Cutting edge Orthopedics

42 • CUTTING EDGE - ORTHOPEDICS The most common classification system for knee dislocations is the Wascher modification of the Schenck classification [20]. The modified Schenck classifies the dislocation according to injury pattern of the knee ligaments (Table 1) [20]. This chapter will mainly address the management of KD III–V, which are knee injuries with three or more ligament injuries. Detailed Review of Pertinent Articles Nonoperative Versus Operative Management Until the past two decades, nonoperative treatment was thought to be a valid option in closed, reducible knee dislocations without vascular injury or significant fracture. For example, Taylor and associates published a case series of 42 knee dislocations, with 16 patients treated opera- tively and 26 patients treated nonoperatively. At the time of the study, nonoperative manage- ment was the preferred modality of treatment, and all cases treated operatively were performed out of “necessity”, either for an irreducible joint, open injury, neurovascular injury, or associ- ated fracture. Nonoperative treatment consisted of brace or casting with delayed motion. Taylor found better outcomes in the nonoperative group when assessing stability, movement, and pain. It should be noted that the operative group underwent multiple different operations, and treatment was not standardized [21]. Current literature on knee dislocations favors operative treatment compared to nonoperative management. In 2001 Dedmond and Almekinders published a meta-analysis comparing opera- tive to nonoperative treatment in knee dislocations [13]. They compared 132 knee dislocations treated operatively to 74 treated nonoperatively. They found a range of motion of 123° in the oper- ative group compared to 108° of motion in the nonoperative group. They also found significantly higher Lysholm scores in the knees treated with an operation, 85.2 compared to 66.5, indicating significantly less disability. However, there was no demonstrated significant difference between the two groups in return to work, return to athletics, or knee instability. Richter and associates published another study that directly compared operative versus nonop- erative treatment of multiligament knee dislocations [14]. It was a retrospective cohort study com- paring 59 patients undergoing repair or reconstruction to 18 patients treated nonsurgically. In their study, they found significantly better Lysholm and Tegner scores in the operative group, 78 versus 65 (Lysholm) and 4.0 versus 2.7 (Tegner), indicating less disability and greater return to activity. Table 1: Wascher modification of Schenck classification. KD I Knee dislocation with both cruciates intact KD II Bicruciate injury with both collaterals intact KD III Bicruciate injury with one collateral torn KD IV Bicruciate injury with both collaterals torn KD V Knee dislocation with periarticular fracture Used with permission of Elsevier fromWascher [20]