Skip to main content

Advertisement

SpringerLink
Log in

Medial Injury in Knee Dislocations: What Are the Common Injury Patterns and Surgical Outcomes?

  • Symposium: Management of the Dislocated Knee
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

When associated with a knee dislocation, management of the medial ligamentous injury is challenging, with little literature available to guide treatment.

Questions/purposes

We (1) compared MRI findings of medial ligament injuries between Schenck KDIIIM and KDIV injuries, (2) compared clinical outcomes and health-related quality of life as determined by Lysholm and Veterans Rand 36-Item Health Survey (VR-36) scores, respectively, of reconstructed KDIIIM and KDIV injured knees, and (3) determined reoperation rates of reconstructed KDIIIM and KDIV injured knees.

Methods

Over a 12-year period, we treated 65 patients with knee dislocations involving bicruciate ligament injury and concomitant medial ligament injuries, without or with posterolateral corner injuries (Schenck KDIIIM and KDIV, respectively); 57% were available for followup at a mean of 6.2 years (range, 1.1–11.6 years). These patients were contacted, and prospectively measured clinical outcomes scores (Lysholm and VR-36) were obtained and compared between subsets of patients. Preoperative MRIs (available for review on 49% of the patients) were rereviewed to characterize the medial ligament injuries.

Results

KDIIIM injuries more frequently had complete deep medial collateral ligament tears and posterior oblique ligament tears compared to KDIV injuries. KDIIIM knees had better Lysholm scores (88 versus 67, p = 0.027) and VR-36 scores (88 versus 70, p = 0.022) than KDIV knees. Female sex (Lysholm: 55 versus 85, p = 0.005; VR-36: 59 versus 85, p = 0.003) and an ultra-low-velocity mechanism (injury that occurs during activity of daily living in obese patients) (Lysholm: 55 versus 80–89, p = 0.002–0.013; VR-36: 60 versus 79–88, p = 0.001–0.017) were associated with worse outcomes. The overall reoperation rate was 28%, and the most common indication for reoperation was stiffness.

Conclusions

Medial ligament injury is common in knee dislocations. Females who sustain these injuries and patients who have an ultra-low-velocity mechanism should be counseled at the time of injury about the likelihood of inferior outcomes. As ROM deficits are the most commonly encountered complication, postoperative rehabilitation should focus on early ROM exercises as stability and wound healing allow. Future prospective studies are needed to definitively determine whether operative or nonoperative management is appropriate for particular medial ligamentous injury patterns.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–F
Fig. 2A–D
Fig. 3A–E

Similar content being viewed by others

References

  1. Campbell JD. The evolution and current treatment trends with anterior cruciate, posterior cruciate, and medial collateral ligament injuries. Am J Knee Surg. 1998;11:128–135.

    CAS  PubMed  Google Scholar 

  2. Chahal J, Al-Taki M, Pearce D, Leibenberg A, Whelan DB. Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study. Knee Surg Sports Traumatol Arthrosc. 2010;18:1098–1104.

    Article  PubMed  Google Scholar 

  3. Fanelli GC, Edson CJ. Surgical treatment of combined PCL-ACL medial and lateral side injuries (global laxity): surgical technique and 2- to 18-year results. J Knee Surg. 2012;25:307–316.

    Article  PubMed  Google Scholar 

  4. Gelber PE, Erquicia JI, Sosa G, Ferrer G, Abat F, Rodriguez-Baeza A, Segura-Cros C, Monllau JC. Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model. Arthroscopy. 2013;29:257–265.

    Article  PubMed  Google Scholar 

  5. Gwathmey FW Jr, Tompkins MA, Gaskin CM, Miller MD. Can stress radiography of the knee help characterize posterolateral corner injury? Clin Orthop Relat Res. 2012;470:768–773.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Halinen J, Lindahl J, Hirvensalo E, Santavirta S. Operative and nonoperative treatments of medial collateral ligament rupture with early anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2006;34:1134–1140.

    Article  PubMed  Google Scholar 

  7. Hastings DE. The non-operative management of collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1980;147:22–28.

    PubMed  Google Scholar 

  8. House CV, Connell DA, Saifuddin A. Posteromedial corner injuries of the knee. Clin Radiol. 2007;62:539–546.

    Article  CAS  PubMed  Google Scholar 

  9. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am. 1973;55:923–940.

    CAS  PubMed  Google Scholar 

  10. Ibrahim SA, Ghafar S, Salah M, Abo Alnas M, Al Misfer A, Farouk H, Al Haran H, Khirait S. Surgical management of traumatic knee dislocation with posterolateral corner injury. Arthroscopy. 2013;29:733–741.

    Article  PubMed  Google Scholar 

  11. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65:323–329.

    CAS  PubMed  Google Scholar 

  12. Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc. 2006;14:58–66.

    Article  PubMed  Google Scholar 

  13. Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res. 1988;226:103–112.

    PubMed  Google Scholar 

  14. Klimkiewicz JJ, Petrie RS, Harner CD. Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures. Clin Sports Med. 2000;19:479–92, vii.

    Google Scholar 

  15. Kovachevich R, Shah JP, Arens AM, Stuart MJ, Dahm DL, Levy BA. Operative management of the medial collateral ligament in the multi-ligament injured knee: an evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc. 2009;17:823–829.

    Article  PubMed  Google Scholar 

  16. LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89:2000–2010.

    Article  PubMed  Google Scholar 

  17. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med. 2010;38:804–809.

    Article  PubMed  Google Scholar 

  18. Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ; Knee Dislocation Study Group. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17:197–206.

    PubMed  Google Scholar 

  19. Marx RG, Hetsroni I. Surgical technique: medial collateral ligament reconstruction using Achilles allograft for combined knee ligament injury. Clin Orthop Relat Res. 2012;470:798–805.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Petersen W, Loerch S, Schanz S, Raschke M, Zantop T. The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee. Am J Sports Med. 2008;36:495–501.

    Article  PubMed  Google Scholar 

  21. Robinson JR, Bull AM, Thomas RR, Amis AA. The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med. 2006;34:1815–1823.

    Article  PubMed  Google Scholar 

  22. Robinson JR, Sanchez-Ballester J, Bull AM, Thomas Rde W, Amis AA. The posteromedial corner revisited. an anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Joint Surg Br. 2004;86:674–681.

    Article  CAS  PubMed  Google Scholar 

  23. Schenck RC Jr. The dislocated knee. Instr Course Lect. 1994;43:127–136.

    PubMed  Google Scholar 

  24. Shelbourne KD, Carr DR. Combined anterior and posterior cruciate and medial collateral ligament injury: nonsurgical and delayed surgical treatment. Instr Course Lect. 2003;52:413–418.

    PubMed  Google Scholar 

  25. Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004;32:337–345.

    Article  PubMed  Google Scholar 

  26. Stannard JP, Bauer KL. Current concepts in knee dislocations: PCL, ACL, and medial sided injuries. J Knee Surg. 2012;25:287–294.

    Article  PubMed  Google Scholar 

  27. Stannard JP, Black BS, Azbell C, Volgas DA. Posteromedial corner injury in knee dislocations. J Knee Surg. 2012;25:429–434.

    Article  PubMed  Google Scholar 

  28. Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am. 2010;92:1266–1280.

    Article  PubMed  Google Scholar 

  29. Yang BS, Bae WH, Ha JK, Lee DW, Jang HW, Kim JG. Posterolateral corner reconstruction using the single fibular sling method for posterolateral rotatory instability of the knee. Am J Sports Med. 2013;41:1605–1612.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA, 22908, USA

    Brian C. Werner MD, Michael M. Hadeed BS, F. Winston Gwathmey Jr. MD, Joseph M. Hart PhD, ATC & Mark D. Miller MD

  2. Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA

    Cree M. Gaskin MD

Authors
  1. Brian C. Werner MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael M. Hadeed BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. F. Winston Gwathmey Jr. MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cree M. Gaskin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph M. Hart PhD, ATC
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mark D. Miller MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark D. Miller MD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no commercial association (eg, consultancies, stock ownership, equity interest, patent/licensing agreements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Werner, B.C., Hadeed, M.M., Gwathmey, F.W. et al. Medial Injury in Knee Dislocations: What Are the Common Injury Patterns and Surgical Outcomes?. Clin Orthop Relat Res 472, 2658–2666 (2014). https://doi.org/10.1007/s11999-014-3483-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-014-3483-3

Keywords

Search

Navigation