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IC 106-2023: Multiligamentous Knee Injuries- Every ...
IC 106 - Multiligamentous Knee Injuries- Everythin ...
IC 106 - Multiligamentous Knee Injuries- Everything You KNEED to know in 2023 (4/6)
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Good morning, everybody. Thanks for coming bright and early on the second day of the conference, I guess. My name is Mike Allais. I'm from NYU. We'll talk about my initial approach to the multiligament knee injury. We get to see a lot of these in Manhattan Tertiary Referral Center, Bellevue Hospital, Jamaica Hospital. So we see a lot of these hot traumas and try to impart some knowledge that I gained over the past several years doing a lot of these cases. So I'm going to break it down into like different points. So the first point that we should know is that a multiligament knee injury does not equal a knee dislocation. I mean, we have this classic historical way to just kind of shepherd all of our injuries into KD2, KD3, KD4. But that doesn't really truly estimate the level of the injury, because a knee dislocation obviously is going to be a lot more soft tissue trauma, potentially bony trauma, than just a simple multiligament knee injury where the ACL and the post-lateral corner are torn. So these are certainly not equal. We know that there's a lot more neurovascular compromise in patients that have sustained the true dislocation that require a reduction. Mike Medvecky and his group out of Yale published a great study in JBJS recently. Any knee that's dislocated, there's about a 40% chance of a nerve injury and almost a 20% chance of an arterial injury, as opposed to a non-dislocated knee that only has about a 4% chance of an arterial injury. So your level of suspicion on a true dislocated knee needs to be very, very high. And the other thing I would submit is that, is there such a thing as a spontaneous reduction? I would probably say that's pretty rare in a true knee dislocation, because the muscles go into spasm. There's that bayonet deformity. It's very hard for something like this to just spontaneously reduce. So I would challenge that. And I would also challenge it because of some of the data that we've been able to obtain over the past several years. If you look at the scan classification, KD1s, less than 20% of patients with a quote-unquote KD1 in terms of ACL, MCL, PCL, post-traumatic coronal will actually have a dislocated knee. And this was just published in OJSM. And we're also going to find out that the clinical outcomes are very, very poor when you look at a knee dislocation. This is a paper that we're going to have in submission very shortly, looking at patients with six and a half years of follow-up on KD3s, dislocated versus non-dislocated. In the IKDCs, the lysomes, the tegners were substantially lower in those patients that have sustained a true knee dislocation. So when you have these patients, counseling is key. And knowing about the potential outcomes are going to be key as well. When you confirm a dislocation, whether it be in your ER, et cetera, this means an overnight admission because some patients will present late with a compartment syndrome, with an arterial injury, et cetera. You have to do serial neurovascular exams. And if you teach residents or fellows or PAs, they have to document, document, document. Every two to four hours there needs to be a note in that chart documenting the neurovascular status because if you miss something like this, it's going to hose you in the end. And then ultimately I would say you have to get an x-ray before you discharge the patient if they're reduced in the brace because you have to make sure that the knee has maintained its reduction in the brace. This was a patient that we had at NYU and these are the images that were of the patient, what he was sent out in. So you can see that this knee is still subluxated. We had no documentation of concentric reduction in the brace. This is a patient that we had to call back in, make sure we get a brace on him that's a concentric reduction. Mega point number two is that these cases require rapid evaluation. Somebody calls you and says, hey, I've got a multi-ligament. It's fresh. It's two days old. This is not someone that you want to say, all right, send it to me in three weeks. No, you want to get them into your office, into your clinic right away because there's lots of things that you can do to expedite what's going to happen in these cases. So number one, you want to rule out bad things like neurovascular injury, but also extensive soft tissue injury. Look at the quality of the soft tissues. Look and see if there's any extraneous injuries. And then there are injuries that need prompt attention. Any injury like an extensor mechanism disruption, a bony injury, a fracture, bucket handle medial meniscus tears, lateral meniscus tears that require reduction, incarcerated collateral ligament injuries like this picture here where you can see an incarcerated MCL flipped underneath the meniscus and into the joint, as well as avulsions like fibulocollateral ligament where you get those cases where the entire postulata corner avulses as a sleeve. Those are cases that are easily fixable in an early fashion. And the sooner you see them, the earlier that you can start the treatment. And every day really does matter with this. And you sort of throw the kitchen sink at them. Early interventions like cryo, immediate physical therapy for quadriceps activation, range of motion in a brace if indicated, aspirate the knee, get the knee to be as biologically quiet as humanly possible as soon as you can. And then DVT prophylaxis. There have been papers showing a pretty high rate of DVT, anywhere up to 15 to 20% after a multiligament knee injury or a knee dislocation. So