Combined articular and ligament reconstructions in neglected fracture-dislocation of the knee

Sujit Kumar Tripathy; Shahnawaz Khan; Paulson Varghese; Deepak Neradi; Mantu Jain; Hursch Patel

doi:10.1016/j.jcot.2024.102475

. 2024 Jun 26;54:102475. doi: 10.1016/j.jcot.2024.102475

Combined articular and ligament reconstructions in neglected fracture-dislocation of the knee

Sujit Kumar Tripathy ^a,^⁎, Shahnawaz Khan ^a, Paulson Varghese ^a, Deepak Neradi ^a, Mantu Jain ^a, Hursch Patel ^b

PMCID: PMC11267039 PMID: 39055128

Abstract

Background

The management of neglected traumatic knee dislocations is challenging and is commonly associated with suboptimal outcomes. In this article we present two cases of neglected knee dislocations in two young trauma victims who presented late due to restrictions during the COVID-19 pandemic.

Methods

Two young patients presented at our center with neglected knee fracture-dislocations after eight weeks and six months of trauma. Comprehensive evaluation was performed using radiographs, computed tomography scans, and magnetic resonance imaging. Surgical intervention included open reduction and internal fixation of the mal-aligned intra-articular fracture fragments. Additionally, articular congruency was restored and repair or reconstruction of the posterior cruciate ligament, anterior cruciate ligament, and meniscus was conducted using suitable tendinous autografts and implants. Following surgery, the knees were immobilized for six weeks, followed by aggressive physical therapy.

Results

After three months of surgical intervention, fracture union and joint stability were achieved. At the >36-month follow-up appointments, both patients were pain-free at rest with a stable knee joint, achieving ≥90 degrees of knee flexion and without extensor deficits. Concurrent with radiographic evidence of osteoarthritic changes in the knee joint, there was mild pain (VAS 2) after prolonged knee movement activities and walking for long distances (>1 km).

Conclusion

Open reduction and internal fixation, along with simultaneous menisco-ligamentous reconstructions in neglected fracture-dislocations of the knee result in satisfactory clinical outcomes. This approach proves to be an effective joint preservation procedure in young patients, even in delayed and neglected conditions.

1. Introduction

Traumatic knee dislocations are rare injuries that can result from high-velocity trauma. They account for only 0.02 % of all extremities injuries¹; however, the incidence is likely underestimated due to spontaneous reductions and missed diagnoses. Knee dislocation is commonly associated with ligamentous injuries of the knee, proximal tibia fractures, and at times, neurovascular injuries.²^,³^,⁴^,⁵^,⁶ For vascular injuries specifically, immediate surgical intervention can save the limb, and early surgical reconstruction of the ligaments and bony injuries can lead to positive outcomes.⁴^,⁵^,⁶ Knee fracture dislocations that are neglected, however, can be challenging to treat and may require combined articular and ligament reconstructions. The literature on neglected knee dislocations remains scant, with few case reports documented. The outcomes of open reduction and internal fixation in these instances have been suboptimal with restrictions in range of motion. Some studies have opted for knee arthrodesis or total knee arthroplasty in these cases to provide a pain-free stable joint.⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹

If left untreated or inadequately treated, neglected fracture-dislocations of the knee can lead to chronic pain, instability, and arthritis. The treatment goal for these fracture-dislocations involves restoring joint stability, alignment, and function while minimizing the risk of post-traumatic arthritis.¹^,²^,⁴^,⁵ Of note, there is no single treatment modality that guarantees promising results. These conditions are often associated with multi-ligamentous injuries, and the presence of a fracture further complicates their management. Additionally, soft tissue contractures and fibrotic changes impose additional clinical challenges. Consequently, the outcomes are guarded.

We report the surgical outcomes of two cases of neglected fracture-dislocations of the knee that were managed by simultaneous open reductions and internal fixation of the fracture, as well as ligament reconstructions.

