Evolving Technique Update The Dislocated Knee: My Algorithm for Success What Has Worked For Me 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 2013 • Multiple Ligament Injured Knee Textbooks 2 nd Edition – Innomed • Stock options: None • Consultant: – Biomet Sports Medicine • PCL ACL Instrumentation System 2015 • Speaker 2 nd Edition – Conmed • Speaker • Research support: None • Educational support: None • Other support: None GC Fanelli
1. Multisystem Injury Complex • Ligaments: • Bones – ACL – Tibia – PCL – Femur – PLC – Patella – LCL – Pelvis – MCL – Spine – PMC • Head Injury • Vessels: – H.O. – Popliteal artery – Spasticity – Popliteal vein • Other Organ System • Skin Trauma • Nerves: – Tibial – Peroneal GC Fanelli
1. Multisystem Injury Complex GC Fanelli
1. Not all knee dislocations are equal Surgical Timing Acute KD GC Fanelli
1. Surgical Timing Acute KD Modifiers-Considerations • My preferred approach – Single stage procedure – Within 2 to 4 weeks of the initial injury • 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 – Visceral trauma • Take home message: – Ideal surgical timing is not always possible – External fixation GC Fanelli
1. External Fixation GC Fanelli
2. Control the Posteromedial and Posterolateral Corners Most of the Time Hyperextension (+ Heel Lift Off) +/- Interference Screw Tibia Fibula Joint Injury Revision PLR Lateral Posterolateral Capsular Shift and/or Reattachment Always Peroneal Nerve Decompression Always Screw and Washer Allows Adjustability GC Fanelli
2. Control the Posteromedial and Posterolateral Corners GC Fanelli
2. Control the Posteromedial and Posterolateral Corners Screw and Washer or Adductor Magnus Loop Posteromedial Capsular Shift and/or Reattachment Always GC Fanelli 9. Surgical Technique
High Grade Acute Medial Side Tear 2. Control the Posteromedial and Posterolateral Corners GC Fanelli
3. Allograft and Autograft Both Successful in PCLR/MLR • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. Arthroscopy, 1996; 12(1):5-14. • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted PCL/posterior lateral complex reconstruction. Arthroscopy,, 1996; 12(5):521-530. • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up. Arthroscopy,, 2002; 18(7):703-714. • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. Arthroscopy,, 2004; 20 (4): 339- 345. • Fanelli GC, Tomaschewski D. Allograft use in the treatment of the multiple ligament injured knee. Sports Medicine and Arthroscopy Review, 2007; 15 (3):139-148. ( Allograft efficacy ) • Fanelli GC, Edson CJ. Surgical treatment of combined PCL, ACL, medial, and lateral side injuries (global laxity): surgical technique and 2 to 18 year results. Journal of Knee Surgery, 2012; 25 (4):307-316. • Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically treated knee dislocations: stability restored, but arthritis is common. Clinical Orthopaedics and Related Research, 2014; 472 (9):2712-2717. • Fanelli GC, Fanelli DG, Edson CJ, Fanelli MG. Combined anterior cruciate ligament and posterolateral reconstruction of the knee using allograft tissue in chronic knee injuries. Journal of Knee Surgery, 2014; 27(5):353-358. • Autograft-allograft, acute-chronic – No statistically significant difference • KT 1000, stress x-ray, HSS, Lysholm, Tegner • Long term results MLIK – Static stability retained • Physical examination, KT 1000, stress x-ray • 18 to 22 years post op Graft Selection GC Fanelli
4. PCLR SB v DB Single vs. Double Bundle PCL Reconstruction Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft tissue. Journal of Knee Surgery, 2012; 25 (1):59-64 • DB reconstructions • SB reconstructions • PCL PL 11 • PCL PL 20 • PCL PM 0 • PCL PM 1 • PCL PL PM 9 • PCL PL PM 2 • ACL PCL PL 11 • ACL PCL PL 12 • ACL PCL PM 5 • ACL PCL PM 2 • ACL PCL PL PM 8 • ACL PCL PL PM 8 • ACL PCL 1 • Total 45 • Total 45 SB BC/KD 22 DB BC/KD 25 No isolated PCL tears GC Fanelli
Single vs. Double Bundle PCL Reconstruction Return to Pre-Injury Level of Function Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft tissue. Journal of Knee Surgery, 2012; 25 (1):59-64 Overall Group Single Bundle 34/45 75.6% Double Bundle 30/45 66.7% p = 0.358 PCL Collateral Single Bundle 20/23 86.9% Ligament Group Double Bundle 15/18 83.3% P = 0.756 Bi-cruciate Group Single Bundle 17/22 73.3% Double Bundle 21/25 84.0% P = 0.572 No SS difference GC Fanelli
4. PCLR Vascular Considerations Know graft location preoperatively PCL ACL Lateral Medial PA tear Gortex Arterial Graft Vascular Repair Vein Graft Kim, Ann Surg, 1989, 210 (6):776-781 ORIF Tibial Plateau Fracture • 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 Butt, J Arthroplasty, 2010, 25 (8):1311-1318 – Normal PA branching 88.1% • 12% of popliteal arteries may have abnormal branching GC Fanelli
4. Mechanical Graft Tensioning • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up. ARTHROSCOPY, 2002; 18(7):703-714. • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. ARTHROSCOPY, 2004; 20 (4): 339-345. • Fanelli GC, Edson CJ, Orcutt DR, Harris JD, Zijerdi D. Treatment of combined ACL-PCL-MCL-PLC injuries of the knee. JOURNAL OF KNEE SURGERY, 2005, 18 (3):240-248. •Normal posterior drawer •(KD) without boot 46% •(KD) with boot 86.6% •(PCL PL) without boot 70% •(PCL PL) with boot 91.7% • PLI and PMI corrected in all series GC Fanelli
Surgical Technique When There Are Open Growth Plates • PCLR SB TTT ATAL FF without bone plug – Femoral tunnel crossed the physis – Cortical suspensory fixation stacked polyethylene buttons – Tibial tunnel below physis • Bioabsorbable interference screw (cortical margin) • Cortical suspensory fixation screw and spiked washer – No fixation device crossed the growth plates • ACLR TTFT • ATAL • Trans physeal tunnels • PLR – FHBF8 STAL + primary repair + capsular shift – Common biceps tendon loop and suture fixation • No fibular head drill holes or hardware distal lateral femur • PMR – Primary repair or posteromedial capsular shift + STAL – Tibial side screw and washer, femoral side AM loop and suture • No fixation device crosses physis • Procedure determined by stage of physeal development PCL Based Multiple Ligament Knee Injuries in Patients 18 Years of Age and Younger Fanelli GC, Fanelli DG. Knee dislocations in patients 18 years of age and younger. Surgical technique and outcomes. Journal of Knee Surgery, 2016; 29(4): 269-277. GC Fanelli
5. Post Operative Rehabilitation Program • Full extension long leg brace • Crutch ambulation – NWB 3 to 5 weeks • Progressive ROM – POW # 3 to POW # 5 • Progressive weight bearing – POW # 3 to 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) Edson, Fanelli, Multiple Ligament Injured Knee, Fanelli (Ed), Second Edition, Springer, 2013 GC Fanelli
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