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European Journal of Orthopaedic Surgery & Traumatology https://doi.org/10.1007/s00590-018-2148-4

GENERAL REVIEW • KNEE - BIOMECHANICS

Management of knee dislocation prior to ligament reconstruction: What is the current evidence? Update of a universal treatment algorithm

Alexander Maslaris1  · Olaf Brinkmann1 · Matthias Bungartz1 · Christian Krettek2 · Michael Jagodzinski2 · Emmanouil Liodakis2

Received: 25 August 2017 / Accepted: 3 February 2018 © Springer-Verlag France SAS, part of Springer Nature 2018AbstractTraumatic knee dislocation is a rare but potentially limb-threatening injury. Thus proper initial diagnosis and treatment up to final ligament reconstruction are extremely important and a precondition to successful outcomes. Reports suggest that evidence-based systematic approaches lead to better results. Because of the complexity of this injury and the inhomogeneity of related literature, there are still various controversies and knowledge gaps regarding decision-making and step-sequencing in the treatment of acute multi-ligament knee injuries and knee dislocations. The use of ankle-brachial index, routine or selective angiography, braces, joint-spanning or dynamic external fixation, and the necessity of initial ligament re-fixation during acute surgery constitutes current topics of a scholarly debate. The aim of this article was to provide a comprehensive literature review bringing light into some important aspects about the initial treatment of knee dislocation (vascular injury, neural injury, immobilization techniques) and finally develop an accurate data-based universal algorithm, enabling attending physicians to become more acquainted with the management of acute knee dislocation.

Keywords Knee dislocation · MLKI · Initial management · Protocol · Vascular injury · Nerve injury · Immobilization · Fixator · Brace · Cast

Introduction

Traumatic knee dislocation (KD) is a rare injury, reach-ing incidences between 0.001% of general population and 0.072% of orthopaedic traumata [1–6]. It can become very challenging, and even more, limb threatening [7–13]. 5–17% of all knee dislocations are open injuries [14], 14–44% appear in the context of a polytrauma, and in 5%, they occur bilaterally [15–19]. They can occur after high or low veloc-ity traumata in the almost equal rates of 53 and 47%, respec-tively [20].

Knee dislocation is widely accepted as a term to define the integrity disruption of the tibiofemoral junction, while multiple ligament knee injury (MLKI) illustrates the rup-ture of at least two of the main four knee ligament stabilizer groups [2–4, 17].

In most cases of knee dislocations, it is both cruciate liga-ments and one peripheral collateral group which are injured [3, 17, 21–24]. However, rare cases with only one disrupted cruciate ligament have also been reported [23, 25–27].

Approximately 50% of all knee dislocations reduce spontaneously before the physician’s arrival. Thus, high

* Alexander Maslaris a.maslaris@krankenhaus-eisenberg.de Olaf Brinkmann o.brinkmann@krankenhaus-eisenberg.de Matthias Bungartz m.bungartz@krankenhaus-eisenberg.de Christian Krettek krettek.christian@mh-hannover.de Michael Jagodzinski jagodzinski.michael@mh-hannover.de Emmanouil Liodakis liodakis.emmanouil@mh-hannover.de

1 Department of Orthopaedics, Rudolf-Elle-Hospital, Friedrich-Schiller-University of Jena, Campus Eisenberg, Klostersnitzer Straße 81, 07607 Eisenberg, Germany

2 Trauma Department, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

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suspicion must be held, and literally every MLKI must be treated immediately as a true knee dislocation until proven otherwise [22, 28].

Failing to recognize the whole injury pattern around the knee can lead to disastrous consequences. Thus, an initial interdisciplinary systematic approach obtains top priority [22, 29–33]. Even though diagnostic image instruments become more and more reliable, physical examination still remains a fundamental element in any accurate assessment of KD.

Several authors describe their own experiences and related treatment strategies of knee dislocation [21, 22, 29, 32, 34–46]. But although a large number of studies about KD and MLKI do exist in medical databases, the complexity of this injury, the inhomogeneity of literature, and the perse-vering controversies in their treatment still make it difficult to draw reliable general conclusions.

