25e Journée de la Recherche POES Evaluation of reconstructive surgery using artificial ligaments in 71 acute knee dislocations. 25e Journée de la Recherche POES Montreal 2005

Authors Philippe Dahan M.D. Eros De Oliveira Pht. Julio Fernandes M.D. Greg Berry M.D. Max Talbot M.D. Pierre Ranger M.D.

G Mondor.S.

KNEE DISLOCATION CATASTROPHE

KNEE DISLOCATION Reconstructive surgery gives better results! (Debmond and al. Am J Knee Surg 2001) Early reconstruction better than late !! (Wascher and al. Am J Sports Med 1999) NO CONSENSUS on surgical treatment !! What to reconstruct? ACL? PCL? 1 or 2 bundles? Allograft vs. Autograft vs. Synthetic The Feared Complication: Arthrofibrosis (ankylosis)

KNEE DISLOCATION OBJECTIVES ARE FULFILLED : USING SYNTHETIC OBJECTIVES ARE FULFILLED : Reduction (recentered knee) Fixation (no harvest) Immediate mobilization Scaffolding (collagen growth) (Healing potential of different structures...)

Ligament Advanced Reinforcement System LARS Ligament Advanced Reinforcement System

Objective H.S.C. Montreal: 6/96 9/04 The purpose of this study is to evaluate the outcome and survival of acute cruciate reconstruction using LARS ligaments after knee dislocations.

H.S.C. Montreal: 6/96 9/04 1 patient had normal ACL & PCL 71 ACUTE KNEE DISLOCATIONS 10 patients excluded: 1 patient had normal ACL & PCL 1 patient had TKR 8 patients lost to follow-up

H.S.C. Montreal: 6/96 09/04 61 patients 47 ♂ 14 ♀ Mean age: 36.1 years 2 bilateral injuries 63 knee dislocations 61 patients 47 ♂ 14 ♀ Mean age: 36.1 years

63 knees 61 patients reviewed 46 High velocity = 15 Low velocity =

Management All patients managed initially according to ATLS. Arthrotomy, primary repair and reconstruction of ACL, PCL (1 vs. 2 bundles), PLC and Collaterals using LARS. Intensive rehabilitation protocol in post-op. (Richter and Al. “..most important prognostic positive prognostic factor.”Am J Sports Med 2002)

Time from trauma to surgery All surgeries were performed in a acute setting (< 6 wks) Average time from injury to surgery = 12,2 days

FOLLOW UP 2 to 6 months = 14 pts. 6 months to 2 years = 18 pts.

EVALUATION Range of Motion TELOS Questionnaires: LYSHOLM IKDC 2000 knee* SF-36 quality of life* A.C.L. P.C.L. at 20° and 90° of flexion * (usually used to evaluate reconstruction of a single knee ligament injury)

RESULTS

Range of motion X Motion Flexion Extension normal + 130.7° - 2.0° injury + 120.2° - 1.1°

ROM

Laxity

Laxity

Laxity

Laxity

LYSHOLM RATING SCALE TOTAL = 100 Instability (25) Pain (25) Locking (15) Swelling (10) Stairs (10) Squatting (5) Limping (5) Walking aid (5) (cane,crutches) TOTAL = 100

Questionnaires (n=46) (n=46) (n=46)

Questionnaires AVERAGE

KNEE DISLOCATION DISCUSSION The only statistical difference (p<0.05) found was on IKDC scores only.

KNEE DISLOCATION DISCUSSION ROM We did not show significant loss of ROM using LARS artificial ligament for acute reconstruction of knee dislocation.

This stability seem to persist over time. KNEE DISLOCATION DISCUSSION STABILITY Laxity exams showed good anterior and posterior stability when using LARS for reconstruction of acutely dislocated knees. This stability seem to persist over time. The 2 bundles PCL reconstruction technique seems to give better posterior stability.

FUNCTION and QUALITY of LIFE KNEE DISLOCATION DISCUSSION FUNCTION and QUALITY of LIFE Patients seem to subjectively get better with time even though knee dislocation is seen as a catastrophe when it happens. Comorbidity can partially explain the lower scores. The Lysholm scale seems to be a good questionnaire to evaluate knee disocations. Additional evidence of the validity of the IKDC scale for knee dislocation is necessary. (Harner et Al. JBJS 2004)

KNEE DISLOCATION CONCLUSION Complete total knee dislocation treated acutely with LARS artificial ligaments seems to give: • good objective results (laxity evaluation and R.O.M.) • good subjective results (Lysholm)

Results seem to be constant with time. KNEE DISLOCATION CONCLUSION Results seem to be constant with time.

KNEE DISLOCATION Min. 10 yrs follow up to evaluate LARS durability. FUTURE RESEARCH Min. 10 yrs follow up to evaluate LARS durability. Compare 1 and 2 bundles PCL reconstruction for posterior laxity. Corellations with e.g. type of injury, comorbidity, age….

Thank You

References Talbot M, “Knee dislocations: experience at the Hôpital du Sacré-Cœur de Montréal”, J Can Surg 2004 Debmond BT, “Operative treatment of knee dislocations: a meta-analysis”, Am J Knee Surg 2001 Wascher DC, “Reconstruction of anterior and posterior cruciate ligaments after knee dislocation: results using fresh-frozen irradiated allografts” Am J Sports Med 1999 Richter M, “Comparison of surgical repair or reconstruction of the cruciate ligaments vs. nonsurgical treatment in patients with traumatic knee dislocation” Am J Sports Med 2002 Harner CD, “Surgical management of knee dislocations” JBJS Am 2004

References Yeh WL, “Knee dislocations: treatment of high-velocity knee dislocation” J Trauma 1999 Jardin C, “Fiabilité de l’arthromètre KT-1000 pour la mesure de laxité antérieure du genou: analyse comparative avec le Telos de 48 reconstructions du ligamnet croisé antérieur et reproductibilité intra- et interobservateur” Revue de Chirurgie Orthopédique 1999 Wong CH, “Knee dislocations: a retrospective study comparing operative vs. closed immobilization treatment outcomes” Knee Surg, Sports Trauma, Arthroscopy 2004

Laxity

Laxity

Laxity

Post-Op Intense Protocol Hinged brace for collaterals NWB 6 wks ROM first, Strenght after. Followed by proprioception and sports training.