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HISTORIC PERSPECTIVES OF TREATMENT ALGORITHMS IN KNEE DISLOCATION

2000; Elsevier BV; Volume: 19; Issue: 3 Linguagem: Inglês

10.1016/s0278-5919(05)70214-3

1556-228X

Larry R. Stayner, Michael J. Coen,

Total Knee Arthroplasty Outcomes

Historically, knee dislocation has been a rare event. The Mayo Clinic had only 14 documented knee dislocations in 2 million hospital admissions, from 1911 to 1960. The New York Reconstructive Hospital had only one knee dislocation in 23,000 hospital admissions.21 Before 1909, only 270 cases were reported in the literature.3, 42 Knee dislocation has been considered a serious injury for hundreds of years. In 1825, Sir Astley Cooper published experiences with a series of knee dislocations. Several different mechanisms of injury were seen that are now less common since we have changed to motorized vehicles. Mechanisms of injury included a cart and horse falling on its owner, and a man on horseback whose leg was pinned between a rail and the horse from which he was being thrown. In most cases, Cooper was able to perform closed reduction, but in open dislocations or irreducible dislocations, he advocated immediate amputation.9 Other authors in the nineteenth century agreed with Cooper's treatment regimen.35 In the twentieth century, there has been more controversy in the accepted treatment protocol for knee dislocations, ranging from casting and prolonged immobilization to early surgical intervention. The end of this century has brought about many technologic advances such as improved magnetic resonance imaging studies and arthroscopic operative techniques that have made it possible to diagnose and treat knee dislocation injuries more precisely. Classically, knee dislocation has been defined as a complete loss of tibiofemoral articulation. More recently, the definition of knee dislocation has expanded to include bicruciate ligament disruption with or without radiographic evidence of knee dislocation.58 Many researchers feel that the true incidence of knee dislocation is unknown but is higher than generally appreciated, secondary to spontaneous reduction before evaluation in the medical setting.4, 47, 58, 59, 63 Several reports have described knee dislocation with an intact posterior cruciate ligament and disrupted anterior cruciate ligament.10, 26, 49 A functional posterior cruciate ligament makes these injuries distinct from classical knee dislocation and would theoretically protect the popliteal artery from injury.45 The classification of knee dislocation is based on the position of the tibia relative to the femur.17, 29 The types of knee dislocation are anterior, posterior, lateral, medial, and posterolateral, in descending order of incidence.14 Anterior knee dislocation is the most common.41 Kennedy demonstrated biomechanically that anterior knee dislocation is caused by a hyperextension force. The posterior capsule is the first structure to tear at approximately 30° of hyperextension. Next, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) tear, followed by the popliteal artery, at approximately 50° of hyperextension.21 The posterior knee dislocation is caused by a direct blow to the tibia with the knee flexed.4, 46 Posterolateral knee dislocation is the least common and is caused by a valgus stress with internal tibial torsion of the knee.5, 6, 15, 17, 35, 39, 40 The medial femoral condyle often buttonholes through the anteromedial capsule with a posterolateral knee dislocation, and open reduction is generally necessary. Knee dislocation can be caused by low-velocity or high-velocity forces with varying amounts of energy involved. High-velocity knee dislocations are caused most commonly by motor vehicle accidents and falls. Low-velocity knee dislocations occur most often in sports, such as football or soccer, but also may occur with minor trauma, such as when the foot gets caught in a hole while walking.42 Vascular and ligamentous injuries are common in low- and high-energy injuries, necessitating careful work-up and treatment for these potential injuries in both groups. Knee dislocation can be associated with catastrophic complications such as popliteal artery injury with subsequent loss of limb, or lesser complications such as peroneal nerve injury, loss of range of motion, or late instability. This article reviews the historical treatment algorithms of vascular, nerve, and ligamentous injuries associated with knee dislocations. The purpose is to better understand the evolution of treatment in this disease process by reviewing the experiences of numerous investigators. To date, knee dislocation is relatively uncommon, and most studies deal with only a small series of patients; this makes the process of understanding the best treatment options for knee dislocation a difficult one and necessitates careful review.