Session VIII - Femur/Knee

Vascular Injuries with Knee Dislocations after Blunt Trauma: Evaluating the Role of Selective Arteriography

James P. Stannard, MD; Todd M. Sheils, MD; Gerald McGwin, Jr., PhD; James Robinson; Jorge E. Alonso, MD; David A. Volgas, MD; University of Alabama at Birmingham, Birmingham, Alabama, USA

Purpose: Knee dislocation as a result of blunt trauma is a severe injury in which arterial injury must be suspected. Use of arteriography for all knee dislocations is an issue that has been refuted in the literature. The purpose of this study was to retrospectively assess occurrence of popliteal artery injury and the indications for arteriography in a large series of patients with knee dislocations.

Methods: A total of 119 patients who sustained 128 knee dislocations (9 bilateral) were evaluated with a retrospective chart review. Patients were also evaluated with clinical examinations by one of the authors. Data collected included the following: age; height; weight; injury severity score (ISS); intensive care unit days; number of surgical procedures on the knee; range of motion; peroneal nerve function; and complications. The vascular examination at the time of injury was noted and data from arteriography was analyzed.

Results: Clinical follow-up data were available for all 119 patients. The mean ISS for patients in this study was 17.4 (range, 9 to 50). Patients required an average of 2.5 surgical procedures on their knee to achieve stability. Sixteen patients (13%) had sustained injuries to their peroneal nerve from their accident, and there were three additional iatrogenic injuries to the peroneal nerve. Eighteen (15%) of the 119 patients underwent arteriography. Nine patients received arteriograms despite normal clinical examination results. None of these patients demonstrated significant findings that required intervention. Nine patients had abnormal vascular examination results at admission. Eight of these patients had abnormal arteriogram findings and required intervention to treat the vascular injury. One patient with decreased pulses underwent arteriography, but the results showed no evidence of vascular injury. There were no late vascular sequelae for any patient in this study. Nine of the 18 arteriograms obtained were unnecessary on the basis of normal clinical examination and normal arteriogram results. There was a highly significant association between the results of the vascular examination and the need for arteriography (p < 0.01).

Discussion and Conclusions: Arterial injury with knee dislocations can be a devastating injury. The risk of missing a vascular injury and the possibility of secondary amputation has led some authors to recommend routine arteriography after knee dislocations, but there is controversy regarding this recommendation. Both Dennis et al. (J. Trauma 35, 1993) and Kendall et al. (J. Trauma 35, 1993) have documented similar findings regarding the need for selective arteriography with smaller studies. Our data, along with those of the reports mentioned above, support obtaining an arteriogram only when the result of the clinical vascular examination is abnormal or when the surgeon has other reasons (such as a history of an abnormal vascular examination result in the field) for high clinical suspicion of a significant vascular injury. On the basis of these findings, the current protocol at our institution is to perform arteriograms only in the face of abnormal clinical examination results or a history of an abnormal examination result in the field.