Knee Dislocations in the Morbidly Obese Patient

  • Ian Power
  • Frederick M. AzarEmail author


Ultra-low-velocity (ULV) knee dislocations are rare but increasingly common events. They occur most frequently in obese, morbidly obese, and super obese patients during everyday activities, but they can be as severe or more severe than high-velocity knee dislocations. ULV knee dislocations frequently are associated with neurovascular injury and other complications. Diagnosis, early reduction, and identification and treatment of vascular injuries are critical to reducing the risk of limb ischemia and possibly amputation. Given the size of the limb, maintenance of reduction in these patients almost always requires external fixation. While surgery on morbidly obese patients may be technically challenging, surgical reconstruction leads to improved subjective and objective results and is recommended.


Knee dislocation Low-velocity mechanism Obesity Diagnosis Arteriography Treatment Outcomes Complications Neurovascular injury Multiligament injuries Ligament reconstruction 


  1. 1.
    Bratt HD, Newman AP. Complete dislocation of the knee without disruption of both cruciate ligaments. J Trauma. 1993;34:383–9.CrossRefGoogle Scholar
  2. 2.
    Brautigan B, Johnson DL. The epidemiology of knee dislocations. Clin Sports Med. 2000;19:387–97.CrossRefGoogle Scholar
  3. 3.
    Hegyes MS, Richardson NW, Miller MD. Knee dislocation. Complications of nonoperative and operative management. Clin Sports Med 2000;19:519–543.CrossRefGoogle Scholar
  4. 4.
    Hoover NW. Injuries of the popliteal artery associated with fractures and dislocations. Surg Clin North Am. 1961;41:1099–112.CrossRefGoogle Scholar
  5. 5.
    Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg Am. 1963;45:889–904.CrossRefGoogle Scholar
  6. 6.
    Meyers MH, Moore TM, Harve JP Jr. Traumatic dislocation of the knee joint. J Bone Joint Surg Am. 1975;57:430–3.CrossRefGoogle Scholar
  7. 7.
    Merrill KD. Knee dislocations with vascular injuries. Orthop Clin North Am. 1994;25:707–13.PubMedGoogle Scholar
  8. 8.
    Sisto DJ, Warren RF. Complete knee dislocation. A follow-up study of operative treatment. Clin Orthop Relat Res 1985;198:94–101.Google Scholar
  9. 9.
    Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–9.CrossRefGoogle Scholar
  10. 10.
    Shelbourne KD, Porter DA, Clingman JA, McCarroll JR, Rettig AC. Low-velocity knee dislocation. Orthop Rev. 1991;20:995–1004.Google Scholar
  11. 11.
    Streubel PN, Arndt S, Armitage MS, Wilson CD, Gladden PB. Fatal knee dislocation in a morbidly obese Jehovah’s Witness. A case report. Obes Surg. 2010;20:1316–8.CrossRefGoogle Scholar
  12. 12.
    Bui KL, Illaslan H, Parker RD, Sundaram M. Knee dislocations: a magnetic resonance imaging study correlated with clinical and operative findings. Skeletal Radiol. 2008;37:653–61.CrossRefGoogle Scholar
  13. 13.
    Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17:1013–26.CrossRefGoogle Scholar
  14. 14.
    McCoy GF, Hannon DG, Barr RJ, Templeton J. Vascular injury associated with low-velocity dislocations of the knee. J Bone Joint Surg Br. 1987;69:285–7.CrossRefGoogle Scholar
  15. 15.
    Marin EL, Bifulco SS, Fast A. Obesity. A risk factor for knee dislocation. Am J Phys Med Rehabil 1990;69:132–134.Google Scholar
  16. 16.
    Hagino RT, DeCaprio JD, Valentine RJ, Clagett GP. Spontaneous popliteal vascular injury in the morbidly obese. J Vasc Surg. 1988;28:458–62.CrossRefGoogle Scholar
  17. 17.
    Georgiadis AG, Mohammad FH, Mizerik KT, Nypaver TJ, Shepard AD. Changing presentation of knee dislocation and vascular injury from high energy falls in the morbidly obese. J Vasc Surg. 2013;57:1196–203.CrossRefGoogle Scholar
  18. 18.
    Azar FM, Brandt JC, Miller TH 3rd, Phillips BB. Ultra-low-velocity knee dislocations. Am J Sports Med. 2011;39:2170–4.CrossRefGoogle Scholar
  19. 19.
    Peltola EK, Lindahl J, Hietaranta H, Koskinen SK. Knee dislocation in overweight patients. AJR. 2009;192:101–6.CrossRefGoogle Scholar
  20. 20.
