Vascular Injury in the Multiligament Injured Knee

Matthewson, Graeme; Kwapisz, Adam; Sasyniuk, Treny M.; MacDonald, Peter B.

doi:10.1016/j.csm.2018.11.001

Cited by 25 publications

(34 citation statements)

References 66 publications

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“…As a result of spontaneous reduction of KDs in up to 50% of cases and concomitant polytrauma, MLKIs are often missed in the acute setting [ 4 ]. Here as well, MRI plays a pivotal role in assessing damaged intra-articular structures and should be routinely used when available [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

“…The term multiligament knee injury (MLKI) is therefore used with less ambiguity when two or more of the four main knee ligaments are injured: these are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterolateral corner (PLC) and posteromedial corner (PMC) [ 2 ]. KDs are rare, with an estimated 0.02–0.2% of orthopaedic injuries, but the true incidence is likely to be underestimated due to spontaneous reduction or missed injuries in the polytrauma patient [ 3 , 4 ].…”

Section: Introductionmentioning

confidence: 99%

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Current concepts in the assessment and management of multiligament injuries of the knee

Scheepers

Khanduja

Held

2021

SICOT-J

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Multiligament knee injuries (MLKIs), though rare, pose significant challenges to the patient and surgeon. They often occur in the setting of high-velocity trauma and are frequently associated with concomitant intra- and extra-articular injuries, the most immediately devastating of which is vascular compromise. A detailed evaluation is required when acute or chronic MLKIs are suspected, and stress radiography, MRI and angiography are valuable adjuncts to a thorough clinical examination. Surgical treatment is widely regarded as superior to non-surgical management and has been demonstrated to improve functional outcome scores, return to work, and return to sport rates, though the incidence of post-traumatic osteoarthritis remains high in affected knees. However, acceptable results have been obtained with conservative management in populations where surgical intervention is not feasible. Early arthroscopic single-stage reconstruction is currently the mainstay of treatment for these injuries, but some recent comparative studies have found no significant differences in outcomes. Recent trends in the literature on MLKIs seem to favour early surgery over delayed surgery, though both methods have distinct advantages and disadvantages. Due to the heterogeneity of the injury and the diversity of patient factors, treatment needs to be individualised, and a single best approach with regards to the timing of surgery, repair versus reconstruction, surgical technique and surgical principles cannot be advocated. There is much controversy in the literature surrounding these topics. Early post-operative rehabilitation remains one of the most important positive prognostic factors in surgical management and requires a dedicated team-based approach. Though outcomes of MLKIs are generally favourable, complications are abundant and precautionary measures should be implemented where possible. Low resource settings are faced with unique challenges, necessitating adaptability and pragmatism in tailoring a management strategy capable of achieving comparable outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Current concepts in the assessment and management of multiligament injuries of the knee

Scheepers

Khanduja

Held

2021

SICOT-J

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“…The appropriate imaging modality as well as other aspects in the treatment of KD remain current topics of a scholarly debate because it is a complex injury represented by inhomogeneous-related literature. 34,35 Furthermore, both imaging modalities seem to be comparable or even superior to the conventional arteriography but not superior to physical examination with or without ABI as the first relevant assessment and should therefore be applied in the role of advanced imaging in cases of abnormal clinical findings.…”

Section: Computed Tomography Angiography Versus Magnetic Resonance Anmentioning

confidence: 99%

“…34 The most recent review from Matthewson et al also cites Nicandri's algorithm and Maslaris's approach of assessing vascular trauma in KD as appropriate recommendations and sum up that proper management of KD requires prompt diagnosis, immediate reduction, and a thorough vascular status assessment consisting of initial physical examination followed by vascular studies such as ABI, CTA, MRA, or traditional angiogram with delay of ligamentous repair if vascular damage warrants surgery. 35 Taking well-known clinical studies as well as recent and comprehensive literature including systematic reviews into consideration, one can conclude that there is no absolute gold standard so far, the old concept of initially performing arteriography is outdated, and more than one advanced acceptable protocol is available and applicable in daily clinical routine. The literature mainly has in common that physical examination followed by ABI and/or duplex sonography combined with the selective use of arteriography or new imaging modalities in cases of abnormal clinical findings is the most frequent and evidence-based protocol.…”

