Experience in diagnosis and treatment of KD-<b>Ⅲ</b>M dislocation of knee joint_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Qian ¹ ,  HUANG Jingmin ¹ , HU Wenjin ² , WU Jiang ¹ , CHEN Xiao ¹ , REN Fuji ¹ , ZHENG Huifeng ¹ , LUO Wei ¹

1. Department of Sports Injury and Arthroscopy, Tianjin Hospital, Tianjin, 300211, P. R. China;
2. Department of Orthopedics, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, 300211, P. R. China;

Corresponding author：

HUANG Jingmin, Email: huangjingmin@126.com

Keywords：

Knee dislocation; dimple sign; posterior medial corner; posterior-medial instability; posterior cruciate ligament; anterior cruciate ligament; arthroscopy

DOI：

10.7507/1002-1892.202105117

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Objective To explore the effectiveness of one-stage posterior medial corner (PMC) repair or reconstruction combined with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction in treating KD-ⅢM dislocation. Methods The clinical data of 15 patients with knee KD-ⅢM dislocation who met the selection criteria between January 2016 and July 2019 were retrospectively analyzed. There were 9 males and 6 females, aged 22-61 years (mean, 40.3 years). Injuries were caused by violence of flexion, valgus, and external rotation, including 10 cases of traffic accident injuries, 3 cases of crush injuries, 1 case of winch injury, and 1 case of explosion injury. The time from injury to operation ranged from 3 days to 6 months, with an average of 18.5 days. PMC repair combined with PCL+ACL reconstruction was performed in 10 cases in acute stage (within 3 weeks after injury), including 3 cases of irreducible dislocation. PMC+PCL+ACL reconstruction was performed in 5 cases with chronic dislocation. Before operation and at last follow-up, the knee joint function was evaluated by Lysholm score and International Knee Documentation Committee (IKDC) 2000 score. KT-3000 was used to evaluate the forward stability of the knee (calculated the difference of tibial anterior displacement of both knees), the X-ray films of the stress position of the knee joint was used to evaluate the valgus of the knee (calculated the difference of medial joint space width of both knees) and the backward stability (calculated the difference of tibial posterior displacement of both knees), and the internal and external rotation stability was evaluated by knee flexion 30° tibial external rotation and knee flexion 90° tibial internal rotation tests (calculated the difference of tibial internal rotation and the difference of tibial external rotation of both knees). Results The operation time was 120-240 minutes, with an average of 186.5 minutes. Patients were followed up 24-48 months, with an average of 27.4 months. There was no complication such as infection, deep vein thrombosis, vascular injury, or heterotopic ossification. At last follow-up, the Lysholm score, IKDC2000 score, the difference of tibial anterior displacement of both knees, the difference of medial joint space width of both knees, the difference of tibial posterior displacement of both knees, the difference of tibial internal rotation and the difference of tibial external rotation of both knees significantly improved when compared with preoperative ones (P<0.05). According to the IKDC2000 valgus stability grading standard, there were 3 cases of grade C and 12 cases of grade D before operation, and 10 cases of grade A and 5 cases of grade B at last follow-up, which was significantly improved when compared with that before operation (Z=−4.930, P=0.000). At last follow-up, the pivot shift tests of 15 patients were negative. The anterior and posterior drawer tests of 10 patients were negative, 5 patients had mild instability, both the anterior and posterior drawer tests were positive. Conclusion KD-ⅢM dislocation of the knee joint can lead to the posterior medial and anterior instability. Acute dislocation combined with “dimple sign” requires surgical reduction as soon as possible to repair PMC and reconstruct PCL and ACL. In chronic patients, PMC is difficult to repair, it is recommended to reconstruct PMC, PCL, and ACL at one stage to improve knee joint stability. The early and middle effectiveness are satisfactory.