Purpose

We here review the following aspects in the acute manage-ment of knee dislocation:

1. Vascular injuries: Which approach provides at once the highest sensitivity and practicability?

2. Nerve injuries: Incidence, injury pattern and treatment algorithm.

3. Immobilization: Fixator or brace? Hinged or fixed? Indi-cations, differences, pros and cons.

We present here an up-to-date comprehensive treatment algorithm for the initial management of acute knee disloca-tion up to the time of a definitive ligament reconstruction.

Methods

For the purpose of this study, literature resources from Pub-Med, MEDLINE, Cochrane Library, Web of Science, and Google Scholar were used. We included all clinical studies, randomized and non-randomized clinical trials, multicen-tre studies, case reports, reviews, systematic reviews, and meta-analysis. There were no limitations chosen in regard to publication date, study population, or cultural/language criteria (1958–2017).

Publications associated with congenital, paediatric cases, arthroplasties, systematic diseases, poliomyelitis, rheuma-toid arthritis, osteochondral or patellofemoral diseases, biomechanical or cadaver studies, surgical techniques and rehabilitations were excluded. Injuries of less than two of the main knee ligament stabilizers were also not taken into consideration. Inclusion criteria involved the management of acute traumatic knee dislocation or MLKI and their compli-cations before ligament reconstruction. Relevant treatment

Fig. 1 Flow chart of study selection procedure Total identified items (n=1593)

PubMed/MEDLINE (n=530) Cochrane Library (n=111) Google Scholar (n=507) Web of Science (n=445)

Items after abstract andfull-text exclusion

(n=120)

VI after KD (n=92) NI after KD (n=31) Immobilization (n=31) Initial management (n=42) Associated injuries (n=44) Irreducible KD (n=39)

Items identifiied by hand search (n=29) VI (n=8) NI (n=7) Immobilization (n=4) Imaging (n=2) Associated injuries (n=4) Ligament examination (n=4)

Items after title andduplicates exclusion

(n=279)

Total number of items included(n=149)

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protocols associated with neurovascular injuries, fractures, and immobilization techniques after KD were reviewed.

Two investigators (AM, MB) performed the study selec-tion and reviewed all relevant published items independently without considering limitations or guidelines for systematic reviews and meta-analysis. A series of keywords (knee dislo-cation, MLKI, initial management, protocol, vascular injury, nerve injury, immobilization, fixator, brace, cast) were com-bined in a logical way to search the electronic database.

Through the initial search and under the previously men-tioned terms, 1593 items were found. After title exclusions and removal of duplicates, a total number of 279 studies resulted. Subsequent to the abstracts and full text reviews finally sorted out, 120 publications were retained (Fig. 1). Further studies concerning specific aspects of our subject or individual treatment proposals were selectively added by hand (n = 29) to establish higher rationale and clarity of statements [11, 47–74].

Results

Vascular injuries: Which approach provides at once the highest sensitivity and practicability?

Vascular injuries after knee dislocation pose a potential limb threat for the patient. Their overall incidence documented in the literature varies widely between 1.6 and 64% [16, 75–80]. In a recent systematic review which included 862 patients with KD, the reported prevalence of vascular inju-ries was 18%, out of which 80% underwent surgery and 12% ended in amputation [13].

Posterior knee dislocations cause direct vessel compres-sion and usually lead to full-thickness tears, whereas anterior dislocations induce traction to the popliteal soft tissues caus-ing partial wall thickness defects (intimal or intimal media tears) [81].

I II

IIIM

IIIL

III

IV

V0

5

10

15

20

25

30

35

Pre

vale

nce

(%)

Posterior Anterior Lateral Medial Rotatory

0

5

10

15

20

25

30

35

Pre

vale

nce

(%)

(a) (b)

Fig. 2 a–b Prevalence of vascular injuries adapted to a the Anatomic Classification of Schenck [82] and b the Directional Classification of Ken-nedy [13]

Fig. 3 Diagnostic algorithm for vascular injury in the context of knee dislocation, as described by Nicandri et al. [38]