think about knee prophylaxis, especially in your patient with multiple medical comorbidities, morbid obesity, low velocity impact, et cetera. The goal here is to decrease the effusion and decrease the soft tissue swelling as soon as you can so that you can prepare them for surgery within two to three weeks. Now I'm not saying that every surgery has to be acute, but you should prepare them as if it's going to happen. The other thing you want to consider is that the earlier they present to you, the earlier you can get a multidisciplinary plan. If you have to talk to trauma, plastic surgery, general surgery, et cetera, the earlier they get into you is the earlier you can communicate with them and establish a good multidisciplinary plan. The other thing we want to look at is patient counseling because this is important. Trauma is no accident. And we say that all the time. You have to look at the social situation, the work obligations, the family obligations, access to postoperative care. I mean, in New York City we have a tremendously high rate of unemployed patients, Medicaid patients, et cetera. These are patients that might have a higher complication rate. So they're going to come into your office and you're going to be salivating because you've got this great case, and then you have to think about what they're going to deal with after the surgery, and that might change your tune a little bit. And Greg's work out of Geisinger, we know the finale says up to 25% are going to have arthritis at 10 years. So that's something that you've got to tell them. Point number three is that not all patients are created equal. We know that older patients do worse from Bruce's work over at Mayo Clinic and Critch. There's up to a 70% complication rate in patients in the morbidly obese. We know that from the Virgin group. Medicaid patients, noncompliant patients, smokers, diabetics, polytrauma, et cetera. Not every multiligament knee is created equal. When you look at the patient with the neurovascular injury, the nerve can actually tell you a fair amount of what's going on inside that knee. It can actually help predict the injury pattern. We've done some work in our own institution. If you look at a patient, they come in acutely with a foot drop. That's pretty much an ACL, posterolateral corner, unless proven otherwise. Over 95% of those patients are going to have an ACL tear with or without a posterior cruciate ligament injury and a posterolateral corner. A lot of them with a foot drop are going to have peroneal nerve displacement. So you're going to want to look for that on an MRI. That nerve is probably going to be displaced outside of its groove where it goes around the fibular head. If a patient comes in with a distal biceps injury that's retracted, assume that the nerve is going to be injured. Up to a 60% chance of a complete peroneal nerve palsy with an avulsion of the distal biceps. When you look at vascular injuries, these are obviously very, very much limb threatening. If you don't get in there acutely and perform a revascularization or the vascular team perform a revascularization within eight hours, there's almost a 90% amputation rate. This data has been corroborated by several studies and it's important to know because if you get in there late, the chances of an amputation are actually very, very high. If a revascularization is performed, our role is to externally fixate it to keep the knee stable for the vascular repair. Theoretically, in a perfect world, we're going to put the X-Fix on before the vascular repair because then the surgeons can rotate the leg internally and externally get access to that area and then do their repair in an expeditious fashion. You can still do a ligament repair acutely if you're doing a revasc, but I would caution you because most of these revascularizations are going to be done with a four compartment fasciotomy. There's going to be skin issues, soft tissue issues. So perhaps it might not be the best idea to do an acute repair, but if you're going to be staring right at the MCL from a medial approach done by the vascular surgeon, sometimes it's easy to just stick a few suture anchors in there if you have to. Revascularization should be delayed. Obviously you want the soft tissue to heal. You want to minimize leg manipulation, which brings me to my fourth point that if an arterial procedure has to be performed, you need to get a CT scan or an MR arthrogram prior to ligament reconstruction. And I can't really stress this enough because that artery is going to be in a different place than where you expect it. This is a case that required revascularization. He had a four ligament injury. He came to my office after he had the vascular repair performed. The angiogram showed that the repair site and the revasc site and the anastomosis was located directly over my medial incision for an MCL reconstruction. So this is a case where you have to get vascular surgery in there. They'll have to dopplegger the leg. They'll have to do the dissection and protect their repair throughout the entirety of it. So CT angiogram is necessary. When you talk about acute knee dislocations and indications to externally fixate, number one, obviously vascular injury. If you've got a patient that you can't maintain the reduction in, whether it be a small amount of subluxation or massive dislocation or displacement inside the brace, then obviously you're going to want to externally fixate that patient. Any patient that's morbidly obese, because a lot of these patients cannot tolerate a knee immobilizer or a drop-lock brace. Patients that are not going to comply with immobilization, schizophrenics, et cetera, I mean we see plenty of them in New York City. Externally fixating them is not a bad idea. Patients with significant soft tissue injury or fractures, like