Skip to main content
SpringerLink
Log in
Book cover

The Multiple Ligament Injured Knee pp 51–62Cite as

Initial Assessment in the Acute and Chronic Multiple-Ligament-Injured Knee

  • Chapter
  • First Online:

  • 2235 Accesses

Abstract

Knee dislocation, and multiligament knee injury, is an uncommon orthopedic diagnosis with a high rate of neurovascular injuries and limb-threatening complications. Disruption of the popliteal artery and common peroneal nerve is relatively common, requiring a complete and timely physical examination. An ankle–brachial index is a safe and reliable way to screen for vascular insufficiency. Imaging, in the form traditional arteriography or computed tomography with vascular reconstructions, should be ordered when there is concern for vascular injury. External fixation is a reliable method for stabilizing and protecting the knee joint in cases of open dislocation, vascular reconstruction, or a grossly unstable reduction that cannot be maintained with a knee immobilizer. Surgical management of multiligament knee injuries has the goal of providing a functional, pain-free, and stable knee. The current controversies pertaining to surgical treatment include early versus delayed management, arthroscopic versus open cruciate surgery, single versus double-bundle cruciate reconstruction, and transtibial versus tibia-inlay posterior cruciate ligament reconstruction. Knowledge of the basic principles surrounding initial and definitive management of knee dislocations, and multiligament knee injuries, aids the treating surgeon in managing these complex injuries.

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

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors: Student Course Manual (7th ed). 2004. Chicago: American College of Surgeons.

    Google Scholar 

  2. Mills WJ, Tejwani N. Heterotopic ossification after knee dislocation: the predictive value of the injury severity score. J Orthop Trauma. 2003;17(5):338–45.

    Article  PubMed  Google Scholar 

  3. Kilicoglu O, Demirhan M. Irreducible posterolateral knee dislocation associated with interposition of the vastus medialis. Am J Sports Med. 2005;33(12):1931.

    Article  PubMed  Google Scholar 

  4. Silverberg DA, Acus R. Irreducible posterolateral knee dislocation associated with interposition of the vastus medialis. Am J Sports Med. 2004;32(5):1313–6.

    Article  PubMed  Google Scholar 

  5. Dubberley J, Burnell C, Longstaffe A, MacDonald PB. Irreducible knee dislocation treated by arthroscopic debridement. Arthroscopy. 2001;17(3):316–9.

    Article  PubMed  Google Scholar 

  6. Meyers MH, Moore TM, Harvey Jr JP. Traumatic dislocation of the knee joint. J Bone Joint Surg Am. 1975;57(3):430–3.

    PubMed  CAS  Google Scholar 

  7. King 3rd JJ, Cerynik DL, Blair JA, Harding SP, Tom JA. Surgical outcomes after traumatic open knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2009;17(9):1027–32.

    Article  PubMed  Google Scholar 

  8. Braband M, Hosbond S, Folkstad L. Capillary refill time: a study of interobserver reliability among nurses and nurse assistants. Eur J Emerg Med, 2011;18(1): p 46–49.

    Google Scholar 

  9. Hollis JD, Daley BJ. 10-year review of knee dislocations: is arteriography always necessary? J Trauma. 2005;59(3):672–5.

    PubMed  Google Scholar 

  10. Klineberg EO, Crites BM, Flinn WR, Archibald JD, Moorman 3rd CT. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma. 2004;56(4):786–90.

    Article  PubMed  Google Scholar 

  11. 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(8):1005–12.

    Article  PubMed  Google Scholar 

  12. 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(6):1261–5.

    Article  PubMed  Google Scholar 

  13. Aboyans V, Ho E, Denenberg JO, Ho LA, Natarajan L, Criqui MH. The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 2008;48(5):1197–203.

    Article  PubMed  Google Scholar 

  14. Frassica FJ, Sim FH, Staeheli JW, Pairolero PC. Dislocation of the knee. Clin Orthop Relat Res. 1991;263:200–5.

    PubMed  Google Scholar 

  15. Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87(5):664–7.

    Article  PubMed  CAS  Google Scholar 

  16. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36(5):267–88.

    PubMed  Google Scholar 

  17. Petrie RS. Harner CD evaluation and management of the posterior cruciate injured knee. Oper Tech Sports Med. 1999;7(3):93–103.

    Article  Google Scholar 

  18. Wissman RD, Verma S, Kreeger M, Robertson M. Extensor mechanism injuries in tibiofemoral dislocations. J Comput Assist Tomogr. 2009;33(1):145–9.

