Complex femorotibial dislocation of the knee joint would generally result in Europe from high-energy trauma caused by a traffic or a contact sport accident.
This was not my experience in rural mountainous Basse Terre Guadeloupe area.
Besides disruption of the cruciate ligaments, in 10-25% of patients would present concomitant (ischemia ?) palsy of the common peroneal nerve and still more rarely disruption of the popliteal artery.
The purpose of this short article is to assess outcome in a monocentric consecutive series of two cases of low energy knee dislocations with total ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.
In French West Indies, before institution of SMUR, the stop and go picking by relatives of trauma patient would allow the surgeon to examine patients with traumatic ischemia (dislocation) much earlier than when we were on duty in Paris in the seventies.
So whereas many popliteal vascular disruption could not be managed before the fourth hour in Paris, in Basse Terre, whatever the education of the resident, I was able to examine all traumatic ischemia (1983-1989, 120 000 inhabitants) in due time, at least before SAMU and regulation bureaucratic Institution…
This retrospective series includes one man and one woman, aged 28 and 45 years.
The left knee was injured in both.
Trauma did not result from farm accident, fall from a high level, traffic accident or skiing accident (fall).
The woman was 7 months pregnant.
Both were fall victims.
There was no morbid obesity.
Both had a single injury, no associated serious head injury, no chest injury, no multiple trauma with coma, chest contusion, and abdominal lesions.
No patient had fracture.
No dislocation was open.
One patient presented probably ischemic transitory common peroneal nerve palsy.
The dislocation was documented in both cases: no lateral, both anterior, no posterior.
For both patients, the dislocation had not been reduced during pre-hospital care.
In one case (the pregnant woman), it is the radio technician who called me, very early in the morning, after the Clermont-Ferrand educated resident had gone back to breakfast…
My first step was to start at once shaving controlateral leg (waiting for the wandering resident).
Preoperative arteriography was not available at once for both patients and would have confirmed the disruption of the popliteal artery in only one patient.
Many years later, fortunately, a important US study would confirm the risk of “waiting” for imaging angiography in those pure sagittal dislocations…
The total ischemia and anterior pure sagittal dislocation diagnosis was obvious in both patients and I directed both immediately to the operative theatre without pre-operative imaging,
Revascularization was achieved with a lower femoral-lower popliteal EXCLUSION bypass using an inverted saphenous graft, thanks to Edouard Kieffer‘s 1975 personal teaching.
The graft was harvested from the controlateral greater saphenous.
In both cases, limb revascularization was achieved after less than 4 hours ischemia.
Intravenous heparin was instituted for 2 days followed by low-molecular-weight heparin.
The dislocation was secondarily stabilized by a cast in both.
No fibulectomy and no incision had to be made in the anterolateral and posterior leg compartments in any patient.
No revision procedure was necessary because of recurrent ischemia. No thin skin grafts were used (no aponeurotomy surfaces).
Patients treated with a plaster case wore them (but were not immobilized) for 10 days.
Surgical ligament repair was not performed in these two patients.
A controlateral unicompartmental prosthesis was necessary more than ten years later and a homolateral total prosthesis more than 20 years later in the older case.
One of my good old friends, spine surgeon, told recently (september 2008) of superior long term good results of conservative knee dislocation followed up in one relative’s knee…
Absence of the ligament repair probably led, however very lately, to arthroplasties (first controlateral) in our still very active farmer.
Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in both patients.
No transient acute renal failure required.
Pregnancy ended normally…
No patients developed any pin track discharge (no pin) and there was no case of septic arthritis of the knee joint.
Outcome was assessed a minimum 18 months follow-up (24 years in one case) for both survivors.
Both patients treated by immobilization without a second surgical procedure did not complain of joint instability without any major clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.
An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma.
The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation may be between 4 and 20%.
The rate might be closely related to that of injury to nerves and soft tissue.
Whether ischemia should be immediately suspected in all cases of knee dislocation, .
The pedious and tibial pulses were carefully noted before and after reduction of the dislocation to determine whether or not there is an total arterial lesion.
If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction.
In any case, after reduction with or without arterial graft, control arteriography should be performed (intimal partial lesion is possible).
Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture.
Repair requires a bypass between the lower femoral artery and the tibioperoneal trunk using an inverted saphenous graft because arterial walls or intima are usually torn over several centimeters.
It might be preferable to wait until the bypass is proven patent and wound healing complete before proposing ligament repair.
This should be done after a precise anatomic work-up to assess each ligament lesion.
Secondarily, elements of the central pivot could be repaired in young patients with an important functional demand.
Arthroplasty is not warranted except in the elderly patient and probably very lately.
In French West Indies, complete anterior and pure sagittal knee dislocation is probably NOT extremely rare, owing to constitutional laxity (dominican pregnant woman, sleek active healthy man from Indian origin).
It might also be in 2009 caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy.
Compression, contusion or disruption of the popliteal artery is not so rarely caused by low energy anterior displacement of the tibia on the femur.
Limb survival may be compromised.
Mandatory emergency restoration of blood supply would possibly modify immediate and subsequent surgical strategies.
There has not however been any study exclusively devoted to double joint and vascular involvement.
This article of mines presents a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single rural center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.
