Cutting edge Orthopedics

48 • CUTTING EDGE - ORTHOPEDICS [13, 14]. Timing of the operation should be based both on operative plan and stability of the patient. Although smaller series have shown adequate stability with chronic knee dislocations [37–39], the preponderance of data favors treating these injuries early, within 6 weeks [15, 16]. If an open approach is favored, it may be possible to treat the injury within 2 weeks; however, if an arthroscopic approach is favored, it may be prudent to wait 3–6 weeks to allow the capsule to seal and provide a favorable environment for arthroscopy. However, if an arthroscopic approach to these injuries is favored, the literature clearly dem- onstrates that early repairs of the collateral ligaments followed by reconstruction of the cruci- ate ligaments lead to late loosening of the collaterals [19, 32]. If arthroscopic treatment of the cruciate ligaments is planned, the PLC should be repaired or reconstructed at the time of the cruciate reconstruction, as was recommended by the Knee Dislocation Study Group [33], and a hinged fixator should be considered to prevent late loosening. The advantages of this methodol- ogy include low risk of revision surgery or arthrofibrosis, minimal incisions, and literature of satisfactory results. Challenges are technical aspects of arthroscopic reconstruction, treatment of concomitant patellar tendon ruptures, complete avulsions and bucket handle meniscus tears, cruciate bony avulsions or articular fractures, and the cost and morbidity of hinged external fixators. An open approach of repair and reconstruction of all structures is also an option. Advantages of this option include completion of treatment in the initial hospitalization period, no require- ment for arthroscopic instruments, and ability to address all soft tissue and bony pathology (patella tendon tears, fractures, bucket handle meniscus tears, complete meniscus avulsions, cruciate ligament avulsions, and collateral ligament avulsions). Challenges of this strategy include the risk of arthrofibrosis, larger incisions, and risk of infection. Predicting Long-Term Outcomes Dislocation of the knee is a devastating injury that can have many long-term consequences. While operative treatment has improved outcomes, the majority of the studies listed above show Lysholm knee scores in the 75–90 range and Tegner knee scores in the 4–5 range. This corre- lates with a “good” outcome and possible return to recreational sports. The major challenge in treating these injuries is balancing stability of the knee with arthrofibrosis and stiffness. “Early” surgical treatment of these severe injuries is recommended. Also repair of all damaged structures in either a single procedure or shortly staged procedures is also recommended. Most reviews are recommending early repair of collateral ligaments, patella tendon avulsions, and displaced meniscal tears. Allograft augmentation of these structures has been proposed but not rigorously studied. Cruciate repair or reconstruction in a single procedure or staged procedures with open or arthroscopic techniques followed by early range of motion produces good results. If staged reconstruction is pursued, concurrent use of a hinged external fixator results in fewer ligament failures. A prospective randomized study on 103 knee dislocations found that use of the hinged external fixator as a supplement to reconstruction offers favorable results. In this study 79 dislo- cations were evaluated for a minimum of 12 months with the mean duration of follow-up being