    Hamblin T, Curtis SH, D’Astous J, Aoki SK. Childhood obesity and low-velocity knee dislocation in a fifteen-year-old girl. A case report. J Bone Joint Surg Am 2010;92:2216–2219.CrossRefGoogle Scholar
  21. 21.
    Centers for Disease Control and Prevention. Defining adult overweight and obesity. Available at Accessed 24 April 2018.
  22. 22.
    American Academy of Orthopaedic Surgeons. Position statement. The impact of obesity on bone and joint health. Available at Accessed 24 April 2018.
  23. 23.
    Johnson JP, Kleiner J, Klinge SA, McClure PK, Hayda RA, Born CT. Increased incidence of vascular injury in obese patients with knee dislocations. J Orthop Trauma. 2018;32:82–7.CrossRefGoogle Scholar
  24. 24.
    Georgiadis AG, Guthrie T, Shepard AD. Beware of ultra-low-velocity knee dislocation. Orthopedics. 2014;37:656–8.CrossRefGoogle Scholar
  25. 25.
    Roman PD, Hopson CN, Zenni EJ Jr. Traumatic dislocation of the knee: a report of 30 cases and literature review. Orthop Rev. 1987;16:917–24.Google Scholar
  26. 26.
    Ranavolo A, Donini LM, Mari S, Serrao M, Silvetti A, Iavicoli S, et al. Lower-limb joint coordination pattern in obese subjects. Biomed Res Int. 2013;2013:142323.CrossRefGoogle Scholar
  27. 27.
    Mignardot JB, Olivier I, Pomayon E, Nourgier V. Origins of balance disorders during a daily living movement in obese: can biomechanical factors explain everything? PLoS ONE. 2013;8:e60491.CrossRefGoogle Scholar
  28. 28.
    Vaidya R, Roth M, Nanavati D, Prince M, Sethi A. Low-velocity knee dislocations in obese and morbidly obese patients. Orthop J Sports Med. 2015;3:2325967.CrossRefGoogle Scholar
  29. 29.
    Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19:457–77.CrossRefGoogle Scholar
  30. 30.
    Lefrak EA. Knee dislocation. An illusive cause of critical arterial occlusion. Arch Surg. 1976;111:1021–4.CrossRefGoogle Scholar
  31. 31.
    Folt J, Vohra T. Low-velocity knee dislocation in the morbidly obese. Am J Emerg Med. 2012;30(2090):e5–6.Google Scholar
  32. 32.
    Shetty RR, Mostofi SB, Housden PL. Knee dislocation of a morbidly obese patient: a case report. J Orthop Surg. 2005;13:76–8.CrossRefGoogle Scholar
  33. 33.
    Natsuhara KM, Yeranosian MG, Cohen JR, Wang JC, McAllister DR, Petrigliano FA. What is the frequency of vascular injury after knee dislocation? Clin Orthop Relat Res. 2014;472:2615–20.CrossRefGoogle Scholar
  34. 34.
    Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86:910–5.CrossRefGoogle Scholar
  35. 35.
    Kaufman SL, Martin LG. Arterial injuries associated with complete dislocation of the knee. Radiology. 1992;184:153–5.CrossRefGoogle Scholar
  36. 36.
    Werner BC, Gwathmey W Jr, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations. Patient characteristics, complications, and outcomes. Am J Sports Med. 2013;42:358–63.CrossRefGoogle Scholar
  37. 37.
    Weinberg DS, Scarcella NR, Napora JK, Vallier HA. Can vascular injury be appropriately assessed with physical examination after knee dislocation? Clin Orthop Relat Res. 2016;474:1453–8.CrossRefGoogle Scholar
  38. 38.
    McDonough EB Jr, Wojtys EM. Multiligamentous injuries of the knee and associated vascular injuries. Am J Sports Med. 2009;37:156–9.CrossRefGoogle Scholar
  39. 39.
    Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004;56:1261–5.CrossRefGoogle Scholar
  40. 40.
    Abou-Sayed H, Berger DL. Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography. Arch Surg. 2002;137:585–9.CrossRefGoogle Scholar
  41. 41.
    Kendall RW, Taylor DC, Slavian AJ, O’Brien PJ. The role of arteriography in assessing vascular injuries associated with dislocations of the knee. J Trauma. 1993;35:875–8.CrossRefGoogle Scholar
  42. 42.
    Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg EF. Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study. J Trauma. 2002;52:247–51.Google Scholar
  43. 43.
    Treiman GS, Yellin AE, Weaver FA, Wang S, Ghalambor N, Barlow W, et al. Examination of the patient with a knee dislocation. The case for selective arteriography. Arch Surg. 1992;127:1056–62.CrossRefGoogle Scholar
  44. 44.
    Howells NR, Brunton LR, Robinson J, Porteus AJ, Eldridge JD, Murray JR. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury. 2011;42:1198–204.CrossRefGoogle Scholar