Citation： ZHAO Qian, HUANG Jingmin, HU Wenjin, WU Jiang, CHEN Xiao, REN Fuji, ZHENG Huifeng, LUO Wei. Experience in diagnosis and treatment of KD-ⅢM dislocation of knee joint. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(1): 33-40. doi: 10.7507/1002-1892.202105117 Copy

1.	Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg (Am), 1963, 45: 889-904.
2.	Schenck RC Jr. Classification of knee dislocations. Oper Techs Sports Med, 2003, 11(3): 193-198.
3.	黄华强, 李箭, 唐新. 膝关节脱位后内侧结构及后外侧角损伤分期分型及诊治体系. 中国修复重建外科杂志, 2017, 31(5): 614-619.
4.	Peskun CJ, Levy BA, Fanelli GC. Diagnosis and management of knee dislocations. Phys Sportsmed, 2010, 38(4): 101-110.
5.	Huang FS, Simonian PT, Chansky HA. Irreducible posterolateral dislocation of the knee. Arthroscopy, 2000, 16(3): 323-327.
6.	Said HG, Learmonth DJ. Chronic irreducible posterolateral knee dislocation: two-stage surgical approach. Arthroscopy, 2007, 23(5): 564.e1-4.
7.	Kilicoglu O, Akman S, Demirhan M, et al. Muscular buttonholing: An unusual cause of irreducible knee dislocation. Arthroscopy, 2001, 17(6): E22. doi: 10.1053/jars.2001.9245.
8.	Ruppanner E. Zur Kenntnis der irreponiblen Kniegelenksluxationen. Langenbeck’s Archives of Surgery, 1906, 83(5): 554-566.
9.	Malik SS, MacDonald PB. The irreducible knee dislocation. J Knee Surg, 2020, 33(4): 328-334.
10.	Al-Juhani W, Ahmed B, AlMugren T. Irreducible knee dislocation with vastus medialis muscle interposition. Knee Surg Relat Res, 2019, 31(1): 72-75.
11.	Lee QJ, Leung WY. Irreducible lateral knee dislocation with bone and soft-tissue interposition following low-energy trauma. Injury Extra, 2009, 40(3): 45-48.
12.	Urgüden M, Bilbaşar H, Ozenci AM, et al. Irreducible posterolateral knee dislocation resulting from a low-energy trauma. Arthroscopy, 2004, 20 Suppl 2: 50-53.
13.	Dubberley J, Burnell C, Longstaffe A, et al. Irreducible knee dislocation treated by arthroscopic debridement. Arthroscopy, 2001, 17(3): 316-319.
14.	Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop Relat Res, 1981, (154): 212-215.
15.	Goebel CP, Domes C. Classifications in brief: The schenck classification of knee dislocations. Clin Orthop Relat Res, 2020, 478(6): 1368-1372.
16.	Amis AA, Bull AM, Gupte CM, et al. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc, 2003, 11(5): 271-281.
17.	Trasolini NA, Lindsay A, Gipsman A, et al. The biomechanics of multiligament knee injuries: From trauma to treatment. Clin Sports Med, 2019, 38(2): 215-234.
18.	Moulton SG, Geeslin AG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, Part 2: Surgical treatment of chronic injuries. Am J Sports Med, 2016, 44(6): 1616-1623.
19.	Haimes JL, Wroble RR, Grood ES, et al. Role of the medial structures in the intact and anterior cruciate ligament-deficient knee. Limits of motion in the human knee. Am J Sports Med, 1994, 22(3): 402-409.
20.	Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev, 2011, 19(2): 167-173.
21.	Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg, 2001, 14(1): 33-38.
22.	Chen W, Zhang YZ, Su YL, Pan JS. Irreducible lateral knee dislocation with incarceration of the lateral femoral condyle in the posterolateral capsule-ligamentary structures: a case report and literature review. Orthop Surg, 2011, 3(2): 138-142.
23.	Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy, 2009, 25(4): 430-438.
24.	Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev, 2011, 19(2): 167-173.
25.	Levy BA, Marx RG. Outcome after knee dislocation. Knee Surg Sports Traumatol Arthrosc, 2009, 17(9): 1011-1012.
26.	Richter M, Bosch U, Wippermann B, et al. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med, 2002, 30(5): 718-727.
27.	Rihn JA, Groff YJ, Harner CD, et al. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg, 2004, 12(5): 334-346.
28.	Wand JS. A physical sign denoting irreducibility of a dislocated knee. J Bone Joint Surg (Br), 1989, 71(5): 862. doi: 10.1302/0301-620X.71B5.2584265.
29.	Howells NR, Brunton LR, Robinson J, et al. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury, 2011, 42(11): 1198-1204.
30.	Burrus MT, Werner BC, Griffin JW, et al. Diagnostic and management strategies for multiligament knee injuries: A critical analysis review. JBJS Rev, 2016, 4(2): e1. doi: 10.2106/JBJS.RVW.O.00020.
31.	Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy, 1996, 12(5): 521-530.
32.	Ng JWG, Myint Y, Ali FM. Management of multiligament knee injuries. EFORT Open Rev, 2020, 5(3): 145-155.
33.	Levy BA, Dajani KA, Morgan JA, et al. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med, 2010, 38(4): 804-809.
34.	Aga C, Risberg MA, Fagerland MW, et al. No difference in the KOOS quality of life subscore between anatomic double-bundle and anatomic single-bundle anterior cruciate ligament reconstruction of the knee: A prospective randomized controlled trial with 2 years’ follow-up. Am J Sports Med, 2018, 46(10): 2341-2354.
35.	Li Y, Li J, Wang J, et al. Comparison of single-bundle and double-bundle isolated posterior cruciate ligament reconstruction with allograft: a prospective, randomized study. Arthroscopy, 2014, 30(6): 695-700.
36.	Yoon KH, Bae DK, Song SJ, et al. 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): 474-480.
37.	Chahla J, Kunze KN, LaPrade RF, et al. The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation. Knee Surg Sports Traumatol Arthrosc, 2021, 29(9): 2976-2986.
38.	Corten K, Hoser C, Fink C, et al. Case reports: a Stener-like lesion of the medial collateral ligament of the knee. Clin Orthop Relat Res, 2010, 468(1): 289-293.
39.	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.
40.	Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res, 2012, 470(3): 806-814.
41.	Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 78-83.
42.	Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 58-66.
43.	Lind M, Jakobsen BW, Lund B, et al. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med, 2009, 37(6): 1116-1122.

