by only loosening, with an excellent prognosis healing device (anterior and posterior dislocation)
Complication s
Complications are the prerogative of bicroisées combined bicroisées or pure, but can also occur in simple bicroisées, including external bicroisées. The two main complications, artery and nerve are extensively described in the literature (1, 13, 14, 15, 16). They are feared and dreaded.
arterial complications make a serious dislocations. Frequent (11% to 88%), it had a rate of amputation very varialbe, according to the time of revascularization and injuries assoiciées (0% to 66%). The frequency and severity of arterial lesions impose their search deal with all lesion bicroisée by the clinic (sign of the tetrad Griffith or hematoma plusatile Bloom), but also systematically by arteriography (Figure) No. 15) because of injuries intimal flap in pulse can be seen late (10% to 30% knee injury. If proven ischemia, arteriography should be considered on operating table to reduce wasted time.
Finally, no study, nor the ESSKA, provides information on the thromboembolic complications, all agree that it must detect before surgical treatment, and that their frequency is high.
The treatment must be given if possible vascular surgeon to repair or bypass as soon as possible, the amputation rate from 86% to 6% if the treatment is carried out before 6 hours (1)
Nerve complications are frequent (9% to 18%) more frequently (30%) lesions in the setting of previous bicroisées pure or combined internal. There are also 12% of lesions of external popliteal sciatic nerve (peroneal nerve or SPE) when external mechanisms bicroisée simple. The lesions of EPS are located mostly in the external condyle and neck of the fibula (17).
Nerve damage is damage by stretching the initial therapeutic abstention is the norm. In the absence of recovery, followed clinically by the sign of Tinel rather than according Sedel EMG (18, 19), needed the transplant does not cut the bridges tendieneux transfer to a palliative, which may be made without prior graft loss if nervous substance is greater than 20 cm. This author has reviewed 16 grafts, 32 months back for a loss of substance averaged 13 cm, obtaining 37.5% of good results, especially for losses of substance of less than 6 cm.
We insist on the frequency of the association vasculo-nervous (41% nerve damage in the series of ESSKA), the neurological damage done to find a vascular injury sub.
Other complications are varied:
- The bone lesions are frequent (15%) with osteochondral fractures of the condyles or plateaus (Figures No. 5 and No. 6). A special form described by H.Dejour must be built combining a previous fracture of the tibial plateau in hyperextension, which will help limit the movement and the subsequent opening (20): bicroisée later. Fractures of the head of the fibula are not uncommon (4 to 10%).
- Lesions of the extensor apparatus is also common (10 to 21%) and may be of interest to the vast internal wing and in case of dislocation, or may interrupt the continuity of the extensor (fractured patella (4%) rupture of the tendon quadricipital (1.5%), rupture of the tendon rotuline (3.5%). They require surgical treatment.
- Some rare lesions are described in the literature as the incarceration of soft tissue at the origin of irreducible dislocation (tendons of the leg of goose, condyle in a buttonhole capsular) with invagination kinking or next to the line( 21, 22, 23, 24).
The dislocation or exposed (Figure 7) occurs in high velocity accidents (road accidents) or in agricultural accidents. It requires an assumption ofemergency (25).
Conduct diagnostic
Dislocated knee: The diagnosis is obvious (Figure 1), the displacement of the tibia determining the direction of dislocation. This is not the most common (only 17% of dislocations have necessitated a reduction in theadmission in our series of ESSKA). In addition to the assessment of skin condition, the vasculo-nervous balance that must prevail. The reduction is needed urgently, under anesthesia which allows for a qualitative testing, supplemented by follow-up radiographs and dynamic exploration of a vascular or ideally by arteriography or angio-MRI.
Most often (68% of cases in our series), the injured is a suspected major knee injury bicroisée this i requires research-related injuries, particularly vascular, and achieve a smooth paradoxically little painful. The constant gives the laxity Polichinelle knee, with an antero-posterior laxity most obvious, it is difficult to separate what is past and what is at the posterior of your Lachman. The device laxity is variable, is important for yawn injuries, significant injuries to the detachment usually identified by a translation front extension (external to internal detachments and detachments for internal external) without yawn.
Sometimes we can not distinguish a lesion clinically bicroisée simple injury combined (15% of cases in our series). We must have recourse to simple X-rays (displacement, incarceration with increase in height of the spacing, bone lesions), dynamic (drawer, yawn, translation) under anesthesia (radiography 8 to 13) and MRI oar. T assessment of the milk must remain qualitative.
The vascular exploration is mandatory, forensic, u is the frequency and severity of arterial lesions.
Therapeutic principles
The treatment still seems controversial among conservative and surgical, DEDMOND (26). As the time for action, no consensus in the literature woulddetermine the timing that allow early control of the correction.
