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Vascular Injuries in Knee Dislocations: The Role of Physical Examination in Determining the Need for Arteriography
James P. Stannard, MD1; Todd M. Sheils, MD1; Robert R. Lopez-Ben, MD2; Gerald McGwinJr, PhD3; James T. Robinson1; David A. Volgas, MD1
1 Department of Surgery, Division of Orthopaedic Surgery, University of Alabama at Birmingham, 510 South 20th Street, FOT 950, Birmingham, AL 35294-3409. E-mail address for J.P. Stannard: james.stannard@ortho.uab.edu
2 Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, JT 368, Birminham, AL 35294-6830
3 Center for Injury Sciences, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294-0016
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 May 01;86(5):910-915
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Background: Popliteal artery injury is frequently associated with knee dislocation following blunt trauma, an injury that is being seen with increasing frequency. The primary purpose of the present study was to evaluate the use of physical examination to determine the need for arteriography in a large series of patients with knee dislocation. The secondary purpose was to evaluate the correlation between physical examination findings and clinically important vascular injury in the subgroup of patients who underwent arteriography.

Methods: One hundred and thirty consecutive patients (138 knees) who had sustained an acute multiligamentous knee injury were evaluated at our level-1 trauma center between August 1996 and May 2002 and were included in a prospective outcome study. Four patients (four knees) were lost to follow-up, leaving 126 patients (134 knees) available for inclusion in the study. The results of the physical examination of the vascular status of the extremities were used to determine the need for arteriography. The mean duration of follow-up was nineteen months (range, eight to forty-eight months). Physical examination findings, magnetic resonance imaging findings, and surgical findings were combined to determine the extent of ligamentous damage.

Results: Nine patients had flow-limiting popliteal artery damage, for an overall prevalence of 7%. Ten patients had abnormal findings on physical examination, with one patient having a false-positive result and nine having a true-positive result. The knee dislocations in the nine patients with popliteal artery damage were classified, according to the Wascher modification of the Schenck system, as KD-III (one knee), KD-IV (seven knees), and KD-V (one knee).

Conclusions: Selective arteriography based on serial physical examinations is a safe and prudent policy following knee dislocation. There is a strong correlation between the results of physical examination and the need for arteriography. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.

Level of Evidence: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James P. Stannard
    Posted on December 14, 2004
    Dr. Stannard responds to Dr. Papavasiliou
    University of Alabama at Birmingham

    To the Editor:

    I appreciate Dr. Papavasiliou's letter regarding our study. The primary point of the study was not whether one classification of knee dislocation determines a higher risk for vascular injuries, but rather that physical examination can safely be employed to screen patients regarding the need for arteriograms.

    However, the data we collected is striking regarding the increased incidence of vascular injuries with KD-IV dislocations. We are able to get MRI's of the knee within hours of admission if we believe it is necessary. Additionally, we perform a physical examination as one of the first steps in evaluating patients. We are aware that rapid access to MRI scanning, including on nights and weekends is not universally available. However, a good physical examination of the knee can provide enough data to classify a patients injury as a probable KD-IV dislocation.

    We believe it is valuable for orthopaedic surgeons to be aware that dislocations in which all four major ligament groups are torn may be associated with a higher risk of vascular injury. If Dr. Papavasiliou's point is that clinical vigilance is necessary for all dislocations, we agree. Despite the higher incidence of vascular injuries with KD-IV dislocations, our protocol advocates serial exams for all dislocations. However, we believe awareness of the potential increased risk with KD-IV dislocations is wise.

    Thank you for your comments regarding our study.

    Sincerely, James P. Stannard, M.D.

    Athanasios V Papavasiliou
    Posted on November 27, 2004
    Vascular injuries in knee dislocations: The role of physical examination
    Oxford Radcliffe Hospitals NHS Trust

    To The Editor:

    I read with interest the article by Stannard et al(1) In it, the knee dislocations were classified according to the anatomic system proposed by Schenck and modified by Wascher (2) (KD-I to KD-V) which was further expanded by the authors. This classification is based on MRI and surgical findings.

    One of the conclusions of the study was that “Increased vigilance may be justified when treating a patient who has a KD-IV dislocation, and the data in the present series indicate that serial examinations should last for at least forty-eight hours”. Although there is a clear outcome in this study and the correlation between the type of knee dislocation (KD-I to KD-V) and arterial damage was not its purpose, I feel that the above conclusion has little clinical value.

    Common clinical practice for uncomplicated knee dislocations does not involve immediate (48 hrs) MRI or surgical exploration so, it is very rare that you can classify (KD-I to KD-V) these knee injuries and actually employ the classification to correlate the injury with possible arterial damage.

    - A.V. Papavasiliou BSc, MD, PhD

    Oxford Radcliffe Hospitals NHS Trust

    Oxford, UK

    References: 1. Stannard J, Sheils T, Lopez-Ben R, McGwin G Jr, Robinson J, Volgas D. Vascular injuries in knee dislocations: The role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86:910-15 2. Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19:457-77

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