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GC Fanelli

The Knee Dislocation 20 Years Later: What I Have Learned,

I Get It Stable, But Do I Solve The Arthritis Problem

Practical Manage of the Multiple Ligament Injured (Dislocated) Knee

Gregory C. Fanelli, M.D.

115 Woodbine Lane

Danville, PA 17822-5212

570-271-6700

gregorycfanelli@gmail.com

GC Fanelli

Disclosure • Royalties:

– Springer

• PCL Textbooks

• Multiple Ligament Injured Knee Textbooks

• Stock options: None

• Consultant:

– Biomet Sports Medicine

• PCL ACL Instrumentation System

• Speaker

– Conmed

• Speaker

• Research support: None

• Educational support: None

• Other support: None

GC Fanelli

1. Vascular Assessment Acute MLIK

• Incidence 1.6 to 50% (Whalen, Green, Welling)

• Bicruciate tears = TF Dislocation (Wascher)

• Beware post traumatic DVT

• Hyperextension – Anterior

– Popliteal artery stretch • Arterial rupture

• Dashboard knee – Posterior

• Arterial contusion (intimal damage)

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• What to do:

• Physical exam + ankle brachial index

• Abnormal pulses or ABI < 0.9

– Arteriography, MRA, CTA

• Mills, J Trauma, 2004

• Non flow limiting intimal tear

– Observe

– No tourniquet during surgery

– Vascular surgery available • ABI = doppler systolic arterial pressure in injured limb (ankle) /

doppler systolic arterial pressure in uninjured limb (brachial)

1. Vascular Assessment Acute MLIK

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Popliteal Artery Variations • Keser, Arthroscopy, 2006; 22 (6):656-659

– PA lateral to central axis 94.3%

– PA on central axis 5.7%

• Kim, Ann Surg, 1989, 210 (6):776-781

– Normal PA branching 92.2%

– PA variants 7.8%

– High origin of anterior tibial artery 72% of the 7.8%

• Butt, J Arthroplasty, 2010, 25 (8):1311-1318

– Anterior tibial artery anterior to popliteus muscle 2.1%

• Mavili, Diagnostic and Interventional Radiology, 2011;

17:80-83

– Normal PA branching 88.1%

• 12% of popliteal arteries may have abnormal branching

GC Fanelli Kim, Ann Surg, 1989, 210 (6):776-781

Butt, J Arthroplasty, 2010, 25 (8):1311-1318

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PCL ACL Lateral Medial PA tear

Vascular Repair Vein Graft

ORIF Tibial Plateau Fracture

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2. Peroneal Nerve Injury

• Incidence as high as 50% KDs

• Contributes to poor outcomes

• Nerve repair:

– Small gap, minimal tension, end to end repair

• Nerve grafting:

– Graft length main predictor of outcome

– Successful functional recovery (Kim, Neurosurgery, 2004)

• < 6 cm, 75%

• 6 to 12 cm, 38%

• 13 to 24 cm, 16%

• Our preferred treatment :

– Peroneal nerve neurolysis

– Serial EMGs after 1 month

– Posterior tibial tendon transfer

• Predictable functional recovery (Cush, SMAR, 2011)

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• Exam under anesthesia assisted with

flouroscopy

• Anterior posterior translation

• Hyperextension

• Varus and valgus laxity

• Determine stable hinge

• Beware axial rotation

• Diagnostic arthroscopy

3. Correct Diagnosis

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• Indications (Stuart, Op Tech Sports Med, 2001)

– Open dislocations

– Vascular repair

– Inability to maintain reduction

• External fixator vs. brace (Khanna, Levy, AANA, 2008) • Preoperative spanning external fixation

• Post op, no SSD, IKDC, Lysholm, manipulation

• ROM external fixator: 102` flexion

• ROM brace: 129` flexion

• P = 0.02

• External fixation group more complex cases

• Post operative external fixation (Compass Knee Hinge )

• Stannard, JBJS, 2014 – Recurrent instability

» Brace 27%

» CKH 4%

» P < 0.05

• Take home message

– Control the knee in a brace, use the brace

– Cannot control the knee in a brace, use external fixation

4. External Fixation

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Ultra Low Energy Injury

• 34 year old female

• 5’4”, 460 pounds

• Slipped on a wet floor in

her kitchen

• Twisting injury to the right

knee

• Acute tibial femoral

posterior dislocation

• Arteriogram negative

• Nerve function intact

• ACL PCL Lateral Side

tears

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4. External Fixation

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• Vascular status

• Medial and lateral side injury severity

• Degree of instability

– Reduction stability

• Delayed or staged reconstruction 2-3 weeks-less

postoperative motion loss

– Fanelli, Arthroscopy, 1996, 2002, 2005, JKS 2005, JBJS 92

A 2010

– Wascher, Arthroscopy, 1999

– Mook, Miller, JBJS 91 A, 2009

• My preferred approach

– Single stage procedure

– Within 2 to 4 weeks of the initial injury

5. Surgical Timing Acute MLIK

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5. Surgical Timing Acute KD Modifiers-Considerations • Vascular injuries

• Irreducible dislocations

• Open injury

• Skin condition

• Extensor mechanism disruption

• Reduction stability

– Collateral ligament injury severity

• Fractures and articular surface injuries

• Other orthopaedic injuries

• Multiple system injuries

– Head trauma

• Take home message:

– Ideal surgical timing is not always

possible

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6. Repair or Reconstruct, Graft Source

• PCL ACL reconstruction (allograft, autograft)

– No SSD between allograft and autograft (Fanelli, Arthroscopy, 1996, 2002)

– Bony/soft tissue avulsions (Beware interstitial ligament damage)

• Posterolateral corner

– Stannard, AJSM, 2005 • Repair only, 37% failure

• Repair + reconstruction, 9% failure

– Levy, AJSM, 2010 • Repair only, 45% failure

• Posteromedial corner

– Levy, AANA, 2008

• Repair only, 29% failure

– Stannsrd, AOSSM, 2009

• Repair only, 20% failure

• Autograft reconstruction, 3.7% failure

• Allograft reconstruction, 4.8% failure

• Take home message

– Posterolateral and posteromedial primary repair with augmentation / reconstruction provides better success than primary repair alone

– Allograft and autograft are both successful

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7. Arthroscopic or Open PCL ACL Reconstruction?

Single v Two Stage

Single Stage Open

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7. Arthroscopic or Open PCL ACL Reconstruction?

Single Stage Open

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7. Arthroscopic or Open PCL ACL Reconstruction?

Single Stage Open

GC Fanelli 7. Arthroscopic or Open PCL ACL Reconstruction?

Single v Two Stage

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Stage 1

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Stage 2

• Take home message:

– Everyone of these cases is different

– The central pivot disruption is relatively constant

– The medial side, lateral side, extensor mechanism injury

severity determines the surgical approach

• Arthroscopic

• Open

• Single stage

• Two stage

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Patient Positioning \ Set Up PCL/ACL Reconstruction

8. Surgical Technique

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PCL Reconstruction Transtibial Technique

Posteromedial Safety Incision Protect the neurovascular structures!

8. Surgical Technique

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PCL Reconstruction

8. Surgical Technique

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ACL Reconstruction 8. Surgical Technique

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Tensioning and Fixation

• Graft tensioning – Graft tensioning boot

– MLIK set 0` (PCL and ACL)

– Full Arc Dynamic Tensioning

• Final fixation flexion angle – PCL DB and SB 70`- 90`

– ACL 20 - 30`

• Full ROM

• Lateral and medial sides (30`)

• Primary fixation – Resorbable interference screw

– Aperture opening

• Back-up fixation – Button

– Spiked ligament washer

8. Surgical Technique

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Lateral Posterolateral Capsular Shift and/or Reattachment Always

