Cutting edge Orthopedics

Knee Dislocations • 43  Frosch and associates conducted a meta-analysis including nine studies evaluating 200 knees across three comparison groups: patients treated without surgical intervention, patients treated by sutures, and patients undergoing reconstruction of the ACL/PCL. The group found that 70% of patients undergoing no treatment of ACL/PCL experienced poor to moderate results, whereas patients treated by sutures of the ACL/PCL demonstrated a significantly higher propor- tion of excellent to good results (40% and 37.5%, respectively). Furthermore, patients undergoing reconstruction of the ACL/PCL ( n = 75) experienced excellent to good results (28% and 45%, respectively). However, no significant difference was observed when comparing sutured ligaments versus reconstructed ligaments. The group determined that the outcome depended considerably on Schenck classification [22]. At the time of surgical treatment with repair or reconstruction, we do not recommend the use of a tourniquet if a vascular injury has occurred. Early Repair Versus Late Repair The majority of the literature on timing of operative intervention in knee dislocations favors early, within 6 weeks, over late repair or reconstruction, with resulting higher subjective knee scores and activity ratings [15, 16]. One study that investigated surgical timing of these injuries was done by Harner and associ- ates [15]. This was a retrospective cohort study of 31 dislocated knees treated in a non-emergent setting. Nineteen of these knee injuries were treated within 3 weeks of the trauma, and the other 12 were treated on a delayed basis at an average of 6.5 months after the index injury. The average Lysholm knee scores of the group treated within 3 weeks was 91, and the average of the delayed surgical group was 80. Furthermore, the average Knee Outcome Sports Activities Scale scores were much higher in the early treatment group, 89 compared to 69. However, they found knee range of motion to be similar and acceptable in both groups. Another study looking at optimal timing of operative fixation of knee dislocations was done by Liow and associates [16]. They presented a series of 22 dislocated knees, with eight treated in the acute phase of less than 2 weeks and 14 treated greater than 6 months after the injury (range 6–72). Injuries were treated with a combination of repair and reconstruction. They found that both Lysholm scores and Tegner activity ratings were higher in the early treatment group, 87 versus 75 and 5 versus 4.4. They also did instrumented testing of knee stability and found that the ACL reconstructions done acutely had less anterior tibial translation than those undergoing delayed treatment. Like Harner and associates, they also found that knee range of motion was not significantly different between the two groups. An alternative method of timing these operations is to separate the repair/reconstructions of the damaged ligaments into a staged procedure. In this approach, the collateral ligaments are either repaired or reconstructed acutely, usually in the first week, and the ACL ± PCL are recon- structed later, usually at around 6 weeks. This method allows surgeons to do an open approach to repair or reconstruct the damaged collateral ligaments early, when the zone of injury is fresh, and it allows the capsule time to heal for the arthroscopic portion of the procedure which can be done at around 6 weeks [23].