a-objectives are:
- Restore the articular congruence (treat fractures and osteochondral lesions of the extensor apparatus)
- Correct the posterior tibial translation, guaranteeing the healing of training devices in a good position (in the case, their position nasty scarring to set the tray later, explaining the failure of secondary ligamentoplasties)
- Avoid secondary displacement (hence the interest of the simultaneous repair of posterior cruciate ligament (CCL) and training devices, or 2 ligaments croisés)
- To recover a good mobility
b-The conservative treatment is not an indication that in case of severe associated injuries (multiple trauma), advanced age of the patient in the absence of complications (skin opening, osteochondral fractures, vascular lesions) or local skills chrirugicales reduced. He used cast or splint in extension, except in the case of hyperextension mechanism (anterior luxation) where the asset will be done in order to avoid bending displacement sos plaster. Restraint is the ideal point "HIV" may be one or two tibio femoral pin for 6 weeks without support. The external fixator is a source of residual stiffness (grip) but it is recommended in the presence of complications vasculo-nerve (radiography No. 16) or skin, as well as among the polytraumatisé who is also the urgency (abdominal, thoracic ... ). The results vary depending on the series, subjectively comparable to that of surgical treatment but anatomically inside due to greater residual laxity (26, 27)
The e-surgical treatment, when it is not considered consensual. If sutures have proven their ineffectiveness, no other technique is really a panacea.Some advocate the simultaneous processing of both lgaments crossed, the other LCP and training devices. No publication advocates the first repair of the anterior cruciate ligament (ACL), but some use (13% in our study).
SHAPIRO (28) and harness both simultaneously reconstruct ligaments croisés using allogreffres, with satisfactory results, not used technique in France.
All series in the literature (26, 27) shows that the difficulty lies in the durable correction of posterior tibial translation. Only his early and effective correction allows a good anatomical result in repositioning the center of knee rotation and allowing a healing prominent peripheral structures. The series of ESSKA has shown that double ligamentoplastie outset was a good way to permanently correct the laxity but at the cost of stiffness séquelaire.
Chrirugicale reconstruction poses several problems:
"When I make?
The best results are obtained after anatomical treatment Ligament early, ideally after the regression of hemorrhagic phenomena, inflammatoirees, tromboemboliques and edematous, ie between 5 and 15 days.
Apart from ischemia and opening the skin which is immediate treatment, we will opt for surgical treatment as early as possible if there is a source ofincarceration or irreducibility incoercibilité (articular incarceration of Collateral Ligament medial, condyle stuck in a buttonhole capsular), osteochondral injury, a disruption of the extensor or bone avulsion of a ligament insertion.
2 - What plugins ligament grafts for what?
This depends on the lesions present, especially on the extensor-against which indicates its use. This also depends on the routes of skin first. For example, if one approaches the inerne plan, you can easily remove the hamstrings. If allografts are not in vogue in France, it is not the same in European countries. For some, the synthetic ligament has a place as a replacement or reinforcement of LCP can be stitched or reinserted as its potential for healing is important (Figure 17). For the anterior cruciate ligament (ACL), the choice must be made between the extensor tendons of homolétéral (often injured) and contralateral, tendons of the feet, or an allograft. Lerat proposes to use a technique to transplant single reconstrurie system expander for the 2 ligaments croisés
Our study highly polymorphic as to the type of ligamentoplastie used, failed to settle, the results are broadly comparable. The choice is more difficult in case of repair of two ligaments cross, as any additional levy homolateral trophic aggravate the disorder and post-operative stiffness.
3 - How to adjust the position antéropostérieure knee?
The "zero point" is an ideal location which allows for repositioning and scarring prominently in training devices. This setting is difficult, beginning with the winding of LCP, close to the extension. We must advocate for early mobilization, because this double ligamentoplastie is enaissante.
Tibio femoral pin may be preferred if one gives up early mobilization. When choosing a capital post-operative rehabilitation in ventral recumbency may be taken between 0 and 06 °.
4 - The detachment peripheral lesions heal without surgery and without sequelae, provided that the "zero point" is restored. It should not be addressed. The yawn injuries should be repaired by simple suture or by confrontation reintegration transosseue, stapling in the case of avulsion, or ligamentoplastie respecting the possible isometry (photograph No. 18). The result in terms of residual posterior laxity front. This is the correct mandatory laxity after healing before training devices.
The meniscus must be respected, and sutured if necessary. The resection rate very high in emergency interventions, probably explains the high rate ofosteoarthritis of the series of ESSKA (43% at 10 years of decline).
The first way is dictated transplants sampling and drilling of tunnels excluded by the proposed classification based on the presence of injuries yawn that must be repaired. Thus, a simple internal bicroisée injury must be addressed internally, an external bicroisée combined approached externally, and a pure non bicroisée addressed in the periphery.
Conclusion
The lesions bicroisées knee injuries are rare. Priority should go to the vascular assessment, because we know the frequency and severity of injuries of the popliteal artery. Stock ligament injury should be accurate, based on clinical examination, radiographic and possibly langio MRI. It will help to classify these lesions in terms of ligament damage devices.
Pure orthopedic treatment is usually reserved for polytraumatisé, the elderly, in the absence of osteo-articular complications, skin and vasculo-nervous.
Although controversial, surgical treatment, the "internal cast" should be preferred because it is the only way to restore the anatomy. Its main requirement is to cancel the posterior tibial translation because it is the only way to restore the anatomy. Its main requirement is to cancel the posterior tibial translation, thus ensuring a better outcome anatomical frontal and sagittal, using either a reconstruction or primary suture combined with a strengthening of the LCP, a double ligamentoplastie emergency stabilizing deferred more and more enraidissante, Although authorized early mobilization.Indeed, the review of cases led to the finding of failure of repair of the central pivot by simple sutures or reinforced, that corroborate studies SHELBOURNE (26) or Keller.
The evolution arthogène is important because of meniscal and osteochondral injuries associated osteoarthritis mainly internal, sometimes global. The functional prognosis is far from devastating, resulting in a decrease in physical and sporting ambitions with hindsight.
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