Peroneal Nerve Decompression and Neurolysis Always

Most of the Time

=/- Interference Screw Hyperextension (+ Heel Lift Off)

Tibia Fibula Joint Injury

Revision PLR

8. Surgical Technique

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8. Surgical Technique

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Medial Posteromedial Reconstruction

Posteromedial Capsular Shift

and/or

Reattachment

Always

Screw and Washer

or

Adductor Magnus Loop

8. Surgical Technique

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High Grade Acute Medial Side Tear

8. Surgical Technique

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• Full extension long leg brace

• Crutch ambulation – NWB 3 to 5 weeks

• Progressive ROM – POW # 3 or POW # 5

• Progressive weight bearing – POW # 3 or POW # 5

• Progressive ROM, strength, proprioceptive skills training

• Sports / heavy work in 12 months – Strength, ROM, proprioceptive skills

• Functional brace (may protect collateral ligament complex)

• Must observe carefully and individualize – Get a “feel for the personality of the knee”

– ROM under anesthesia

Edson, Fanelli, Beck. Postoperative rehabilitation of the MLIK

Sports Medicine Arthroscopy Review, 2011, 19 (2)

9. Post Operative Rehabilitation Program

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10. Outcomes: What To Expect Long Term

• Fanelli, Edson, Giannotti. AA combined ACL PCL reconstruction.

Arthroscopy, 1996

• Fanelli, Edson. AA assisted combined ACL PCL reconstruction. 2-10

year results. Arthroscopy, 2002

– No graft tensioning boot

• Fanelli, Edson, et al. Treatment of combined ACL PCL MCL PLC

injuries of the knee. J Knee Surgery, 2005

– Tensioning boot utilized

• Fanelli, Beck, Edson. Single compared to double bundle PCL

reconstruction using allograft tissue. J Knee Surgery, 2012

• Fanelli, Edson. Combined PCL ACL lateral and medial side (global

laxity) reconstruction. Technique and 2 to 18 year results. J Knee

Surgery , 2012

• Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically

treated knee dislocations: stability restored, but arthritis is common.

CORR, 2014

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• Autograft-allograft, acute-chronic

– No statistically significant difference • KT 1000, stress x-ray, HSS, Lysholm, Tegner

• Mechanical graft tensioning boot (Biomet)

– Without boot 46% normal posterior drawer

– With boot 87-92% normal posterior drawer

– PLI and PMI corrected in both series

• SB vs DB PCL Reconstruction

– No statistically significant difference

• Static stability (stress x-ray [2.56mm and 2.36 mm], KT 1000)

• Return to pre-injury level of function (73 to 84%)

• Long term results MLIK

– 60% return to pre-injury level of function (Tegner) • 93% same or one Tegner grade lower level of activity

– 23 to 30% rate of degenerative joint disease

– Static stability retained • Physical examination, KT 1000, stress x-ray

• 18 to 22 years post op

10. Outcomes: What To Expect Long Term

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• Rom: R 0-112°, L 0-105°

• KT 1000 (mm excursion)

– PCL screen L=0, R=1, SSD=1

– Corrected Posterior L=1, R=2, SSD=1

– Corrected Anterior L=2, R=1, SSD=1

– 30° ADM 30# L=10, R=11, SSD=1

• HSS L 92/100, R 87/100

• Lysholm L90/100, R 95/100

• Tegner 4, preinjury 4-5

10. Outcomes: What To Expect Long Term

Seven Years s/p Bilateral Knee Dislocations

GC Fanelli 22 Years Post Op PCL ACL PL PM Reconstruction

10. Outcomes: What To Expect Long Term

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Gregory C. Fanelli, M.D.

115 Woodbine Lane TYJ

Danville, PA 17822-5212

570-271-6700

gregorycfanelli@gmail.com

2013 2015