    Article  PubMed  Google Scholar 

  19. Nicandri GT, Chamberlain AM, Wahl CJ. Practical management of knee dislocations: a selective angiography protocol to detect limb-threatening vascular injuries. Clin J Sport Med. 2009;19(2):125–9.

    Article  PubMed  Google Scholar 

  20. Redmond JM, Levy BA, Dajani KA, Cass JR, Cole PA. Detecting vascular injury in lower-extremity orthopedic trauma: the role of CT angiography. Orthopedics. 2008;31(8):761–7.

    Article  PubMed  Google Scholar 

  21. Ahmad F, Turner SA, Torrie P, Gibson M. Iatrogenic femoral artery pseudoaneurysms—a review of current methods of diagnosis and treatment. Clin Radiol. 2008;63(12):1310–6.

    Article  PubMed  CAS  Google Scholar 

  22. Coates M, Stewart N, Morganti V, Twaddle B. Magnetic resonance findings in knee dislocation: pictorial essay. Australas Radiol. 2000;44(4):373–84.

    Article  PubMed  CAS  Google Scholar 

  23. Twaddle BC, Hunter JC, Chapman JR, Simonian PT, Escobedo EM. MRI in acute knee dislocation. A prospective study of clinical, MRI, and surgical findings. J Bone Joint Surg Br. 1996;78(4):573–9.

    PubMed  CAS  Google Scholar 

  24. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg. 2001;14(1):33–8. Winter.

    PubMed  CAS  Google Scholar 

  25. Levy BA, Krych AJ, Shah JP, Morgan JA, Stuart MJ. Staged protocol for initial management of the dislocated knee. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):1630–7.

    Article  PubMed  Google Scholar 

  26. Davidovic LB, Cinara IS, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil and war peripheral arterial trauma: review of risk factors associated with limb loss. Vascular. 2005;13(3):141–7.

    PubMed  Google Scholar 

  27. Beyersdorf F, Schlensak C. Controlled reperfusion after acute and persistent limb ischemia. Semin Vasc Surg. 2009;22(1):52–7.

    Article  PubMed  Google Scholar 

  28. Farber A, Hamburg N, Onigman T, et al. Delayed fasciotomy in patients with extremity vascular injury is associated with increased risk of adverse limb outcomes: a review of the National Trauma Data Bank. J Vasc Surg. 2010;52(4):1118.

    Article  Google Scholar 

  29. Hossny A. Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified? J Vasc Surg. 2004;40(1):61–6.

    Article  PubMed  Google Scholar 

  30. Reber PU, Patel AG, Sapio NL, Ris HB, Beck M, Kniemeyer HW. Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma. J Trauma. 1999;47(1):72–6.

    Article  PubMed  CAS  Google Scholar 

  31. Kronja G, Misović S, Tomić A. Indications and results of fasciotomy in vascular injuries of the lower extremities. Vojnosanit Pregl. 2000;57(3):271–6.

    PubMed  CAS  Google Scholar 

  32. Abouezzi Z, Nassoura Z, Ivatury RR, Porter JM, Stahl WM. A critical reappraisal of indications for fasciotomy after extremity vascular trauma. Arch Surg. 1998;133(5):547–51.

    Article  PubMed  CAS  Google Scholar 

  33. Magit D, Wolff A, Sutton K, Medvecky MJ. Arthrofibrosis of the knee. J Am Acad Orthop Surg. 2007;15(11):682–94.

    PubMed  Google Scholar 

  34. 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(4):804–9.

    Article  PubMed  Google Scholar 

  35. Liow RY, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br. 2003;85(6):845–51.

    PubMed  CAS  Google Scholar 

  36. Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86-A(2):262–73.

    PubMed  Google Scholar 

  37. Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A. Surgical treatment of multiple knee ligament injuries in 44 patients: 2–8 years follow-up results. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):739–49.

    Article  PubMed  Google Scholar 

  38. Strobel MJ, Schulz MS, Petersen WJ, et al. Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities. Arthroscopy. 2006;22(2):182–92.

    Article  PubMed  Google Scholar 

  39. Karataglis D, Bisbinas I, Green MA, et al. Functional outcome following reconstruction in chronic multiple ligament deficient knees. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):843–7.

    Article  PubMed  CAS  Google Scholar 

  40. Zhao J, He Y, Wang J. Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligaments with autogenous hamstring tendons. Arthroscopy. 2006;22(5):497–504.

    Article  PubMed  Google Scholar 

  41. Engebretsen L, Risberg MA, Robertson B, et al. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17(9):1013–26.

    Article  PubMed  Google Scholar 

  42. Bibbo C, Brueggeman J. Prevention and management of complications arising from external fixation pin sites. J Foot Ankle Surg. 2010;49(1):87–92.