2. Case series

2.1. Case 1

A 37-year-old man who works as a home guard presented with pain, swelling, and inability to bear weight on his right limb following a dashboard injury from a road traffic accident that occurred eight weeks ago. He received primary care at the nearby hospital during the time of the accident where an above-knee slab was applied. Due to the COVID-19 pandemic lockdown, he did not seek any subsequent medical treatment before visiting our OPD clinic. Upon examination, a dimple on the anterior aspect of the knee was appreciated, and tenderness over the lateral aspect of the knee was noted. The knee range of motion was painful from a 40 to 20°’ flexion-extension arc. There was no distal neurovascular deficit. The radiographs revealed a subluxated knee joint with comminuted fractures of the right lateral tibial plateau (split depression) and tibial spine. The computed tomography scan with 3D reconstruction demonstrated comminution and fracture fragments (Fig. 1). Magnetic resonance imaging revealed a disrupted anterior cruciate ligament, everted medial meniscus from its posterior peripheral part, avulsed posterior cruciate ligament from the tibial attachment site, and subluxated knee joint. There was a partial tear of the patellar tendon from the lateral side as well (Fig. 2). Open reduction and internal fixation followed by reconstruction of the ligaments were planned. The patient was operated on under regional anesthesia in the supine position. A tourniquet was inflated to 250 mmHg. An anterior approach to the knee was utilized with a lateral parapatellar arthrotomy. The patella was everted medially. Fibrous adhesions were released, and the anterior cruciate ligament was debrided. The joint was distracted manually, and the everted meniscus was placed back to its original position. Next, the knee joint was reduced. The fracture surface of the lateral condyle of the tibia was cleaned and washed with normal saline. The fragments were reduced, and the tibial spine was fixed with two partially threaded cancellous screws. The metaphyseal fragment was reduced and fixed with a screw. The avulsed posterior cruciate ligament was repaired using fiber tape (looped around PCL fibers) and a suture wheel that was attached to the tibial cortex. The medial meniscus was repaired using the inside-out technique. The anterior cruciate ligament was reconstructed using an open method and all-inside technique which utilized a semitendinosus autograft and two tight ropes (Fig. 3). After the fixation, the knee joint was found to be stable. Subsequently, the skin was closed in layers. The knee was immobilized for six weeks using a knee extension brace, and the patient was allowed to walk under non-weight bearing precautions for the affected limb using a pair of crutches. Isometric quadriceps exercises, ankle pump, and hip abductor strengthening exercises were advised for six weeks. After six weeks, knee bending was started with the Continuous Passive Motion (CPM) machine, and the patient was allowed to start toe touch weight bearing. Full weight bearing was allowed after three months when the fracture was completely united. The range of motion at the end of three months was 0–60° (Fig. 4) and the patient was able to return to his previous job thereafter. He had follow-up appointments at 6, 12, 24 and 36 months. During a recent 42-month follow-up visit, the patient could walk unassisted and was working at his job comfortably. He experienced no pain at rest and mild pain (VAS score of 2/10) after walking or engaging in knee movement activities. The knee range of motion was from 0 to 90°, and the joint was stable. Radiographs showed complete healing of the fracture, along with osteoarthritic changes in the knee joint (Fig. 5). The average Knee injury and Osteoarthritis Outcome Score (KOOS²⁰) was 71 % (Symptoms + Stiffness subtotal: 75 %; Pain subtotal: 81 %; Function, daily living subtotal: 81 %; Function, sports and recreational activities subtotal: 35 %; Quality of life subtotal: 81 %).

Fig. 1 — Radiograph (A) and 3D computed tomography scan (B) of a 37-year-old male showing neglected fracture dislocation of the right knee.

Fig. 2 — Coronal and sagittal cut sections (A) of the computed tomography scan imaging showed comminuted fracture of the lateral tibial plateau and tibial spine. Magnetic resonance imaging (B) showed disrupted anterior cruciate ligament, everted medial meniscus from its posterior peripheral part, avulsed posterior cruciate ligament from the tibial attachment site and subluxated knee joint.