Knee dislocation or MLKI

Immidate reduction

Physical examinationAnkle Brachial Index

Periph. pulse asymmetryNormal reperfusion

ABI <0.9

Periph. pulse presentNormal reperfusion

ABI >0.9

Periph. pulse absentHard signs of vascular injury

Arteriography Immidiate ORSurgical exploration

± intraop. arteriography

24h indoor observationArterial & venous

Duplex prior to surgery

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Table 1 Vascular injury treatment protocol with selective arteriography after knee dislocation

ABI: ankle-brachial index, CPN: common peroneal nerve, SSVI: soft signs of vascular injury, HSVI: hard signs of vascular injury, KDIIIL: knee dislocation III° by Schenck with lateral side injury, CTA: CT angiography

Findings, checklist Indicated procedure

✓ Normal peripheral pulse 24–48-h indoor observation,✓ Normal reperfusion arterial and venous duplex sonography✓ ABI > 0.9 prior  to surgery✓SSVI: 1. Trauma proximity to major limb vessel (popliteal fossa) 2. Non-expanding haematoma 3. History of moderate bleeding 4. Diminished or asymmetrical peripheral pulses 5. Anatomically related nerve injury (CPN) 6. ABI < 0.9 7. Abnormal flow velocity waveform on Doppler✓ Posterior dislocations or ≥ KDIIIL Duplex sonography or/and  CTA ✓ Restricted assessment: 1. Obesity 2. Shock 3. Hypothermia 4. Pre-existing peripheral artery disease✓ Poor prognostic factors with moderate posttraumatic amputation rates 1. Age > 55 years (16%) 2. Associated fractures (14%) 3. Injury location popliteal (14%)✓ Pre-injury on-going anticoagulant therapy

✓ HSVI 1. Pulsatile haemorrhage 2. Expanding haematoma 3. Peripheral pulse absent 4. Arterial occlusion (5 P’s) 5. Popliteal thrill or bruit Emergency CTA followed by emergency operation with surgical

exploration, revascularization within 6 h, prophylactic fasciotomy, or intraoperative « on-table » angiography if necessary, external fixator

✓ SSVI ≥ 6 h from injury✓ Poor prognostic factors with significant posttraumatic amputation rates 1. Major soft tissue injury (26%) 2. Compartment syndrome (28%) 3. Multiple arterial injuries (18%) 4. Ischaemia duration > 6 h (24%)

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Posterior and lateral knee dislocations KD IIIL are highly connected with concomitant vascular trauma (25 and 38%, respectively) [13].

The prevalence of vascular injuries in relation to Ken-nedy’s Directional [4] and Schenck’s Anatomic Classifica-tion [82] is illustrated below (Fig. 2a–b).

Evidence-based standardized algorithms which combine pedal pulse palpation and the ankle-brachial index (ABI) for the assessment of vascular status in the management of knee dislocation, such as the one described by Nicandri et al. [33] (Fig. 3), have shown significantly higher sensitivity than that seen after a solely physical examination [33, 38, 83–91].

Although the decision-making between selective or routine angiography in the context of KD or MLKI initial diagnostic measurements remains controversial, there is a general tendency towards selective angiography protocols when also risks of invasiveness, practicability, and cost and time efficiency in the medical daily practice are concerned [47, 52, 89, 92–96].

In this regard, depending on the appearance of any soft (SSVI) or hard sign of vascular injuries (HSVI) [48], or any restricted clinical assessment [49], or poor prognostic fac-tors predisposing high incidences of posttraumatic amputa-tion [50], a timely and clear indication of proper treatment should be set.

CT angiograms (CTA) are mostly preferred, as they provide a higher sensitivity and specificity and almost one-fourth less radiation than conventional angiograms do [47, 51].

In view of the following three points, we introduce a protocol for the vascular assessment of knee dislocation as shown in Table 1:

• If any SSVI exceeds 6 h after injury, or if HSVI is evi-denced, emergency operation with on-table angiography, surgical exploration, revascularization, and prophylactic fasciotomy is indicated. In certain cases with a small time slot remaining up to acute surgery, prior angiogra-phy may also be eligible. However, any further delay for comprehensive preoperative diagnosis should be avoided. During initial vascular interventions, the attending ortho-paedic surgeon should be present to take account of his future operation field [50, 52, 90, 93, 97].

• The indications for a selective duplex sonography (DS) and/or CT angiography are extensively summarized in Table 1. If finally a vascular injury is detected in DS or CTA, emergency surgery is indicated [47, 48, 51, 53, 54, 97, 98].

• In case of normal signs of limb perfusion or exclusion of a vascular injury through DS or CTA, limb immobiliza-

Fig. 4 Treatment algorithm for CPN injury after knee dislocation by Woodmass et al. [101]. AFO: ankle foot orthosis, CPN: common peroneal nerve, EMG: electromyography, MRC: medical research council, NCS: nerve conduction studies, ROM: range of motion

Knee dislocation with clinical evidence of CPN palsy

Incomplete CPN palsy (MRC 1)87% achieve MRC 5/5

Complete CPN palsy (MRG 0)38% achieve MRC 3/5

Reinnervationafter 3mo?

Good prognosis

PTTT

- AFO- Ankle ROM exercises

NoYes

YesNo

Planned PLC-repair/ reconstruction?

Poor prognosis

Observation

Observationserial NCSs & EMGs

6we, 3mo, ± 6mo

CPN exploration& neurolysis

MRC <3 after 6mo?

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tion and monitoring via serial physical examination and ABI for 24–48 h are recommended [52, 89, 97] (Fig. 6).

Nerve injuries: Incidence, injury pattern, and treatment algorithm

Common causes of neural injuries after KD or MLKI are fractures of lateral femoral condyle, lateral tibia plateau, and fibula head, leading to direct nerve damage. Further injury mechanisms are nerve tractions, induced by varus stress, hyperextension, or a direct compression through a massive tibia translation. The incidence of common peroneal nerve (CPN) injury after KD ranges from 14 to 25%, whereas after posterolateral dislocation it rises up to 45%. Tibial nerve (TN) damage appears only rarely [16, 78, 99].

Nerve lesions are classified in ascending order of damage in neuropraxy, axonotmesis, and neurotmesis, providing use-ful information about their prognosis and treatment strate-gies [55]. Depending on the severity, location, and time of injury, as well as the age or concomitant comorbidities of the patient, outcomes of nerve injuries can differ significantly. Peripheral peroneal nerve injuries in young patients are asso-ciated with a better prognosis [100, 101]. 50% of the neural lesions after knee dislocation recover spontaneously [58, 102]. In a recent systematic review, 87.3% of all common peroneal nerve partial injuries showed full recovery, whereas just 38.4% of the complete tears healed only partially [101].

Among the existing image diagnostics for neural inju-ries, utilization of ultrasound has gained over recent years increasingly in importance. It can be performed immediately and with less costs compared to MRI, and it is superior to EMG as it provides information about the injury level, the extent and discrimination between axonotmesis and neurot-mesis, and allows additionally a visualization of perineural damages (e.g. haematoma) [56, 103]. The limitations of ultrasound are associated with the necessity of a certain level of experience and learning curve as well with the depend-ence on equipment requirements needed to address reliable findings.

The conservative treatment of nerve injuries consists of physiotherapy, bracing, medication, and serial follow-ups. Surgical procedures are typically the decompression and neurolysis in the early setting and the intercalary grafting and tendon or nerve transfer in the late setting or after unsuc-cessful early treatment [100, 101]. End-to-end nerve repair techniques can be performed as primary or secondary tasks, depending on the time of surgery. Such techniques need limb immobilization postoperatively, which can be a limitation for some rehabilitation strategies after ligament reconstructions which require a direct postoperative motion. Although sev-eral surgical techniques are available for early treatment of

peripheral nerve injuries after KD, they show no superiority to initial conservative therapy [101].

The magnitude of nerve defect is also related to poor out-comes. While studies have shown unsatisfactory results after grafting nerve defects longer than 6 cm [72], nerve injuries after KD reach dimensions of over 15 cm [73], so that graft-ing or transfer procedures have in recent times no longer been recommended [101].

However, if no reinnervation occurs within the first year of injury (9–12 months), irreversible muscle atrophy and fibrosis will lead to worst functional outcomes [57, 58]. As a damaged nerve grows with a speed of 3 cm/month plus 1 month for reinnervation of targeted muscle [74], a total recovery time of approximately 8 months after a KD is to be expected.