  45. 45.
    Nicandri GT, Dunbar RP, Wahl CJ. Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized? Knee Surg Sports Traumatol Arthrosc. 2010;18:1005–12.CrossRefGoogle Scholar
  46. 46.
    O’Donnell TF Jr, Brewster DC, Darling RC, Veen H, Waltman AA. Arterial injuries associated with fractures and/or dislocations of the knee. J Trauma. 1977;17:775–84.CrossRefGoogle Scholar
  47. 47.
    Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14:33–8.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Geeslin AG, Moulton SG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, Part 1: surgical treatment of acute injuries. Am J Sports Med. 2016;44:1336–42.CrossRefGoogle Scholar
  49. 49.
    Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86:262–73.CrossRefGoogle Scholar
  50. 50.
    Sims WF, Jacobson KE. The posteromedial corner of the knee: medial-sided injury patterns revisited. Am J Sports Med. 2004;32:337–45.CrossRefGoogle Scholar
  51. 51.
    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;34:1815–23.CrossRefGoogle Scholar
  52. 52.
    Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990;254:216–9.Google Scholar
  53. 53.
    Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al. Prevention of VTE in orthopedic surgery patients. Antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141 (Suppl):e278S–325S.Google Scholar
  54. 54.
    Werner BC, Hadeed MM, Gwathmey FW Jr, Gaskin CM, Hart JM, Miller MD. Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes? Clin Orthop Relat Res. 2014;472:2658–66.CrossRefGoogle Scholar
  55. 55.
    Scarcella NR, Weinberg DS, Bowen S, Vallier HA. Clinical and functional results of 119 patients with knee dislocations. J Orthop Trauma. 2017;31:380–6.CrossRefGoogle Scholar
  56. 56.
    Ridley TJ, Cook S, Bollier M, McCarthy M, Gao Y, Wolf B, et al. Effect of body mass index on patients with multiligamentous knee injuries. Arthroscopy. 2014;30:1447–52.CrossRefGoogle Scholar
  57. 57.
    Hanley J, Westermann R, Cook S, Glass N, Amendola N, Wolf BR, et al. Factors associated with knee stiffness following surgical management of multiligament knee injuries. J Knee Surg. 2017;30:549–54.CrossRefGoogle Scholar
  58. 58.
    Werner BC, Higgins MD, Pehlivan HC, Carothers JT, Browne JA. Super obesity is an independent risk factor for complications after primary total hip arthroplasty. J Arthroplasty. 2017;32:402–6.CrossRefGoogle Scholar
  59. 59.
    Zusmanovich M, Kester BS, Schwarzkopf R. Postoperative complications of total joint arthroplasty in obese patients stratified by BMI. J Arthroplasty. 2018;33:856–64.CrossRefGoogle Scholar
  60. 60.
    Meller MM, Toossi N, Johanson NA, Gonzalez MH, Son MS, Lau EC. Risk and cost of 90-day complications in morbidly and superobese patients after total knee arthroplasty. J Arthroplasty. 2016;31:2091–8.CrossRefGoogle Scholar
  61. 61.
    Seenath MM, Parry DJ, Macdonald D, Pollard SG, Scott DJA. Pathological knee dislocation in the morbidly obese. EJVES Extra. 2005;10:15–7.CrossRefGoogle Scholar
  62. 62.
    Carr JB, Werner BC, Miller MD, Gwathmey FW. Knee dislocation in the morbidly obese patient. J Knee Surg. 2016;29:278–85.CrossRefGoogle Scholar
  63. 63.
    Sems SA, Levy BA, Dajani K, Herrera DA, Templeman DC. Incidence of deep venous thrombosis after temporary joint spanning external fixation for complex lower extremity injuries. J Trauma. 2009;66:1164–6.CrossRefGoogle Scholar
  64. 64.
    Born TR, Engasser WM, King AH, Krych AJ, Dahm DL, Levy BA, et al. Low frequency of symptomatic venous thromboembolism after multiligamentous knee reconstruction with thromboprophylaxis. Clin Orthop Relat Res. 2014;472:2705–11.CrossRefGoogle Scholar
  65. 65.
    Delis KT, Hunt N, Strachan RK, Nicolaides AN. Incidence, natural history and risk factors of deep vein thrombosis in elective knee arthroscopy. Thromb Haemost. 2001;86:817–21.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Orthopaedic Surgery & Biomedical EngineeringUniversity of Tennessee-Campbell ClinicMemphisUSA

Personalised recommendations