Fig. 3 — Intraoperative picture (A) shows articular congruency restoration and repair of avulsed PCL (fiber tape tied to PCL base was fixed at the tibial cortex with a suture wheel) followed by reconstruction of ACL (All inside technique) and peripheral part of medial meniscus (inside out). The patellar tendon was found to be disrupted from the lateral side and it was fixed to the tibial tuberosity with an anchor suture. Postoperative radiograph (B) shows articular and metaphyseal fragment restorations and fixation with screws.

Fig. 4 — At the end of 3-months the fracture united (A) and the patient had 0–60 degrees of flexion at the knee (B).

Fig. 5 — Clinical (A, B) and radiological outcomes (osteoarthritis changes) of the patient after 42 months of surgery.

2.2. Case 2

A 42-year-old man who works as a mason presented to our outdoor clinic with chief complaints of inability to bear weight on the right limb and a deformity in the knee observed over the last six months. He was involved in a road traffic accident six months ago where he sustained a right knee fracture-dislocation. He was taken to a local healthcare facility where a closed reduction was attempted, and an above-knee slab was applied for six weeks. Because of the COVID-19 pandemic lockdown, he did not attend any subsequent medical care before presenting to us six months later. On examination, there was tenderness over the lateral aspect of the knee, and the knee was fixed in flexion of 20°. Upon observation, there was a dimple over the anterior aspect of the right knee. There was no distal neurovascular deficit appreciated. The radiographs revealed a well-reduced knee joint with a comminuted fracture of the right lateral condyle of the tibia. An intra-articular fragment was found to be tented between the tibia and femur, and the lateral tibial plateau was depressed. The computed tomography scan delineated the fracture fragments (Fig. 6). Magnetic resonance imaging revealed an osteochondral indentation injury in the lateral femoral condyle caused by the tented bony fragment with non-visualization of the anterior cruciate ligament in addition to a torn posterior cruciate ligament. The medial meniscus was intact, whereas the lateral meniscus was found to be displaced along with the underlying bone (Fig. 7). Open reduction and internal fixation were planned using an anterior midline incision and medial parapatellar arthrotomy. The anterior horn of the lateral meniscus was detached and flipped to half of its original circumference. The tented fracture fragment was disengaged, and all comminuted fracture fragments of the lateral tibial condyle were mobilized. The fragments were reduced to restore the articular part of the tibial plateau. It was observed that the articular part of the lateral tibial plateau was widened, likely due to compression injury at the time of impact. Furthermore, the articular part of the lateral tibial plateau was restored up to the articulating margin of the lateral femoral condyle. The fragments were temporarily fixed with k-wires, and definite fixation was performed with headless Herbert screws (Fig. 8). The posterior cruciate ligament was reconstructed using an autogenous peroneus longus tendon graft, fixed with an adjustable tight rope on the femoral side and a bio-absorbable screw on the tibial side. The anterior horn of the lateral meniscus was repaired using a loop of fiber tape, fixed to the tibial cortex using an Attachable Button System (ABS). The anterior cruciate ligament was subsequently reconstructed using a hamstring graft fixed with a tight rope on the femoral side and a bio-absorbable screw on the tibial side. Ultimately, the osteochondral defect on the lateral femoral condyle was addressed. A sharp thin osteotome was used to cut the defect up to 1 cm in depth, and an equivalently shaped osteochondral graft was subsequently harvested from the nonarticular part of the lateral femoral condyle. The graft was fixed over the defect with two Herbert screws. The donor area was closed with a synovial fold (Fig. 8). The knee stability was assessed and was found to be stable. The wound was closed in layers after applying a negative suction drain.

Fig. 6 — 42-year-man presented with neglected right knee fracture dislocation (A). A bony fragment of the lateral tibial plateau was found to be tented between tibia and femur causing indentation injury on the lateral femoral condyle (B–G).

Fig. 7 — MRI (A, B) shows an osteochondral indentation injury in the lateral femoral condyle caused by the tented bony fragment with nonvisualization of the anterior cruciate ligament and torn posterior cruciate ligament.