If a posterolateral surgical approach of the knee is planned for the treatment of KD, nerve exploration with neu-rolysis belongs to the standard procedures. If no posterolat-eral approach is intended or after neurolysis, physiotherapy with ankle motion exercises, bracing and serial follow-ups including NSCs and EMGs in 6 weeks and then after 3 and 6 months should take place. After no sign of improvement (MRG 0) is seen up to 3 months, a reconstruction with pos-terior tibial tendon transfer (PTTT) is advocated, because it shows superiority to other neurosurgical techniques in terms of restoration of the antigravity dorsiflexion [101, 104]. If any treatment response is detected up to that time, further follow-ups are recommended. However, for any persistent moderate nerve function (MRG < 3) after 6 months, surgical treatment using PTTT within the first year is recommended [57, 58, 99, 101] (Fig. 4). Since though there is currently not enough evidence available about which treatment protocol is really superior, individual strategies should be adapted to the patient’s needs [100].

Immobilization: fixator or brace? Hinged or fixed? Indications, differences, pros and cons

Initial knee immobilization after joint reduction prior to ligament reconstruction offers many benefits. It provides stability of bony and neurovascular structures, loss of soft tissue tension and pain relief. Furthermore, it improves limb perfusion and suppression of the posttraumatic inflammatory reaction.

The preferences among specialists, concerning immobi-lization strategies before and after ligament reconstruction, however, still remains controversial [105–110].

Immobilization techniques are divided into invasive (joint-spanning external fixation) and non-invasive (brace or cast) types. The external fixation (EF) appears to have some advantages compared to braces or casts. It offers better stability, sufficient monitoring of the soft tissue and the neurovascular status, and finally an easier medical

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care of open wounds. Its disadvantages include an inva-siveness of the procedure, risk of pin infections, and a potential damage of the extensor mechanism of the knee and joint rigidity, whereby the severity of injury alone appears to be a more predisposing factor of joint stiff-ness [107]. Extended immobilization has also a negative effect on cartilage (inhibition of proteoglycan synthesis, degeneration), menisci, ligaments, bone (disuse atrophy/osteopenia) and joint function (arthrofibrosis) [59–61]. Some authors prefer for this reason more aggressive reha-bilitation protocols without EF, in order to avoid the side effects of elongated inactivity [111–113] risking this way an early reconstruction failure.

The hinged joint fixation, which originates from elbow dislocation treatment strategies [114], allows early controlled mobilization of the knee and shows promising results [115, 116]. It reveals lower reconstruction failure rates and wider ROM than the hinged braces do [109, 110]. New designs of dynamic hinged EF use the transepicondylar axis as rota-tional axis and also imitate the normal knee kinematics in the sagittal plane by reproducing the four-bar-linkage model of cruciate ligaments [117]. The exact identification of the rotational axis, which is essential for a normal femorotibial alignment and physiological joint loads, is, however, very challenging and demonstrates a high variability [118–120].

Studies using hinged EF by neglected KD for 6 weeks after open reduction and ligament reconstruction/repair [121–123] have provided better results than those using unilateral stable EF in 20° flexion for 6 weeks [124–127].

The Ilizarov external fixation introduces another reliable alternative for a two-stage treatment of neglected chronic KD with primary gradual reduction and secondary definitive ligament reconstruction [127–130].

Indications for initial application of an external fixation after KD/MLKI are: (1) open major trauma (III° open frac-tures), (2) vascular injury, (3) compartment syndrome, (4) unstable dislocated joint fractures, (5) polytrauma patients during damage control up to the time of a definitive treat-ment, and (6) practical difficulties or insufficient stability after brace (e.g. obese patients) [105, 131].

Hinged EFs have been used mostly in two-stage knee ligament treatment strategies, and chronic or neglected KD and/or MLKI which show good results. In the acute stage of injury, however, an initial short time immobilization with a stable joint-spanning EF is for the soft tissue condi-tioning alone essential [21, 132]. If ligament reconstruc-tions should be delayed or contraindicated, the hinged EF might be considered as a treatment option.

Depending also on age and grade of pre-existing joint degeneration, constrained total knee arthroplasty (TKA) after chronic KD constitutes a reasonable treatment alter-native with satisfactory results [133, 134] as an isolated

spanning EF after KD is not capable of restoring joint sta-bility [135].

