Knee Dislocations—What is the Best Treatment?
Abstract & Commentary
Synopsis: Surgical repair or reconstruction of the cruciate ligaments in patients with traumatic knee dislocations is superior to nonsurgical treatment.
Source: Richter M, et al. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30(5):718-727.
Traumatic dislocation of the knee, which typically involves damage to both the anterior and posterior cruciate ligaments, is more severe than the more common isolated rupture of a cruciate ligament. The present study evaluates the difference between surgical repair or reconstruction vs nonsurgical treatment.
This was a retrospective study of 89 patients treated for traumatic knee dislocation. To be included, the dislocation had to be traumatic as documented by photograph or radiograph, or involve a complete rupture of the ACL, PCL, and medial and/or lateral collateral ligament. Only patients with at least 2 years of follow-up were included. All patients were examined clinically including KT-1000 arthrometer assessment (Medmetric, San Diego, Calif) of cruciate ligament stability (using the Lachman and inverse Lachman tests) and radiographs. The Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and ability to do work or participate in sports were used to determine outcome. The Jager and Wirth radiologic rating scale was used to measure knee osteoarthritis.
Of the 89 patients evaluated, surgical repair or reconstruction of the cruciate ligaments was performed on 63 (49 repairs and 14 reconstructions; 71%). In the remaining 26 patients (26%), no ACL or PCL repair or reconstruction was performed. A total of 27 patients (30%) underwent a functional rehabilitation program, including none of the patients in the nonsurgical group but all of the patients with cruciate reconstructions (14). Sixty-two patients (70%) were treated with an immobilization regimen.
At an average follow-up of 8.2 years, the outcome in the surgical group was better than for the nonsurgical group in all measured respects as follows: Lysholm score (P = 0.001), Tegner score (P < 0.001), IKDC activity level (P = 0.05), Jager and Wirth (P = 0.002), Lachman (P < 0.001), inverse Lachman (P = 0.02), working ability (P = 0.006), and sports ability (P = 0.004). Within the surgical treatment group, there were no differences observed between cruciate ligament reconstruction and transosseous fixation (P > 0.05). However, transosseous fixation produced better outcomes than did ligament-to-ligament sutures.
Additionally, better outcomes were found in those patients who were 40 years old or younger, had sports injuries as opposed to motor vehicle accident injuries, and had undergone functional rehabilitation instead of immobilization.
Comment by Brian J. Cole, MD, MBA and Nina Shervin
Although there is an increasing incidence of traumatic knee dislocations due to increased sports participation and the continuing high rate of vehicular trauma, the recommended treatment options are controversial in some centers. The present study sought to evaluate the influence of surgical treatment (reconstruction or repair) vs nonsurgical treatment, as well as other prognostic factors. Surgical treatment is the prevailing option, although earlier studies have reported good results in nonoperative treatment in patients with closed knee dislocations and no associated neurovascular injuries. The findings of this study suggest that traumatic knee dislocations should be treated surgically, but given the large number of varying factors, the method of cruciate ligament restoration should not be overestimated. In particular, a functional rehabilitation regimen, which requires the high primary stability provided by surgical treatment, should be considered. We agree that surgical treatment is generally the optimal treatment option for the traumatic, multiligament injured knee.
Dr. Cole is Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL.