Session III - Femur/Knee

*Is Cruciate Ligament Reconstruction for Traumatic Knee Dislocations Better than Repair or Nonoperative Treatment?

Martinus Richter MD; Burkhard Wippermann, MD; Ulrich Bosch MD; Torsten Gerich MD; Christian Krettek, MD, Hannover Medical School, Hannover, Germany (all authors ­ a-"University Internal Achievement Support" Grant)

Purpose: The appropriate method for treatment of the cruciate ligament in traumatic knee dislocations is still controversial. We analyzed the records of patients treated at our level 1 trauma center from January 1974 to May 1999 to determine the prognostic factors. We especially evaluated the influence of choice of treatment of cruciate ligaments (reconstruction, repair, or nonoperative) on the outcome.

Methods: We analyzed the occurrence, causes, treatment, and outcome of patients with knee dislocations clinically, radiographically, by Lysholm score, by Tegner Score, and by International Knee Documentation Committee (IKDC) rating. The inclusion criteria for patients studied were a traumatic dislocation documented by photograph or radiograph, a complete rupture of the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) and the medial collateral ligament (MCL) or the lateral collateral ligament (LCL) (ACL+PCL+MCL/LCL).

Results: Eighty-nine patients with knee dislocations were included. The mean age at the time of injury was 33.5 years (range, 15 to 76) , 78% (n = 69) were men and 22% (n = 20) were women. Sixty-three percent (n = 56) of the dislocations occurred because of motor vehicle accidents, 19% (n = 17) in sports, 9% (n = 8) in industrial accidents, and 9% (n = 8) in falls (nonsport). Forty-three percent (n = 38) of the dislocations were on the right side, 57% (n =51) were on the left side, and there were no bilateral dislocations. Six percent (n = 5) were open dislocations. The direction of dislocation was determined in 87 (98%) cases: 15% (n = 13) were anterior, 40% (n = 36) were posterior, 25% (n = 22) were medial, 15% (n = 13) were lateral, and 3% (n = 3) were rotational. The MCL was ruptured in 40% (n = 36) of the patients, the LCL in 38% (n=34), and both the MCL and LCL were ruptured in 21% (n = 19). Lesions of the menisci were observed in 48% (n = 43): 20% (n = 18) medial, 17% (n = 15) lateral, and 11% (n = 10) in both. Vascular injuries were registered in 20% (n = 18) and nerve injuries in 17% (n = 15). Twenty-eight (33%) patients also had associated fractures of the ipsilateral femur or tibia, and 23 (26%) were classified as having "polytrauma." ACL/PCL repair (refixation or suture) was performed in 49 (55%) patients, ACL and/or PCL reconstruction (patellar ligament or semitendinosus tendon autografts) in 14 (16%) patients, and there was no ACL/PCL repair in 26 (29%) patients. Ten patients of the nonoperative group sustained an operative procedure (other ligaments, menisci, nerve or vascular procedure). In total, 27 (30%) patients were treated functionally and 62 (70%) with immobilization (cast or external fixator). Seventy-seven surviving patients (seven died) without arthrodeses (n = 3) or total knee replacement (n = 2), completed the follow-up of an average of 8 years (range, 1 to 23). In the total follow-up group 75% (n = 58) returned to work, and 45% (n = 35) were able to play sports. The mean Lysholm score was 75 points (range, 35 to 100), and the mean Tegner score was 3.7 (range, 0 to 8). In the IKDC ranking, 0% were classified group A, 21% (n = 16) group B, 55% (n = 42) group C, and 25% (n = 19) group D. A lack of extension (60%, n = 42) and/or flexion (82%, n = 63) was, in the majority of patients, responsible for classification into group C or D. The outcome for patients in the reconstruction and repair groups was better than in the nonoperative group, with mean values for the respective groups: (nonoperative, reconstruction, and repair) Lysholm, 64/78/79; Tegner, 2.7/4.0/4.3; working ability (%), 67/85/75; sports ability (%), 17/54/58. The difference between nonoperative and reconstruction and nonoperative and repair in all categories was significant (P <0.05); there was no significant difference in outcome between the reconstruction and repair groups. The Lysholm and Tegner scores were significantly (P <0.05) higher in patients with an age of 40 years or less at the time of trauma than in older patients, in sports injuries than in dislocation caused by motor vehicle accidents, and after functional treatment rather than after immobilization.

Discussion: The determination of prognostic factors was problematic because the duration of follow-up varied considerably. Both given factors (age, cause of trauma) and factors that can be influenced (treatment) affected the outcome. Younger patients (£ 40 years at the time of trauma) and those with low-energy dislocations (sports injuries) had a better outcome than did older patients (> 40 years) and those with high-energy dislocations from motor vehicle accidents. Both the repair and reconstruction groups showed better results than did those with nonoperative treatment. After repair or reconstruction, more than three-fourths of the patients returned to work and more than half were able to play sports. The main problem among the patients in the nonoperative group was not instability but lack of motion. The best results were observed after repair or reconstruction and functional postoperative treatment. The patients in those groups showed the highest range of motion in combination with sufficient stability.

Conclusion: Numerous factors influenced the outcome of traumatic dislocations. For the cruciate ligaments, reconstruction and repair were superior to nonoperative treatment, but reconstruction was not better than repair. However, due to the considerable variation in our study group (injury pattern, age, cause, etc.), the influence of cruciate ligament management alone should not be overestimated. A more important factor was, for example, functional postoperative treatment, for which a high primary stability is essential. Procedures with ligament reconstruction or refixation/suture are recommended to enable early functional treatment.