Instructional Course for Surgeons on the Treatment of Severe Knee InjuriesEveryone faces the decision to 'repair or replace' when it comes to clothes, cars, computers, household possessions, and so on. Sometimes the decision is based on finances. In other cases, it's just a matter of convenience, time, or personal preferences. But when faced with the same decision for complex knee injuries, suddenly the stakes are much higher.
Knee injuries so severe that there is dislocation, fracture, and/or multiple ligaments ruptured require careful consideration when planning treatment. The decision to repair versus reconstruct is an important one.
In this article, a group of surgeons present an instructional course lecture on the management of complex knee ligament injuries. The information was first presented at the American Academy of Orthopaedic Surgeons' annual meeting.
Injuries of this type are usually the result of trauma that require emergency evaluation and treatment. The surgeon must quickly but thoroughly assess the extent of damage to the bones, soft tissues, nerves, and blood vessels in the leg. Knee dislocations are notorious for causing nerve injury even when the patella (knee cap) automatically reduces (goes back into place).
Tools used to conduct the evaluation begin with visual inspection (e.g., location of the injuries, signs of blood loss) and include testing for blood supply (e.g., Doppler, CT angiography, ultrasound). The presence of any damage to blood vessels or loss of blood supply to the area means a vascular surgeon must scrub up along with the orthopedic surgeon to perform the necessary procedures.
Before surgery can be done, X-rays and MRIs are taken to identify the extent of ligament injury (location and severity). This information helps the surgeon plan what must be done in the operating room. A plastic surgeon may be needed if there has been so much soft tissue damage that the wound can't be closed without a graft. Sometimes there are torn or ruptured ligaments that get put on the back burner (repaired later) because of the need to restore blood supply and save the leg first.
When it's clear that there are multiple ligaments torn, reconstruction (rather than just repair) of the ligaments is usually preferred. Studies show that the outcomes (in terms of symptoms, motion, and function) are better with reconstruction over repair in the management of such complex ligament injuries. In some cases (e.g., medial collateral ligament, four ligament ruptures), the failure rate is much higher (20 per cent) with repair versus reconstruction (only four per cent).
The authors provide detailed descriptions of surgical techniques used to accomplish this type of reconstructive surgery. Location and direction of incisions, source of tissue for grafts, tunnels for the graft tissue, graft positioning, and fixation of graft tissue are discussed. Drawings, X-rays, and color photos taken during surgery are provided to help instruct surgeons in understanding what is recommended for treatment of major injuries of this type.
Because there are many different surgical techniques possible for some of these injuries (e.g., posterolateral corner injury, multiple ligamentous damage), the authors also reviewed all of the evidence of what works best for each one. Preferred techniques and author recommendations are made.
One particularly challenging problem is fracture-dislocation of the patella with multiple knee ligament ruptures. The surgeon has to find a way to anchor the reconstructed ligaments to bones that are often broken into pieces and unstable. There aren't a lot of studies to show what works best for these types of complex injuries. In general, the results are poor no matter what efforts are made to stabilize the knee. Complications are also common (e.g., infection, pain, scarring).
Most of these complex injuries require staged procedures. That means everything that needs to be done can't be completed in one day or during one operation. They try and treat any fractures or dislocations the first day. Blood supply is restored and stabilized.
Reconstruction of soft-tissue injuries may be delayed for up to one week before the next stage of treatment can begin. Ligament reconstruction (phase three) takes place three to four weeks later. There may even be a stage or phase four if the knee is still unstable and further reconstruction is needed.
At that point, the main part of the surgeon's job may be done. Close monitoring and follow-up are the major focus now. But the patient's work has just begun. Rehab and recovery may take another set of stages over a period of weeks to months. The more damage present, the more extensive the surgery, and the longer the recovery time. Return-to-work and/or return-to-sports for athletes can be achieved with a work- or sports-specific rehab program.
The authors concluded by saying there is still much about the treatment of complex knee ligament injuries that remains unknown. Studies are small and reports of results are fairly limited. There is a need for comparison of various surgical techniques, the timing of surgery (early versus late), and optimal treatment and rehab protocols.
Gregory C. Fanelli, MD, et al. Management of Complex Knee Ligament Injuries. In The Journal of Bone & Joint Surgery. September 15, 2010. Vol. 92-A. No. 12. Pp. 2235-2246.
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