    Article  PubMed  Google Scholar 

  43. Stuart MJ. Evaluation and treatment principles of knee dislocations. Oper Tech Sports Med. 2001;9:91–5.

    Article  Google Scholar 

  44. Egol KA, Bazzi J, McLaurin TM, Tejwani NC. The effect of knee-spanning external fixation on compartment pressures in the leg. J Orthop Trauma. 2008;22(10):680–5.

    Article  PubMed  Google Scholar 

  45. Roman PD, Hopson CN, Zenni Jr EJ. Traumatic dislocation of the knee: a report of 30 cases and literature review. Orthop Rev. 1987;16(12):917–24.

    PubMed  CAS  Google Scholar 

  46. Thomsen PB, Rud B, Jensen UH. Stability and motion after traumatic dislocation of the knee. Acta Orthop Scand. 1984;55(3):278–83.

    Article  PubMed  CAS  Google Scholar 

  47. Owens BD, Neault M, Benson E, Busconi BD. Primary repair of knee dislocations: results in 25 patients (28 knees) at a mean follow-up of 4 years. J Orthop Trauma. 2007;21(2):92–6.

    Article  PubMed  Google Scholar 

  48. Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature. Arthroscopy. 1997;13(5):646–51.

    Article  PubMed  CAS  Google Scholar 

  49. Hirschmann MT, Zimmermann N, Rychen T, et al. Clinical and radiological outcomes after management of traumatic knee dislocation by open single stage complete reconstruction/repair. BMC Musculoskelet Disord. 2010;11:102.

    Article  PubMed  Google Scholar 

  50. Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence based review. Sports Med Arthrosc. 2011;19(2):167–73.

    Article  PubMed  Google Scholar 

  51. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14(1):35–8.

    Article  PubMed  CAS  Google Scholar 

  52. Jung YB, Tae SK, Lee YS, Jung HJ, Nam CH, Park SJ. Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surg Sports Traumatol Arthrosc. 2008;16(8):729–33.

    Article  PubMed  Google Scholar 

  53. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am. 2008;90(8):1621–7.

    Article  PubMed  Google Scholar 

  54. May JH, Gillette BP, Morgan JA, Krych AJ, Stuart MJ, Levy BA. Transtibial versus inlay posterior cruciate ligament reconstruction: an evidence-based systematic review. J Knee Surg. 2010;23(2):73–9.

    Article  PubMed  Google Scholar 

  55. Fanelli GC, Beck JD, Edson CJ. Double bundle posterior cruciate ligament reconstruction: surgical technique and results. Sports Med Arthrosc. 2010;18(4):242–8.

    Article  PubMed  Google Scholar 

  56. Kim SJ, Shin JW, Lee CH, et al. Biomechanical comparisons of three different tibial tunnel directions in posterior cruciate ligament reconstruction. Arthroscopy. 2005;21(3):286–93.

    Article  PubMed  Google Scholar 

  57. Huang TW, Wang CJ, Weng LH, Chan YS. Reducing the “killer turn” in posterior cruciate ligament reconstruction. Arthroscopy. 2003;19(7):712–6.

    Article  PubMed  Google Scholar 

  58. Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med. 2004;32(2):346–60.

    Article  PubMed  Google Scholar 

  59. McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med. 2002;30(3):312–7.

    PubMed  Google Scholar 

  60. Stannard JP. Anatomic posterior cruciate ligament reconstruction with allograft. J Knee Surg. 2010;23(2):81–7.

    Article  PubMed  Google Scholar 

  61. Noyes FR, Barber-Westin S. Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a tibial inlay technique. J Bone Joint Surg Am. 2005;87(6):1241–52.

    Article  PubMed  Google Scholar 

  62. Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009;91(11):2543–9.

    Article  PubMed  Google Scholar 

  63. Bergfeld JA, McAllister DR, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Am J Sports Med. 2001;29(2):129–36.

    PubMed  CAS  Google Scholar 

  64. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy. 2006;22(3):320–8.

    Article  PubMed  Google Scholar 

  65. Mauro MA, Jaques PF, Moore M. The popliteal artery and its branches: embryologic basis of normal and variant anatomy. AJR Am J Roentgenol. 1988;150(2):435–7.

    PubMed  CAS  Google Scholar 

  66. Hoppenfeld S, DeBoer P, Buckley R. Surgical Exposures in Orthopaedics: The Anatomic Approach. (4th Ed) 2009. Phladelphia. Lippincott Williams and Wilkins.