Fig. 8 — Intraoperative clinical picture shows indentation injury (A) with elevated bony fragments of lateral tibial plateau over which the lateral meniscus is attached. ACL and PCL fibers are disrupted. The bony fragments are reduced and fixed (B) followed by the cruciate ligaments and meniscus. The indentation injury was managed by osteochondral bone graft fixation harvested from the lateral side of lateral femoral condyle (C–E). The donor site was covered with a synovial fold (F).

The knee was immobilized for six weeks using an extension knee brace. With the brace on, movements were strictly restricted to isometric quadriceps exercises and straight leg raises. The post-operative period was uneventful. After six weeks, knee bending was initiated with the CPM machine. The patient was allowed to perform toe touch weight bearing at six weeks and was allowed to mobilize with a walker. The knee range of motion gradually increased every week. At the end of 3 months, the fracture union was evident, and full weight bearing was permitted. Fortunately, the patient was successfully able return to his job as a mason. He had follow-up appointments scheduled at 6, 12, 24 and 36 months (Fig. 9). At a 38-month follow-up visit, the patient was walking independently without resting pain or instability. There was mild pain (VAS 2/10) after walking for a long distance (>1 km). The range of motion around the knee was 0–95°. Of note however, a radiograph showed early arthritic changes in the knee joint (Fig. 10). Assessment using KOOS²⁰ revealed an average score of 73 % (Symptoms + Stiffness subtotal: 71 %; Pain subtotal: 83 %; Function, daily living subtotal: 90 %; Function, sports and recreational activities subtotal: 40 %; Quality of life subtotal: 81 %)

Fig. 9 — At the end of one year, the x-ray shows healed fracture with mild joint depression on the lateral side (A). Clinical picture shows range of motion of 0–90° (B, C).

Fig. 10 — Clinical outcomes after 38 months showed 0–95 degrees of flexion-extension arc and x-ray revealed early arthritis changes in the knee joint.

3. Discussion

Knee dislocations are commonly associated with ligament injuries. The addition of a bony injury further complicates this scenario. Early reduction and stabilization prevent vascular damage, which can be a limb-saving procedure.⁴ In cases of articular fractures, most commonly after the dislocation is reduced, an articular reconstruction is performed and immobilization of the joint is achieved using a knee-spanning external fixator or a slab. Vascular injuries are often a result of an endothelial injury, which leads to thrombus formation.¹^,²

Most commonly, the knee dislocates posterolaterally and is accompanied by button-holing which makes it irreducible.⁵ Anterior dislocations are rarely reported.⁶^,⁷ In this report, both of our subjects had posterior knee dislocation and were managed conservatively in a slab or brace. It is important to note that such a practice can lead to the loss of reduction, causing chronic instability and joint stiffness.

Though neglected knee dislocation cases are a relatively rare entity in the current literature, there are some reports from various parts of the world from 1990 until present.⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹ The management of such cases also varies. The treatment modalities and outcomes at the final follow-up have been summarized in Table 1.

Table 1.

Literature available on neglected knee dislocation and its management.

Study	Year of publication	Duration of injury to presentation	Management	Results at final follow-up
Henshaw et al.¹³	1996	6 months	Open reduction + Steinman pin and cast for 12wks	5–40°
Vincente-Guillen et al.¹²	1998	15 years	Arthrodesis	Successful Arthrodesis
Matthai et al.¹⁰	2015	1 year	Arthrodesis	Successful Arthrodesis
Ibrahim et al.¹¹	2022	3 months	Arthrodesis	Successful Arthrodesis
Leonardi et al.⁷	2017	3 years	–	NA
Ramnath et al.¹⁴	2020	25 years	TKA	0–120°
Mani et al.⁵	2016	1 month	Crossed Steinman pins	0–50°
Saini et al.¹⁵	2010	3 months	Open reduction + PCL and MCL reconstruction + ex-fix	0–90°
Richter et al.¹⁶	1998	1 month	Open reduction + ACL and PCL recon + hinged ex-fix	0–50°
Petrie et al.⁸	2000	4 months	TKA	3–95°
Petrie et al.⁸	2000	4 months	TKA	0–80°
Simonian et al.²	1998	3 months	Open reduction + PCL + ACL + PLC recon + hinged ex-fix	−5 to 105°
Simonian et al.²	1998	5 months	Open reduction + PCL + ACL + PLC recon + hinged ex-fix	30–90°
Watanabe et al.¹⁷	2001	6 months	Ilizarov then ORIF for proximal tibia fracture and patella tendon recon	15–110°
Chen et al.⁹	2007	30 years	TKA (LPS)	0–90°
Karn et al.⁶	2009	4 months	Open reduction + knee spanning ex-fix	5–70°
Garnaoui¹⁸ et al.	2022	2 years	Ex-fix + Steinman pin	0–30°