If an external fixation is indicated, MRI-compatible pins should be applied at least 10 cm far from joint line on both sides to leave enough space for the ligament reconstructions intended [24].

If PCL is affected after MLKI or KD, reduction and limb immobilization should be performed in a 20° knee flexion, in order to prevent spontaneous posterior tibia translation and preserve safety of the popliteal neurovascular structures [136]. A non-invasive alternative method—preferably for isolated PCL tear and intact soft tissues—is a posterior tibia-stabilizing splint (PTS) with a posterior pelotte beneath the tibia to eliminate gravity-induced posterior subluxation of the tibia.

Discussion

Authors on both sides of Atlantic describe their own expe-riences in the management of knee dislocation or multiple ligament knee injury [21, 22, 24, 29, 32, 34–46].

After a thorough literature analysis of this challenging orthopaedic emergency, we were able to summarize and update a comprehensive treatment protocol for the initial management of KD or MLKI considering all pitfalls and potential complications. Certain steps taken systematically in appropriate order can now unfold the following treatment algorithm:

1. “First stabilize the patient, then the knee”: As knee dislocations are commonly associated with other life-threatening injuries, initial management should be per-formed according to ATLS principles (Primary and Secondary Survey). A concomitant significant vascular injury which bleeds actively has an impact on the circu-lation of the patient and must be treated appropriately during the primary survey by immediate compression to stop blood loss and, if necessary, intravenous fluid substitution and on-going resuscitation. Otherwise, knee dislocation is to be treated throughout the secondary sur-vey of ATLS.

2. Emergencies: Certain findings after KD or MLKI demand urgent surgical treatment and any delay might end up limb-threatening.

I. Vascular injuries (see Table 1) II. After open injuries with severe soft tissue damage,

initial joint reduction, immobilization, serial physical and neurovascular examinations, as well as immedi-ate i.v. antibiotics are the first essential steps to be taken until emergency surgery is started. An on-table angiography should be performed in the operating theatre in the presence of a vascular surgeon. During

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surgery, wound management with efficient debride-ment, lavage, and antibiotic agents depending on contamination degree are commonly necessary. In the case of a significant soft tissue defect, a staged procedure is necessary. The techniques of temporary wound coverage (TWC) usually performed include the negative pressure wound therapy (NPWT, e.g. with a vacuum pump), synthetic skin replacement (SSR, e.g. Epigard) or dynamic wound closure (DWC, e.g. Ligaloops). For secondary wound cov-erage (SWC), definitive suture closure, grafting, or flaps should be considered.

III. Unstable dislocation fractures of the knee require an immediate joint reduction, realignment of main frac-tures and immobilization with an external fixation. Under convenient terms involving the surrounding soft tissues, and depending on associated injuries and the general condition of the patient, it is preferable to repair acutely any ligament avulsion at the same surgical stage.

IV. The appearance of a “dimple sing” from the medial side of the joint predicts an irreducible posterolat-eral knee dislocation, where the femoral condyle typically “buttonholes” through medial capsular tissue and entraps capsuloligamentous elements in the intercondylar notch. Urgent surgical joint reduc-tion is required to avoid any cutaneous necrosis [22, 126, 137–140]. Usually, both cruciate (cruciform) ligaments and one collateral capsuloligamentous

group are ruptured, which then incarcerates in the joint. Cases with femoral avulsions of ACL, PCL, and MCL complex, whereby both menisci and LCL complex remained intact [138], or other cases with entrapment of ruptured LCL/PLC complex in the joint [141] have been described. Acute arthrotomy (transverse dissection of capsule/retinaculum), open reduction, and external fixation, followed by inten-sive rehabilitation yielded satisfactory results [139]. Some authors prefer to leave the avulsed cruciate lig-aments untreated [139], while others advocate their acute repair [140]. If, however, the patient’s condition allows it, acute repair of ligament avulsion is gener-ally recommended. An on-table angiography in the operating room to rule out any subclinical intimal vascular lesion should be obtained. Immobilization according to that shown in Chapter 3.3 can follow reduction.