1. Kennedy JC. Complete dislocation of the knee joint. J Bone Joint Surg (Am), 1963, 45: 889-904.
2. Schenck RC Jr. Classification of knee dislocations. Oper Techs Sports Med, 2003, 11(3): 193-198.
3. 黄华强, 李箭, 唐新. 膝关节脱位后内侧结构及后外侧角损伤分期分型及诊治体系. 中国修复重建外科杂志, 2017, 31(5): 614-619.
4. Peskun CJ, Levy BA, Fanelli GC. Diagnosis and management of knee dislocations. Phys Sportsmed, 2010, 38(4): 101-110.
5. Huang FS, Simonian PT, Chansky HA. Irreducible posterolateral dislocation of the knee. Arthroscopy, 2000, 16(3): 323-327.
6. Said HG, Learmonth DJ. Chronic irreducible posterolateral knee dislocation: two-stage surgical approach. Arthroscopy, 2007, 23(5): 564.e1-4.
7. Kilicoglu O, Akman S, Demirhan M, et al. Muscular buttonholing: An unusual cause of irreducible knee dislocation. Arthroscopy, 2001, 17(6): E22. doi: 10.1053/jars.2001.9245.
8. Ruppanner E. Zur Kenntnis der irreponiblen Kniegelenksluxationen. Langenbeck’s Archives of Surgery, 1906, 83(5): 554-566.
9. Malik SS, MacDonald PB. The irreducible knee dislocation. J Knee Surg, 2020, 33(4): 328-334.
10. Al-Juhani W, Ahmed B, AlMugren T. Irreducible knee dislocation with vastus medialis muscle interposition. Knee Surg Relat Res, 2019, 31(1): 72-75.
11. Lee QJ, Leung WY. Irreducible lateral knee dislocation with bone and soft-tissue interposition following low-energy trauma. Injury Extra, 2009, 40(3): 45-48.
12. Urgüden M, Bilbaşar H, Ozenci AM, et al. Irreducible posterolateral knee dislocation resulting from a low-energy trauma. Arthroscopy, 2004, 20 Suppl 2: 50-53.
13. Dubberley J, Burnell C, Longstaffe A, et al. Irreducible knee dislocation treated by arthroscopic debridement. Arthroscopy, 2001, 17(3): 316-319.
14. Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop Relat Res, 1981, (154): 212-215.
15. Goebel CP, Domes C. Classifications in brief: The schenck classification of knee dislocations. Clin Orthop Relat Res, 2020, 478(6): 1368-1372.
16. Amis AA, Bull AM, Gupte CM, et al. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc, 2003, 11(5): 271-281.
17. Trasolini NA, Lindsay A, Gipsman A, et al. The biomechanics of multiligament knee injuries: From trauma to treatment. Clin Sports Med, 2019, 38(2): 215-234.
18. Moulton SG, Geeslin AG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, Part 2: Surgical treatment of chronic injuries. Am J Sports Med, 2016, 44(6): 1616-1623.
19. Haimes JL, Wroble RR, Grood ES, et al. Role of the medial structures in the intact and anterior cruciate ligament-deficient knee. Limits of motion in the human knee. Am J Sports Med, 1994, 22(3): 402-409.
20. Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev, 2011, 19(2): 167-173.
21. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg, 2001, 14(1): 33-38.
22. Chen W, Zhang YZ, Su YL, Pan JS. Irreducible lateral knee dislocation with incarceration of the lateral femoral condyle in the posterolateral capsule-ligamentary structures: a case report and literature review. Orthop Surg, 2011, 3(2): 138-142.
23. Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy, 2009, 25(4): 430-438.
24. Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev, 2011, 19(2): 167-173.
25. Levy BA, Marx RG. Outcome after knee dislocation. Knee Surg Sports Traumatol Arthrosc, 2009, 17(9): 1011-1012.
26. Richter M, Bosch U, Wippermann B, et al. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med, 2002, 30(5): 718-727.
27. Rihn JA, Groff YJ, Harner CD, et al. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg, 2004, 12(5): 334-346.
28. Wand JS. A physical sign denoting irreducibility of a dislocated knee. J Bone Joint Surg (Br), 1989, 71(5): 862. doi: 10.1302/0301-620X.71B5.2584265.
29. Howells NR, Brunton LR, Robinson J, et al. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury, 2011, 42(11): 1198-1204.
30. Burrus MT, Werner BC, Griffin JW, et al. Diagnostic and management strategies for multiligament knee injuries: A critical analysis review. JBJS Rev, 2016, 4(2): e1. doi: 10.2106/JBJS.RVW.O.00020.
31. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy, 1996, 12(5): 521-530.
32. Ng JWG, Myint Y, Ali FM. Management of multiligament knee injuries. EFORT Open Rev, 2020, 5(3): 145-155.
33. Levy BA, Dajani KA, Morgan JA, et al. Repair versus reconstruction of the fibular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med, 2010, 38(4): 804-809.
34. Aga C, Risberg MA, Fagerland MW, et al. No difference in the KOOS quality of life subscore between anatomic double-bundle and anatomic single-bundle anterior cruciate ligament reconstruction of the knee: A prospective randomized controlled trial with 2 years’ follow-up. Am J Sports Med, 2018, 46(10): 2341-2354.
35. Li Y, Li J, Wang J, et al. Comparison of single-bundle and double-bundle isolated posterior cruciate ligament reconstruction with allograft: a prospective, randomized study. Arthroscopy, 2014, 30(6): 695-700.
36. Yoon KH, Bae DK, Song SJ, et al. 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): 474-480.
37. Chahla J, Kunze KN, LaPrade RF, et al. The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation. Knee Surg Sports Traumatol Arthrosc, 2021, 29(9): 2976-2986.
38. Corten K, Hoser C, Fink C, et al. Case reports: a Stener-like lesion of the medial collateral ligament of the knee. Clin Orthop Relat Res, 2010, 468(1): 289-293.
39. 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.
40. Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res, 2012, 470(3): 806-814.
41. Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 78-83.
42. Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc Rev, 2006, 14(2): 58-66.
43. Lind M, Jakobsen BW, Lund B, et al. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med, 2009, 37(6): 1116-1122.

Chinese Journal of Reparative and Reconstructive Surgery

Experience in diagnosis and treatment of KD-ⅢM dislocation of knee joint

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