this patient on the right who sustained a mid-shaft tibia with a knee dislocation, those are ones that you're going to want to think about externally fixating. And then obviously your large open injury that's requiring serial washouts. Typically I'll take off the external fixator between two and four weeks. But I'll not keep them in there for longer than four weeks because you're going to get that patient really, really stiff. Once the patient comes out of the external fixator, I'll typically give them the quote unquote external fixator holiday until the motion is completely restored. Because a lot of times you can give it time to see what declares. So although it might be a four-ligament injury when it comes in, when you do your repairs that may or may not be necessary it might only be now a two-ligament injury. So you've got to see what declares. You can give it time. There's no rush to getting to these patients. It is also important to know and convey this to your trauma colleagues that a lot of patients can be successfully braced. And not every patient with a knee dislocation needs an external fixator. We see that all the time where a patient sustains a knee dislocation. They get brought to the OR. The trauma surgeon has put on an external fixator when the patient already had a concentric reduction. And now you've got decisions to make in terms of when to take the external fixator off, et cetera. So really touch base with the trauma team and orthopedics in terms of what you want to do for these patients. If they've got fractures you definitely have to figure out where the incisions are going to be, et cetera. When we talk about indications to stage, and I think the other guys are going to be talking more about this, number one is surgeon comfort. Number two, patient parameters. These large medial-sided blowout lesions, I tend to be a little bit more aggressive in terms of staging these because of the capsular injury. These are patients that get tremendously stiff. So if you want to go in acutely and do the MCL, you're more than welcome to do that. Let the motion come back. Let the knee declare and then you can come back for the cruciates at another time. Fractures and then extensor mechanism disruptions, you know, it's not the best idea in the world I don't think to do an extensor mechanism repair and a four-ligament knee reconstruction all at the same time. Those are the patients that are going to be excessively arthrofibrotic and you're probably going to regret doing that. And then my last point, unless there's an absolute indication for an early intervention, there's really no right answer in terms of the treatment of these patients. For me personally, my algorithm is to try and reduce or limit the number of rehabs. A lot of these polytraumas, you're not going to want to rehab them for two years. You try and get everything done early, so the rehab's about three to six months, and then they can hopefully go about the rest of their lives. If you delay them, remember that there's an issue with scarring of the soft tissue planes, but it does give the ligaments a chance to declare. So the other thing is stress radiographs, which we'll touch basically on here. I use these when the patient is anesthetized in an acute setting, and I'll also do it in the chronic setting when the patients don't have any pain, don't have any swelling that limits the ability of me to perform a good stress exam. This is a patient that the PCL scarred in nicely on. He's the 350-pound guy, tore his ACL, PCL, MCL, and LCL. And you can see that his PCL stiffened up over time. I was able to just do a three-ligament reconstruction and not have to go in the back on a morbidly obese guy. So it made my life a little bit easier. And then obviously expect the unexpected. Attention to detail is very, very important for these cases. Every case is a learning opportunity. No multi-ligament knee injury or knee dislocation is the same. Always ask your question, how could I have done this better? The more you regroup and reload after this and talk to your team about what went right and what went wrong is going to actually make you a lot better at these. The literature is great, but most of our literature unfortunately is plagued by Level 4 evidence. So literature on these can only help so much. Experience is helpful. Pick up the phone, call a friend, call another partner for help. And always expect the unexpected. That 350-pound guy that we just did four weeks ago showed up into my office, didn't have a brace on. All his incisions are healed. He's walking on it, not complying with anything. And you're like, all right, I'm screwed. Range of motion is actually 0 to 100, and he's got perfect stability. And you're just wondering, what the hell? How did this happen? You expect that guy to be revised. But every case is a learning opportunity to figure out what the heck is going on here. But that's really all I've got for you. We'll continue with the other talks, and thank you for your attention.
Video Summary
In this video, Dr. Mike Allais from NYU discusses his approach to multiligament knee injuries. He emphasizes that a multiligament knee injury does not necessarily mean a knee dislocation and that a true dislocation requires higher suspicion due to potential nerve and arterial injuries. Dr. Allais also highlights the importance of rapid evaluation, indications for external fixation, and the need for a CT scan or MR arthrogram before ligament reconstruction in cases of arterial injury. He concludes by emphasizing the need for individualized patient counseling and learning from each case.
Asset Caption
Michael Alaia, MD
Keywords
multiligament knee injuries
knee dislocation
nerve and arterial injuries
rapid evaluation
external fixation
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