V. High suspicion of compartment syndrome through-out the clinical examination (typically dispro-portional to injury and therapy-resistant pain intensity) or a supplementary increase of the intra-compartmental pressure (ICP) through invasive measurements of  >  30  mmHg by stable haemo-dynamics [63] or a threshold of delta pressure (ΔP = DBP − ICB) < 30 mmHg preferably by unsta-ble haemodynamics [64, 65] indicate immediate fas-ciotomy of all four compartments. If clinical signs are not distinct, and ΔP lies > 30 mmHg, continuous ICP

Fig. 5 Current treatment algo-rithm of associated fractures after knee dislocation in adult patients, as depicted by Sabesan et al. [147]

of osseous and ligamentous injury

Examination of ligament laxity

No ligamentous laxity Ligamentous laxity

Functional instability No functional instability

Delayed treatment after fracture healing

Post-op. rehabilitation

ligamentreconstruction Total knee arthroplasty

Younger ageNo radiographicdegenerative changesHigh pre-injury activity level

Increased ageradiographic

degenerative changesLowpre-injury activity level

Removal of hardware

Standard post-op. protocol for fractures

around the knee

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monitoring and serial clinical examinations should be performed consistently. Care must be taken not to elevate the injured limb above heart level in order to avoid perfusion depression [142]. Cast or other dress-ings should be removed in order to allow continu-ous monitoring and avoid further compression of the soft tissues. After fasciotomy, further staged wound management (TWC with NPWT, SSR, or dynamic suture techniques) will be required. Subsequent to a KD or MLKI, arthroscopy should be performed at least 1 week after injury, to avoid fluid extravasation through the freshly injured capsular tissue which can induce iatrogenic compartment syndrome.

3. History report: A rush history report, if possible, will reveal the injury mechanism (ultralow-, low-, or high-velocity trauma), providing important informa-tion about the potential severity of the injury pattern, and allowing appropriate measurements to be made on time.

4. Inspection: Inspection of the limb can immediately reveal important injuries of vessels or soft tissues requiring emergency treatment. The direction of the dislocated tibia [4], unstable limb deformities that pre-dict dislocated fractures, and finally signs of irreduc-ible knee dislocation [143–145] should be ruled out at this stage.

5. Pre-reduction neurovascular assessment: Initial neu-rovascular status prior to knee reduction should be evaluated and documented promptly. Pedal pulses will be assessed bilaterally for their presence, diminu-tion, asymmetry, or absence. Motoric and sensibility

Fig. 6 Up-to-date treatment algorithm for the initial management of acute KD or MLKI prior to ligament reconstruction

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of peroneal and tibial nerve should be proven and the severity of muscle weakness, if evidenced, should be quantified using the Scale of Medical Research Council (MRC).

6. Reduction: Subsequent reduction of the knee under sedation through short manipulations to avoid further damages should be performed with no further delay to restore lower limb perfusion [124]. If a “pucker sign” [143] or “dimple sign” [144, 145] is evident, suspicion of an irreducible posterolateral knee dislocation should be raised. In this case, no preclinical attend but a direct emergency open reduction in the operating room is to be undertaken.

7. Post-reduction neurovascular assessment: Vascular re-evaluation after joint reduction and comparison with initial findings is essential for one to witness any potential deterioration. Manual and Doppler-assisted examination followed by ABI measurements improves the sensitivity of statements and should be performed in all cases. A treatment algorithm of vascular injury, influenced by recent publications [38, 48] is described here, so as to guide physicians to their next decisive steps. If peroneal nerve palsy is evidenced, an ankle foot orthosis (AFO) after reduction should be adjusted. Further treatment unfolds according to Woodmass’s algorithm [101] (Fig. 4).

8. Initial imaging: Radiological evaluation using X-ray inspection is essential to assess joint position and potential bony lesions (e.g. Segond, reverse Segond fracture and other marginal avulsions), which are associated with major ligament and meniscal injuries. This can indicate a spontaneous KD reduction [67, 68]. Although initial X-rays would be preferable, any delay in joint reduction due to prolonged radiological exami-nations should be avoided. Finally, post-reduction radi-ographs are necessary not only to confirm proper joint articulation but also to assess any concomitant bony injuries.

9. Ligament laxity test: After exclusion of any emergen-cies requiring acute surgical treatment, ligament lax-ity tests can be performed, ideally while the patient is still lying down sedated after joint reduction, since examination under anaesthesia (EUA) provides higher sensitivity and specificity than the conventional clini-cal examination does [11, 22, 69, 71]. Various clas-sification systems have been described, that provide important information about the injury pattern [4, 27, 75, 146]. Stress fluoroscopy gives quantitative and qualitative evidence about the joint instability and can often be very useful for surgical planning and docu-mentation [70].

10. Immobilization: After joint reduction and initial assess-ment of injury pattern, immobilization of the injured

limb will follow, as described previously. Attention must be paid to avoid any posterior tibia translation in cases where PCL is unstable.

11. Further imaging: External fixation must always be fol-lowed by X-ray assessment to confirm correct articula-tion and pin position and to evaluate realignment and possible concomitant osseous injuries [68]. Further image diagnosis with CT (after intraarticular fractures) and MRI is fundamental for the overall evaluation of injury and the surgical preparation.

12. Further surgical procedures: The type and sequence of further surgical interventions following initial manage-ment of a knee dislocation depend on the severity of injury (Fig. 6):

I. In order to achieve best possible results for the treat-ment of neurovascular injuries, a close multi-discipli-nary collaboration with continuous communication between specialist surgeons is essential.

II. After initial treatment of an open KD, a second-look procedure in 1–2 days should be established. Flap wound cover in cases of massive soft tissue defects (e.g. Gustilio 3b) with exposed bone should be considered at this stage of treatment. More sur-gical follow-ups in the context of wound manage-ment will be needed and secondary wound closure (SWC) via sutures, grafting or flaps may be possible after 8–14 days. Early ligament reconstruction can be performed within 2–3 weeks after appropriate soft tissues conditioning and an adequate limb perfusion have been ensured [22, 46]. Ligament reconstruc-tion can be performed by using open or arthroscopic methods either with direct suturing and/or bracing of the ruptured ligaments or by using tendon autografts or allografts. No evidence-based recommendations are apparently available at the present time for the treatment of choice here.

III. For a knee dislocation fracture, it is generally rec-ommended to treat the fracture first and then the ligaments [147]. After achieving joint reduction and anatomic realignment of the fracture, immobilization with an external fixation is usually necessary until consolidation of a soft tissue oedema occurs. In the meantime, the definitive internal fixation according to intraoperative and radiological findings (MRI, CT) can be planned. After a period of 4–6 days with consistent immobilization, anti-swelling measures, as well as anti-inflammatory procedures, definitive osteosynthesis can usually take place. If clinical and radiological signs of joint instability still persist, a staged approach of ligament reconstructions after osseous union is generally advocated. Procedures of ligament reconstruction are preferably performed after 4–6 weeks in young patients, since outcomes of

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osseous tunnels depend on bone quality and its level of consolidation.

If, however, the patient remains asymptomatic in regard to joint instability, despite any positive radio-logical instability signs, a more conservative therapy for the ligament injuries can still be considered in certain cases [147].

A current study showed a 3.5 times higher prob-ability of TKA in patients who had been treated for tibial plateau fractures in comparison with the gen-eral population, especially among aged patients and cases involving complex fracture types [66]. There-fore, in older patients with significant radiographic degeneration changes and low demands, total knee arthroplasty after bone consolidation (TKA) may be the best solution [147]. Another study could show that the likelihood of a TKA after cruciate ligament reconstructions especially in female patients, iso-lated ACL surgery, high comorbidity or low surgical experience increases up to seven times more than that seen for the general population (i.e. from 0.2 to 1.4%) [148]. An interesting treatment algorithm for adult patients with combined KD/MLKI and tibia frac-ture was recently published by Sabesan et al. [147] (Fig. 5).

IV. After lower leg compartment fasciotomy, a certain period of time spent on wound management is usu-ally required before ligament reconstruction can be undertaken.

V. After emergency treatment of an irreducible KD (s. algorithm step 2IV), and dependent on residual findings, a radiological evaluation (MRI, CT) and planning of further ligament treatment may follow as outlined in Fig. 6.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of interest.

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