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PCL: posterior cruciate ligament, ACL: Anterior cruciate ligament, Ex-fix: external fixation, TKA: Total knee arthroplasty.

Both cases in our series were managed at other centers before coming to us. They were not managed completely and consequently developed painful, deformed knees. The patients did not visit any healthcare facility due to the fear of the COVID-19 pandemic and attended our service only when significant morbidity had occurred. This emphasizes the need to handle the knee fracture-dislocation at an early stage properly.

The main goal of treatment is to provide a painless, mobile, and functional knee joint with normal anatomy. Closed reduction maneuvers are usually unsuccessful in these long-standing cases due to the ensuing fibrotic changes in the soft tissues, intra-articular displaced bony fragments, and buttonholing of the menisci. Therefore, open reduction and appropriate reconstructions of both bones and ligaments are necessary to achieve a mobile yet stable knee joint. One clinically challenging aspect involves the displaced intra-articular bony fragments which are difficult to reposition to normal anatomy because of fibrous adhesions, callus formation, and overlying menisci or ligamentous attachments. In such a scenario, the meniscus may be surgically detached at the anterior or posterior horn and elevated towards the middle for better visualization. The torn cruciate ligaments can be debrided for better delineation of the fragment. After complete release, the intra-articular bony portion can be fixed to the underlying native bone using headless screws. Once the articular surface is restored, the metaphyseal part can be reconstructed. The metaphysical pieces can be anatomically reduced and fixed to the parent bone using plates and screws. However, locking plate fixation with fixed-direction screws can interfere with the bone tunnels which must be drilled for menisco-ligamentous reconstruction. Therefore, we used screws in both cases, as a buttress plate would have made the cruciate reconstruction cumbersome and interfered with the tunnels. Once the bony architecture is made, the ligaments can be reconstructed using tight ropes or screws with suitable tendinous grafts. The anterior horn of the meniscus is then reattached to the bone using a nonabsorbable suture or fiber tape and an ABS/suture wheel. The periphery of the meniscus is sutured to the rim of the tibial plateau using a nonabsorbable suture (Prolene). The principle is to create a flat articular surface for the menisci to prevent joint degeneration. Handling the articular osteochondral bone fragments and menisco-ligamentous structures is essential to avoid iatrogenic injury to the articular structures and subsequent secondary arthritis.

The associated osteochondral or cartilaginous defects can be addressed in the same setting. These defects are in the form of indentation or transchondral injuries. Osteochondral plugs, mosaicplasty, or osteochondral allograft transfers are appropriate for such defects. In our case, the diseased cartilage was debrided, and a chunk of an osteochondral fragment of the same size as the defect was taken from the non-weight-bearing portion of the knee (lateral part of lateral femoral condyle at the level of trochlear) and was placed onto the defect. The graft was harvested manually using an osteotome and was fixed with headless screws since it was a non-contained defect. The donor site was covered with a synovial fold (for delivery of mesenchymal stem cells and vascularity) for subsequent healing. The procedure could have been completed quickly using an osteochondral plug harvester; however, this was expensive for our setup.

Such cases require a certain period of immobilization to enable the healing of the ligaments and articular bone fragments, which is approximately six weeks. Subsequent aggressive physiotherapy can restore excellent knee function. Full weight bearing usually starts when radiographic evidence of fracture union is visible. We achieved a good range of motion in both of our cases, even though their issues were neglected for a prolonged period of time.

