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- Implies difficult closed reduction, will require open reduction. Approach?
- Likely direct incision (anteromedial approach) over pucker to reduce
Pucker sign.pdf17017.3KB
- Need to rule out COMPARTMENT SYNDROME
- Need to assess carefully for NEUROVASCULAR injuries
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- Anterior - most common 40% [Anterior associated with popliteal vessel traction injury, posterior associated with complete rupture of popliteal artery]
- Lateral
- Medial
- Posterior
- Rotatory
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- KD1 = ACL or PCL only
- KD2 = ACL and PCL
- KD3 = ACL and PCL + one collateral
- KD4 = all 4
- KD5 = + fracture
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- Tethered at 3 areas:
- Adductor hiatus
- Popliteal fossa
- Soleus Arch
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- Common peroneal nerve - 25%
- Prognosis is poor - only 50% recovery
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- Controversial
- "I will discuss with my vascular colleagues and monitor with serial PE and ABPI for at least 48 hours in these patients."
- Study by James Stannard et al. JBJS 2004 examined 138 knees with 10 having abnormal PE findings. 9 of these had flow-limiting popliteal artery damage (i.e., 1 false positive).
- Paper concluded that selective arteriography based on serial PE is a safe and prudent policy. Strong correlation exists between PE results and need for arteriography. Increased vigilance is justified for patients with KF-4 dislocation.
- Another study by Weinberg et al. found that a combination of palpable dorsalis pedis and posterior tibial pulses combined with an ABPI of > 0.9 was 100% sensitive for ruling out vascular injury.
- For KD-4 dislocations - perform serial PE for at least 48 hours.
Stannard.pdf254.4KB
weinberg.pdf422.5KB
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- History of ischemia at any point (before or after reduction) - weak pulses or loss of CRT
- ABPI < 0.9
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- Popliteal Fossa Approach (to Popliteal Artery)
- Position - prone
- Incision - gently curved S-shaped incision with medial limb distally (SPN is lateral) at biceps muscle
- Superficial Dissection -
- Identify the short saphenous vein and medial sural cutaneous nerve (from the tibial nerve) → Trace this into the apex of the popliteal fossa
- At the apex, this is where the CPN separates from the tibial nerve.
- From the tibial nerve, the popliteal artery and vein (vein medial to artery) lie deep and medial to the tibial nerve
- Incise popliteal fascia proximally, following the tibial nerve → CPN should split from the tibial nerve at the apex of the incision
- Structures - Artery is deepest → Vein → Nerve (AVN; also from medial to lateral)
- Deep dissection → Detach tendinous origin of the medial and lateral head of gastrocnemius
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- Position patient supine and place shunt first
- While supine, apply lateral femoral pins and anteromedial tibial pins
- Turn patient prone for vascular repair
- Turn supine again to place rods to pins
- Turn prone again for vascular anastomoses
- Perform concurrent fasciotomies to prevent reperfusion injury
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- Reference from Mook et al. recommends staged procedure
- 1st stage = Extra-articular collateral ligament repair vs reconstruction
- Timing: within 3 weeksTiming: within 3 weeks
- Repair LCL/PLCRepair LCL/PLC
- MCL can heal with bracing → reassess at 6 weeks before 2nd stage to determine need for surgery [Exception: MCL-stener type lesion or MCL flipped into joint]
- Use Jack's brace to allow PCL to healUse Jack's brace to allow PCL to heal
- 2nd stage = ACL and consider PCL
- Timing: 6-8 weeksTiming: 6-8 weeks
- This duration serves two purposes:This duration serves two purposes:
- Allows capsular healing to prevent extravasation during arthroscopy
- Prevents arthrofibrosis
- Mook et al. Staged approach shows higher percentage of subjective excellent scores and better ROM preservation
mook2009 (1).pdf613.1KB
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- Delay for 6 months to allow vessel repair to mature
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- Nerve grafting if within 6 months
- Tendon transfer if > 6 months = Posterior tibialis tendon transfer
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The lips of the righteous know what is acceptable, but the mouth of the wicked, what is perverse. Proverbs 10:32