Section: Knee Dislocation Literaturementioning

confidence: 99%

Vascular Injuries following Knee Dislocation

Stannard

Schreiner

2020

J Knee Surg

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Knee dislocations (KDs) are frequently found in high-energy impact injuries, ranging from automobile accidents to contact sports. KDs require careful examination due to the limb-threatening nature of these injuries. A key examination in any KD comprises a proper assessment of the vascular status. The risk of popliteal artery injury with a KD has varied from 7 to 40%, with more contemporary studies reporting injury in the range of 7 to 15%. The notion of mandatory emergent arteriography was challenged in the trauma literature as several small retrospective studies suggested that selective arteriography was a safe and effective treatment protocol. New imaging modalities have evolved and have found their way into trauma surgery. Computed tomography angiography and magnetic resonance angiography are two contemporary imaging modalities that have different characteristics as well as availability. Arteriography has been the gold standard and is a reliable and proven method of evaluation. However, it has a number of negative aspects that must be considered when determining the ideal imaging for a patient following KD. Besides cost savings of about more than US$500,000, conventional arteriography, which comprises the use of X-ray, arterial puncture and cannulation, and the use of contrast agents containing iodine, has got a complication rate as high as 9% and more patient discomfort compared with the new imaging modalities. This clinical practice review documents that our algorithm of clinical examination first combined with advanced imaging in cases with abnormalities documented on examination is a safe and prudent policy in treating patients following KD.

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“…High-energy trauma, in particular, can result in multisystem injuries, which may involve both isolated or multi-ligamentous knee injuries [1,2]. The acute traumatic dislocation of the knee is considered the most severe ligament injury of the lower extremity and may be associated with devastating and limb-threatening complications [3][4][5][6]. The incidence for knee dislocations is very low and has been estimated to be 1.2 per million person-years, mainly from high-energy trauma [7].…”

Section: Introductionmentioning

confidence: 99%

Which Risk Factors Predict Knee Ligament Injuries in Severely Injured Patients?—Results from an International Multicenter Analysis

Weber

Solomon

Lefering

et al. 2020

JCM

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Introduction: Ligament injuries around the knee joint and knee dislocations are rare but potentially complex injuries associated with high-energy trauma. Concomitant neurovascular injuries further affect their long-term clinical outcomes. In contrast to isolated ligamentous knee injuries, epidemiologic data and knowledge on predicting knee injuries in severely injured patients is still limited. Methods: The TraumaRegister DGU® (TR-DGU) was queried (01/2009–12/2016). Inclusion criteria for selection from the database: maximum abbreviated injury severity ≥ 3 points (MAIS 3+). Participating countries: Germany, Austria, and Switzerland. The two main groups included a “control” and a “knee injury” group. The injury severity score (ISS) and new ISS (NISS) were used for injury severity classification, and the abbreviated injury scale (AIS) was used to classify the severity of the knee injury. Logistic regression analysis was performed to evaluate various risk factors for knee injuries. Results: The study cohort included 139,462 severely injured trauma patients. We identified 4411 individuals (3.2%) with a ligament injury around the knee joint (“knee injury” group) and 1153 patients with a knee dislocation (0.8%). The risk for associated injuries of the peroneal nerve and popliteal artery were significantly increased in dislocated knees when compared to controls (peroneal nerve from 0.4% to 6.7%, popliteal artery from 0.3% to 6.9%, respectively). Among the predictors for knee injuries were specific mechanisms of injury: e.g., pedestrian struck (Odds ratio [OR] 3.2, 95% confidence interval [CI]: 2.69–3.74 p ≤ 0.001), motorcycle (OR 3.0, 95% CI: 2.58–3.48, p ≤ 0.001), and motor vehicle accidents (OR 2.2, 95% CI: 1.86–2.51, p ≤ 0.001) and associated skeletal injuries, e.g., patella (OR 2.3, 95% CI: 1.99–2.62, p ≤ 0.001), tibia (OR 1.9, 95% CI: 1.75–2.05, p ≤ 0.001), and femur (OR 1.8, 95% CI: 1.64–1.89, p ≤ 0.001), but neither male sex nor general injury severity (ISS). Conclusion: Ligament injuries and knee dislocations are associated with high-risk mechanisms and concomitant skeletal injuries of the lower extremity, but are not predicted by general injury severity or sex. Despite comparable ISS, knee injuries prolong the hospital length of stay. Delayed or missed diagnosis of knee injuries can be prevented by comprehensive clinical evaluation after fracture fixation and a high index of suspicion is advised, especially in the presence of the above mentioned risk factors.

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Vascular Injury in the Multiligament Injured Knee

Cited by 25 publications

References 66 publications

Current concepts in the assessment and management of multiligament injuries of the knee

Current concepts in the assessment and management of multiligament injuries of the knee

Vascular Injuries following Knee Dislocation

Which Risk Factors Predict Knee Ligament Injuries in Severely Injured Patients?—Results from an International Multicenter Analysis

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