There is no standard treatment protocol for the management of neglected knee dislocations. Most studies have stated that they performed arthrodesis or arthroplasty in such cases.⁹^,¹⁰^,¹¹^,¹²^,¹³ However, in our case, both patients were relatively young. Any surgery like arthrodesis or arthroplasty would not only add to expenses, but also increase the need for future revision surgeries. The decreased availability of bone stock in future surgeries would not only make the surgery difficult, but also necessitate the use of constrained implants, further limiting the function of the joint (Table 1). Therefore, we believe open reduction followed by ligament reconstruction is an excellent way to restore the normal or near normal anatomy of the knee. Only a few authors have managed to do ligament reconstructions.³^,¹⁶^,¹⁷ Reduction of the dislocated knee joint, ligament reconstruction, and prolonged period of immobilization using external fixation have resulted in a restricted range of motion in a few reports; this emphasizes the importance of aggressive physiotherapy in such patients. The clinical outcomes beyond 36 months in both cases showed satisfactory results. The literature has reported that radiographic posttraumatic arthritis usually does not correlate to clinical outcomes in healed tibial plateau fractures.²¹ We had similar observations in our own cases. Although radiographs were indicative of arthritic changes in the knee, the functional outcome was positive for both patients, especially as they were able to resume their previous work comfortably. A detailed analysis of the latest KOOS for both patients revealed minimal pain and stiffness, and they were able to perform their daily activities. However, they experienced significant challenges in sports and recreational activities. Of note, neither patient indicated the need to achieve those higher forms of functional activities. Neither patient demanded any additional treatment. Nevertheless, these patients need long-term follow-up to monitor for the development of severe arthritis and functional limitations.

To conclude, neglected fracture dislocation of the knee in young patients needs open reconstruction of the articular surface and the metaphyseal fragment followed by menisco-ligamentous reconstruction. Simultaneous reconstructions of the bony and menisco-ligamentous structures can lead to a satisfactory outcome and delay the need for arthroplasty.

4. Conflict-of-interest statement

The authors of this manuscript declare that they have no conflicts of interest to disclose.

Credit author statement

SKT, SK, and PV prepared the initial draft. SKT and MJ managed the patient. PV and SK collected all data. SKT, SK and HP prepared the final draft. SKT, MJ, HP and DN provided intellectual content to the manuscript. All authors read the final manuscript and approved the study.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Contributor Information

Sujit Kumar Tripathy, Email: sujitortho@aiimsbhubaneswar.edu.in, sujitortho@yahoo.co.in, ortho_sujit@aiimsbhubaneswar.edu.in.

Shahnawaz Khan, Email: skhanortho2022@gmail.com.

Paulson Varghese, Email: paulguvera@gmail.com.

Deepak Neradi, Email: ortho_deepak@aiimsbhubaneswar.edu.in.

Mantu Jain, Email: ortho_mantu@aiimsbhubaneswar.edu.in.

Hursch Patel, Email: hursch.patel@kansascity.edu.

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[bib2] 2.Stannard J.P., Schreiner A.J. Vascular injuries following knee dislocation. J Knee Surg. 2020;33(4):351–356. doi: 10.1055/s-0040-1701210. [DOI] [PubMed] [Google Scholar]

[bib3] 3.Simonian P.T., Wickiewicz T.L., Hotchkiss R.N., Warren R.F. Chronic knee dislocation: reduction, reconstruction, and application of a skeletally fixed knee hinge. A report of two cases. Am J Sports Med. 1998;26(4):591–596. doi: 10.1177/03635465980260042201. [DOI] [PubMed] [Google Scholar]

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PERMALINK

Combined articular and ligament reconstructions in neglected fracture-dislocation of the knee

Sujit Kumar Tripathy

Shahnawaz Khan

Paulson Varghese

Deepak Neradi

Mantu Jain

Hursch Patel