    Google Scholar 

  67. Papalia R, Osti L, Del Buono A, Denaro V, Maffulli N. Tibial inlay for posterior cruciate ligament reconstruction: a systematic review. Knee. 2010;17(4):264–9.

    Article  PubMed  Google Scholar 

  68. Carr AJ. Evidence-based orthopaedic surgery: what type of research will best improve clinical practice? J Bone Joint Surg Br. 2005;87(12):1593–4.

    Article  PubMed  CAS  Google Scholar 

  69. Crawford C, Nyland J, Landes S, et al. Anatomic double bundle ACL reconstruction: a literature review. Knee Surg Sports Traumatol Arthrosc. 2007;15(8):946–64.

    Article  PubMed  Google Scholar 

  70. Bedi A, Musahl V, Steuber V, et al. Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy. 2011;27(3):380–90.

    Article  PubMed  Google Scholar 

  71. Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am. 2002;84-A(6):907–14.

    PubMed  Google Scholar 

  72. Norwood Jr LA, Cross MJ. The intercondylar shelf and the anterior cruciate ligament. Am J Sports Med. 1977;5(4):171–6.

    Article  PubMed  Google Scholar 

  73. Norwood LA, Cross MJ. Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities. Am J Sports Med. 1979;7(1):23–6.

    Article  PubMed  CAS  Google Scholar 

  74. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. 2005;33(10):1579–602.

    Article  PubMed  Google Scholar 

  75. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part 2. Am J Sports Med. 2005;33(11):1751–67.

    Article  PubMed  Google Scholar 

  76. Khan MS, Seon JK, Song EK. Risk factors for anterior cruciate ligament injury: assessment of tibial plateau anatomic variables on conventional MRI using a new combined method. Int Orthop. 2011;35(8):1251–6.

    Article  PubMed  Google Scholar 

  77. Markolf KL, Park S, Jackson SR, McAllister DR. Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am. 2009;91(1):107–18.

    Article  PubMed  Google Scholar 

  78. Markolf KL, Park S, Jackson SR, McAllister DR. Contributions of the posterolateral bundle of the anterior cruciate ligament to anterior-posterior knee laxity and ligament forces. Arthroscopy. 2008;24(7):805–9.

    Article  PubMed  Google Scholar 

  79. Branch TP, Siebold R, Freedberg HI, Jacobs CA. Double-bundle ACL reconstruction demonstrated superior clinical stability to ­single-bundle ACL reconstruction: a matched-pairs analysis of instrumented tests of tibial anterior translation and internal rotation laxity. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):432–40.

    Article  PubMed  CAS  Google Scholar 

  80. Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2008;36(7):1414–21.

    Article  PubMed  Google Scholar 

  81. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH. A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med. 2011;39(3):474–80.

    Article  PubMed  Google Scholar 

  82. Chhabra A, Kline AJ, Harner CD. Single-bundle versus double-bundle posterior cruciate ligament reconstruction: scientific rationale and surgical technique. Instr Course Lect. 2006;55:497–507.

    PubMed  Google Scholar 

  83. Whiddon DR, Zehms CT, Miller MD, Quinby JS, Montgomery SL, Sekiya JK. Double compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model. J Bone Joint Surg Am. 2008;90(9):1820–9.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Orthopaedics, Department of Surgery, University of Toronto, #507-95 Prince Arthur Avenue, Toronto, ON, Canada

    Christopher Peskun M.D.

  2. Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, 55 Queen St. E (Suite 800), Toronto, ON, Canada

    Daniel B. Whelan M.D., M.Sc., F.R.C.S.C.

Authors
  1. Christopher Peskun M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel B. Whelan M.D., M.Sc., F.R.C.S.C.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel B. Whelan M.D., M.Sc., F.R.C.S.C. .

Editor information

Editors and Affiliations

  1. GHS Orthopaedics, Woodbine Lane 115, Danville, 17822-5212, Pennsylvania, USA

    Gregory C. Fanelli

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer Science+Business Media New York

About this chapter

Cite this chapter

Peskun, C., Whelan, D.B. (2013). Initial Assessment in the Acute and Chronic Multiple-Ligament-Injured Knee. In: Fanelli, G. (eds) The Multiple Ligament Injured Knee. Springer, New York, NY. https://doi.org/10.1007/978-0-387-49289-6_4

Download citation

  • DOI: https://doi.org/10.1007/978-0-387-49289-6_4

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-0-387-49287-2

  • Online ISBN: 978-0-387-49289-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation