knee dislocation and multiligamentous injury utku kandemir, md revised october 2011 original author:...
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Knee Dislocation and Multiligamentous Injury
Utku Kandemir, MDRevised October 2011
Original Author: William R. Creevy, MS, MD; Mark A. Neault, MD & Brian D. Busconi, MD; March 2004;Robert P. Dunbar, Jr., MD; Revised January 2007
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Anatomy: Tibiofemoral Joint
Bones• femoral condyles• tibial plateau
Dissimilar surfaces Little/No inherent
bony stabilityMay be cause of
additional instability if fractured
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Stabilizers of the Tibiofemoral JointSoft tissues: stabilize
while allowing ROM• Ligaments• Joint capsule• Menisci
• Musculotendinous units (DYNAMIC)
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Anatomy – 4 groups of ligamentsACL
PCLMCL, posteromedial
capsuleLCL & PLC (popliteofibular
ligament, popliteus, capsule, ITB, biceps
femoris)
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Vascular AnatomyPopliteal artery at risk for being tethered • Adductor hiatus• Soleus arch
If blood flow through popliteal artery disrupted
Inadequate blood supply distally
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Anatomy: NervesInfluences LongTerm Outcome Peroneal nerve
• More commonly injured• Tethered around the fibular
neck• Mechanism of injury
• Tension (Varus ± hyperextension, Translation
(Anterior /Posterior dislocation)• Direct impact
• Iatrogenic (aggressive varus/hyperextension during EUA
(!)
Tibial nerve
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Knee Dislocation–Multiligamentous InjuryDisruption of
normal relationship of tibiofemoral
jointUsually requires the injury to 2 of
the 4 major groups of ligaments
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Knee Dislocation–Multiligamentous Injury
Large Spectrum of injury
Increased severity with more structures involved
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Pathomechanics
May occur not only with high energy but also with low energy
Low energy• Athletic activity (more with contact sports)
• Fall down stairs• Jump of the low height
High energy• MVA• PVA
• Fall from height
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PathomechanicsCadaveric studyProgressive Hyperextension
model Anterior dislocation
@≈30 degrees: tear of posterior CAPSULE
Followed by tear of PCL & ACL DISLOCATION
@≈50 degrees: rupture of POPLITEAL ARTERY
Kennedy JC. 1963Kennedy JC. 1963
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PathomechanicsCadaveric studyCombined cruciate ligaments injury
in hyperextension
Low rate of strain (100%/sec) midsubstance tear of PCL
High high rate of strain (400%/sec) avulsion of PCL from
femurACL: Mixed pattern of injury
Schenck RC et al. 1999 Schenck RC et al. 1999
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Why Important?
…serious injury which can have
long-term adverse effects which
may impair the patient’s return to
physical employment and
recreational activity.
Robertson A et al. 2006Robertson A et al. 2006
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Epidemiology
“It is unlikely that any single
physician personally cares for
more than a few knee dislocations
in a lifetime of practice”
Meyers MH, Harvey JP. 1971Meyers MH, Harvey JP. 1971
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EpidemiologyTrue incidence is underreported• Spontaneous reduction
• Definition (documented complete dislocation vs. ≥1 cruciate + one collateral
injury)• Obesity interferes with exam and
mechanism
Presented in a variety of clinical practices• Trauma Center• Sport Medicine
• General Orthopaedics
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Epidemiology
0.2 % of all orthopaedic injuries
Young ♂MVA, sports trauma
14-44 % associated w multiple traumaBilateral 5 %
Robertson A et al. 2006Robertson A et al. 2006
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Ligamentous Injury in Polytrauma PatientSuspect & Examine in any• Lower extremity long bone fracture
• Polytrauma• Head injury
Isolated femoral shaft fx• Associated knee ligament injury: 33% (Walling
AK 1982)
Isolated tibial shaft fx• Associated knee ligament injury: 22%
(Templeman DC 1989)
Ipsilateral Femoral & tibial shaft fx• Associated knee ligament injury: 32-53% (Szalay
MJ 1990, vanRaay JJ 1991)
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Diagnosis
Hyperextension Popliteal ecchymosis
Vascular insufficiency Peroneal nerve deficit
Diffuse tenderness but Absence of hemartrosis
(capsular disruption) Obese pt low energy fall
If any of the following present r/o Multiligamentous injury (Spontaneous reduction UNDERDIAGNOSED)
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Physical Examination
Evaluate soft tissues • Open
• Puckering (irreducible dislocation)
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Vascular ExaminationColor, temperature, PulsesDorsalis Pedis a. & Tibialis
Posterior a.ABI (Ankle Brachial Index)• ≥0.9: Serial examination
• <0.9: further study/exploration• Johanson, K, JT
Reduce if dislocated and Reexamine
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Vascular ExaminationABI ≥0.9 & no signs of vascular
injury: Arterial study may not be necessary if
• Serial examination q 2-4 hrs for 48 hrs can reliably be
performed
If not, arterial study may be ordered to r/o vascular injury
Mills WJ 2004, Stannard JP 2004Mills WJ 2004, Stannard JP 2004
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Vascular ExaminationABI <0.9 OR Temperature, Color, OR
Expanding swelling (hematoma) around the knee
Arterial study• Arteriography in OR ( on table
by surgeon)• Angiography (radiology suite)
• CT- Angiogram
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Vascular Injury~20% (5-30%) of all
dislocations
EMERGENCY if NO distal perfusion
Patterns of Vascular injury• rupture
• incomplete tear• intimal injury (may cause
thrombosis)
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Neurologic ExaminationPeroneal Nerve
• Motor: EHL, Tib. Anterior, Peroneals
• Sensory: dorsum of the foot and 1st web space
Tibial Nerve• Motor: FHL, Gastrosoleus, Tib
Posterior• Sensory: Plantar surface and
lateral border of the foot
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Neurologic Injury
Common peroneal nerve palsy
Incidence ~20% (10-40%)Most Common with varus
injuryUsually axonothmesisPROGNOSIS is POOR
Complete recovery ~ 20%
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Examination of LigamentsVarus Stress test (20-30°, extension)
• Don’t overdo: iatrogenic peroneal
nerve palsy !)
Valgus Stress Test (20-30°, extension)
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Examination of LigamentsLachman Test
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Examination of LigamentsPosterior Drawer test
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Examination of LigamentsExternal Rotation Recurvatum test
Dial test (at 30° and 90°) (positive if 10-
15° difference)
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Examination of LigamentsInjury Severity: based on the difference of contralateral knee
• Grade I: <5 mm Sprain• Grade II: 5-10 mm Partial tear/avulsion
• Grade III: >10 mm Complete tear/avulsion
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Positive Ligamentous TestsVarus stress @ 30°• LCL
Varus stress in Extension and @ 30°• LCL/PLC & Cruciate (ACL/PCL)
Valgus stress @ 30°• MCL
Valgus stress in Extension and @ 30°• MCL & Cruciate (PCL/ACL)
Lachman• ACL
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Positive Ligamentous Tests
Posterior Drawer or Quad Active @ 90°• PCL
Posterolateral Drawer @ 30° • PLC
Posterolateral Drawer @ 90° and @ 30°• PCL and PLC
External Rotation Recurvatum test• PLC and PCL
Dial test @ 30°• PLC
Dial test @ 30° and @ 90°• PLC and PCL
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ImagingPlain X-rayArteriogram• On OR table• Angiography• CT Angio
MRICT scan
• Avulsions ( better detail)• Associated fractures (distal
femur, proximal tibia)• CT Angio
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Imaging - Plain X-ray
Plain x-ray : AP and Lateral • Abnormal joint space
• Subluxation• Associated Fractures (prox
tibia, distal femur)
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Imaging - Plain X-rayAvulsions
• Medial epicondyle (MCL)• Lateral epicondyle (LCL)• Fibular head (LCL)• Tibial spine (ACL)• Posterior tibial (PCL)
• Capsular – anteriolateral(Segond)
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Imaging - MRIIndicated for ALL multiligamentous injury
Gives detail of all non-bony structures• Menisci
• Articular cartilage• Ligaments
• Tendons (biceps, Popliteus, ITB)
MR Angiogram (MRA)
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Imaging - MRIIdentify ligament injury• Partial vs. Complete
• Midsubstance vs. Avulsion from origin/insertion
Meniscus• Displaced tear
Helps Determine Treatment Plan• Timing (early in ligament
avulsions, displaced meniscus tear)• Procedure (repair vs.
reconstruction)• Surgical Approach
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Diagnosis - EUAInvaluable to determine Treatment
plan
When ?• If they go to OR for other reasons in
multiply injured
• After ALL femoral & tibial IMN
• Before prepping for surgery (knee) to confirm findings & instability
With/Without Fluoroscopy
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Classification
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Classification - PositionalTibial position with respect to femur
Anterior (40%)Posterior (33%)Lateral (18%)Medial (4%)
Rotational (5%)
Most common: Anterior/PosteriorKennedy JC. 1963Kennedy JC. 1963
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Classification - PositionalPROBLEMSSpontaneous reduction: Unclassifiable
The status of ligaments NOT described
Dislocation with intact cruciate not included
HELPFULReduction maneuver
Kennedy JC. 1963Kennedy JC. 1963
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Classification - Fracture DislocationsType I: Split
Type II: Entire CondyleType II: Rim Avulsion
Type IV: Rim CompressionType V: Four-Part
“Fracture dislocation of the knee is much more serious injury than a plateau fracture”
Moore TM. 1981Moore TM. 1981
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Classification – Anatomic (Injured Structures)
KD-I Single cruciate + CollateralKD-II Both cruciates TORN, Collaterals INTACT
Most Common patternKD-III Both cruciates + One Collateral TORN :
ACL+PCL+ MCL / ACL+PCL+ LCL+PLC
KD-IV ALL torn: ACL+PCL+ MCL+LCL+PLC KD-V Dislocation with fracture
C = Arterial InjuryN = Nerve Injury
Schenck RC et al. 1992Schenck RC et al. 1992
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Classification – Injured Structures
Schenck RC et al. 1992Schenck RC et al. 1992
V
C
N
III L ACL / PCL / LCL+PLC MCL intact
IV ACL / PCL / MCL / LCL+PLC
III M ACL / PCL / MCL LCL+PLC intact
Schenck 1992
II
arterial injury
nerve injury
fracture dislocation
Anatomic Classification of Knee Dislocations
I single cruciate + collateralACL + collateral
PCL + collateral
ACL / PCL collaterals intact
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Fracture Dislocations: KD-VKD-V1 Dislocation without both
cruciates involvedKD-V2 Bicruciate disruption
onlyKD-V3M Bicruciate +
posteromedial disruptionKD-V3L Bicruciate +
posterolateral disruptionKD-V4 Bicruciate +
Posteromedial AND Posterolateral disruption
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Classification -Anatomic
ADVANTAGES
Better DEFINITION of injuries better communication
Guides TREATMENT i.e. what is tornHelpful to COMPARE different types
of treatment, studies
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Treatment
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Treatment – Closed ReductionShould be done EMERGENTLY/URGENTLY
with sufficient muscle relaxation (Don’t apply aggressive force!)
Closed Reduction• In the field• In ED
• Under general anesthesia if not reducible with conscious sedation (Rare as the bony anatomy
of the knee is not constrained)
Direct force against Popliteal fossa & hyperextension should be AVOIDED
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Closed Reduction ManeuverPOSITION of DISLOCATION
(Tibia relative to Femur)
Anterior• Traction & elevation of distal femur
Posterior• Traction & extension of proximal tibia
Lateral / Medial• Traction & correctional translation
Rotational• Traction & correctional derotation
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Open ReductionIrreducible by Closed methods
RareTypically POSTEROLATERAL• Dimple sign – Puckering of
anteromedial skin• Buttonhole of medial femoral
condyle through soft tissues (capsule, MCL, retinaculum,
vastus medialis)• Watch for skin necrosis
Urguden M 2004
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Initial StabilizationDepends on the STABILITY after reduction
Stability correlated with the extent of injured structures
Knee immobilizer• If grossly stable
External Fixator• If grossly unstable
Long leg splint with medial/lateral slabs• Does not allow serial checks of vascular status and
compartments
NEED TO CONFIRM REDUCTION AFTER STABILIZATION (X-ray)
Complicated by Obesity and Other Injuries
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Initial Stabilization-External FixationIndications:• Grossly Unstable Knee
• Soft tissue Reasons (open wounds, compromised skin, Arterial repair)
• Mark future incisions before inserting pins
Temporary • until definitive treatment
Definitive treatment • if patient not a surgical
candidate
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External Fixation Spanning the knee– Avoid anticipated incisions for repair / reconstruction
– Use MRI compatible clamps– Femur: Anterior/Anterolateral /Lateral pins
– Tibia: Anterior/Anteromedial pins
Dynamic Hinged– To protect repair/reconstruction
while allowing ROM (Stannard JP 2002)
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Treatment - Vascular InjuryScenario 1:
ISCHEMIC LIMB after REDUCTION
EMERGENCY EXPLORATION
Location of injury predictableOn table Arteriogram can be done
Circulation has to be restored in 6-8 hrs
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Treatment - Vascular InjuryRepair vs. reversed saphenous vein graft
Prophylactic fasciotomy of leg compartments
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Treatment - Vascular InjuryScenario 2:
ABNORMAL VASCULAR EXAM – perfused LIMB
URGENT ARTERIAL STUDY
CT- AngiogramAngiography
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Treatment - Vascular Injury
Scenario 3: NORMAL VASCULAR EXAM – no Planned
Extremity Surgery
Serial examination q 2-4 hrs for 48 hrs if can reliably be performed
If NOT, order arterial study to r/o vascular injury
MR Angio may be preferred as it will also show injured structures
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Treatment - Vascular Injury
Scenario 4: NORMAL VASCULAR EXAM – Planned
Extremity Surgery
Serial examination q 2-4 hrs for 48 hrs if can reliably be performed
If NOT, order arterial study to r/o vascular injury
MR Angio for both to r/o vascular injury and operative planning
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Treatment – Neurologic Injury
Common peroneal nerve palsy
Most Common with varus injury (III L)
PROGNOSIS is POORComplete Recovery ~ 20%
Niall DM et al. 2005; Bonnevialle P. 2010 Niall DM et al. 2005; Bonnevialle P. 2010
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Treatment – Neurologic Injury
Mostly explored & decompressed during repair/reconstruction:• Macroscopically normal:
Observe• In continuity but injured:
Observe or Grafting• Disrupted: Repair/Grafting
ENMG @ 6-12 weeks if not explored and no signs of
recovery
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Treatment – Neurologic Injury
Nerve Injury impairs Function & Activity level
May consider limited surgery
Avoid Equinus (AFO, Dorsiflexion exercises to
preserve mobility of ankle
Salvage: Tendon transfer if no recovery after 1 year
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TreatmentDiscuss the prognosis with the patient
Patient’s factors• Multiply Injured vs. Isolated injury
• Age, Activity Level• Compliance with WB and PT is CRUCIAL
PT/Rehab• Necessary for Best possible outcome
Individualize treatment per the injury and the patient
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Nonoperative vs. Operative TreatmentNo prospective Randomized Clinical Trial
(rare, large spectrum of injury)Grade I –II injuries generally treated
nonoperatively
Recent clinical series reported BETTER outcomes with early (2-4 weeks) OPERATIVE treatment of Grade III
injuries• Repair/reconstruction of injured structures
Engebretsen L 2009, Harner CD 2004, Liow RY 2003, Fanelli GC 2002, Robertson A 2006Robertson A 2006
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Nonoperative TreatmentLess commonly recommended as better results with Operative treatment
Indications• Nonambulatory• Critically ill
• Severely injured soft tissues• Cannot do PT postop• High grade open• Multiply injured
Exfix or Knee Immobilizer • depending on the degree of stability and
alertness of the patient• Exfix if grossly unstable
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Nonoperative TreatmentImmobilization 3-6 weeks– Reevaluate q 2-3 weeks, once stable start
ROM
Followed by ROM in hinged knee brace– with valgus mold in LCL/PLC injury
– With varus mold in MCL injury
Isometric exercises as early as
possible– Especially quadriceps in PCL injuries
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Operative TreatmentTiming (Early vs.Delayed)Repair/reattachment vs.
ReconstructionSimultaneous Reconstruction
Cruciates vs. STAGED (PCL 1st, ACL later)
Fractures
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Operative Treatment - Timing
MULTIPLY INJURED vs.
ISOLATED INJURY
Risk of HO & Stiffness– Polytrauma (ISS>26 : at least 2-system
injury)– Early Open surgery
LIMITED early surgery ( fixation of avulsions) recommended
DELAY reconstructive surgeryMills WJ, Tejwani N. 2003Mills WJ, Tejwani N. 2003
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Operative Treatment - TimingTYPE of INJURY:
Avulsion with bone vs. Midsubstance tear / Soft tissue avulsion
EARLY fixation of Bony avulsions– More simple than reconstruction (usually
needed if delayed)
Exception: Soft tissue avulsion / midsubstance tears of MCL may be repaired
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Operative Treatment - Timing
TYPE of INJURY: LCL/PLC Injury
Identification of tissues is very difficult after 2 weeks
EARLY reconstruction may be better than repair (Stannard 2005)
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Operative Treatment - TimingRECONSTRUCTION of CRUCIATES
Recently, Good results reported with COMBINED reconstruction of PCL &ACL
STAGED reconstruction (PCL 1st, ACL later) may DECREASE the incidence of
stiffness
Engebretsen L 2009, Harner CD 2004, Fanelli GC 2002, Engebretsen L 2009, Harner CD 2004, Fanelli GC 2002, Ohkoshi Y 2002, Shelbourne KD 1991Ohkoshi Y 2002, Shelbourne KD 1991
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Operative TreatmentFRACTURE DISLOCATIONSSTAGED Treatment
FIRST: Fracture fixation + reattachment of avulsionsReevaluate at 3-6 months
• Treat residual instability as many will be stable/stiff
Treatment of ALL injuries (fracture + dislocation) at once may have
high risk for stiffness• Assess Intraop after fixation of fracture: Treat ligamentous injuries
EARLY if grossly unstable
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Operative TreatmentVariety of techniquesNo consensus on methods
Cruciates: Arthroscopic / Arthroscopic aided
Medial and lateral: Open
Allografts used for reconstructionsRepair capsule
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ComplicationsSTIFFNESS
• Most concerning problem• EARLY ROM is CRUCIAL
• Occurs with both nonoperative & operative treatment
• High velocity, Multiple injured, Head injury: HIGH RISK
• HO may not be present• VERY DIFFICULT TO TREAT
• Think of early MUA (6 weeks) if no progress with aggressive PT
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ComplicationsInstability – Residual Laxity• Nonoperative tx
• Failure of reconstruction• Easier to treat than stiffness
Compartment syndrome• Capsule torn: Be very careful
with arthroscopy
Iatrogenic vascular /nerve injuryOsteonecrosis
• After surgical treatment, 2nd hit?
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Outcomes
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Goal of Treatment
Stable kneePainless knee
Full ROMReturn to preinjury level of activity
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35 patients, 2-10 yrs f/u19 acute, 16 chronic
Reconstruction/repair of ALL injuriesGood outcomes (Lysholm, Tegner, HSS)
No difference between acute and chronic
Conclusion: Combined repair/reconstruction provides reliable outcome
Fanelli GC 2002Fanelli GC 2002
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31 patients, 2-6 yrs f/uReconstruction/repair of ALL injuries
19 operated ≤3 weeks, 12 patients >3 weeksHigher subjective scores and better objective
stability in acutely treated groupMostly uncomplicated LOW energy (!)
Conclusion: ROM same, Stability BETTER in ACUTELY treated
Harner CD 2004Harner CD 2004
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85 patients, 2-9 yrs f/uNo difference acute vs. chronic surgery
WORSE outcome in HIGH energyWORSE outcome in KD-IV (all 4 ligaments
Injured)Selective arteriography based on serial
exam is SAFE87% grade II-IV arthritis compared to
36% on uninjured side
Engebretsen L 2009Engebretsen L 2009
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Outcome - SummaryEarly Reconstruction with modern Arthroscopic techniques results in a
better outcome
Return to preinjury level is UNCOMMONWasher 1997, Liow 2003, Harner 2004,
• 40% nearly Normal• 40% Abnormal
• 20% severely abnormal
Robertson A et al. 2006.Robertson A et al. 2006.
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Case Examples
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KD-I: ACL + MCL34 y/o female s/p PVAClosed injury
Neurovascular intact
Lachman Grade IIIValgus stress Grade III • @30° AND in extension
The rest of Lig. Exam WNL
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KD-I: ACL + MCL
MRI consistent with PE: • midsubstance MCL• Midsubstance ACL
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KD-I: ACL + MCLMCL grade III does not heal when it is
midsubstance and associated with ACL
EUA confirms the degree of instability
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KD-I: ACL + MCLArthroscopic ACL reconstruction with allograft hamstring tendon (autohamstring not chosen due
to medial sided injury)
Open Reconstruction of MCL with Allograft Achilles tendon (bone
plug on the femoral side)( Repair was not feasible) AND repair of
posteromedial capsule
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KD-I: ACL+MCLHinged knee brace• Locked in extension• Molded in varus
NWB/TDWB for 8 weeksIsometric hamstring exercises
Started ROM 0-30°@ postop week 2
• Advanced ROM 30° every 2 weeks
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KD-I: PCL + LCL + PLC
23 y/o male s/MVA
Closed injuryReduced in ED
Neurovascular intact
Posterior sag (+)Posterior drawer grade III
Varus stress grade III• @30° AND in extension
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KD-I: PCL + LCL + PLC
MRI: Extensive Lateral midsubstance injury PCL midsubstance injury
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KD-I: PCL + LCL + PLC
EUA and Arthroscopy confirms Grade III injuries
Note the “drive through sign” and space of the lateral compartment in
arthroscopy
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KD-I: PCL + LCL + PLCPCL reconstructed using allograft tibialis
posterior with transtibial arthroscopic technique
LCL and popliteofibular ligament reconstructed using Allograft Achilles (LaPrade) and
incorporating the LCL remnant.IT band reattached to Gerdy’s tubercle
Poterolateral capsule repaired
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KD-I: PCL + LCL + PLCHinged knee brace• Locked in extension• Molded in valgus
NWB/TDWB for 12 weeksIsometric quadriceps exercises
Started ROM 0-30°@ postop week 2
• Advanced ROM 30° every 2 weeks
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KD-IIIL: ACL + PCL + LCL + PLC
39 y/o fall downstairsClosed injury
Vascular exam WNLHypoestesia on the dorsum
of the foot and weakness of dorsiflexion (3/5)
Neuro deficit persistent after reduction
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KD-IIIL: ACL + PCL + LCL + PLC
MRI: ACL + PCL + Lateral side injury
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KD-IIIL: ACL + PCL + LCL + PLCEUA: all tests
positive except valgus stress
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KD-IIIL: ACL + PCL + LCL + PLC
Surgery @ post-injury day 11Combined arthroscopic ACL &
PCL reconstruction with allograft
Repair of LCL avulsion from femoral origin, popliteaus,
Posterolateral capsule and IT band
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KD-IIIL: ACL + PCL + LCL + PLCHinged knee brace
• Locked in extension• Molded in valgus
NWB/TDWB for 12 weeksIsometric quadriceps exercises
Started ROM 0-30°@ postop week 2
• Advanced ROM 30° every 2 weeks
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KD-IIIL: ACL + PCL + LCL + PLC9 months follow up
Nerve recovered to 4+/5 strength and full
sensationROM : 0-95°
Physically less active compared to preinjury
activity level
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KD-IV: ACL+PCL+MCL+LCL+PLC
ALL torn
51 y/o cab drivers/p MVA
Closed injuryNeurovascular intactReduced in the field
Grossly unstable in ED
Ex-fix placed day of injury
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KD-IV: ACL+PCL+MCL+LCL+PLC
ALL torn
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KD-IV: ACL+PCL+MCL+LCL+PLC
ALL tornSurgery @ post-injury day 18
Arthroscopic ACL & PCL reconstruction with allografts
LCL & Popliteofibular ligament reconstruction with allograft,
repair of popliteus and posterolateral capsule
Repair of MCL and posteromedial capsule
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KD-IV: ACL+PCL+MCL+LCL+PLC
ALL tornHinged knee brace• Locked in extension
NWB/TDWB for 12 weeksIsometric quadriceps exercises @
day 1
Started ROM 0-30°@ postop week 2
• Advanced ROM 30° every 2 weeks
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KD-IV: ACL+PCL+MCL+LCL+PLC
ALL torn1 year follow up
ROM: lacking 10°flexion compared
to noninjured sideBack to work at 1 year
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Take home MessagesDo not MISS Vascular Injury
Evaluate the severity of injuryALL unstable knees are NOT the same
EUA is key in decision making for treatmentPLAN, PLAN, PLAN before surgery
Stiffness is major problemReturn to Previous Activity Level is
UNCOMMON
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BibliographyBonnevialle P et al. OTRC. 2010;96(1): 64-9.
Engebretsen L et al. KSSTA 2009; 17(9):1013-26. Fanelli GC et al. Arthroscopy 2002;18:703–714.
Harner CD et al. JBJS 2004; 86A;262-273. CD et al. JBJS 2004; 86A;262-273. Kennedy JC. JBJS 1963; 45A:889-904.
Liow RW et al. JBJS Br 2003:85(6):845-51.Meyers MH et al. JBJS 1971; 53A:16-29.Mills WJ et al. JOT. 2003;17(5):338-45.
Mills WJ et al. J Trauma 2004;Mills WJ et al. J Trauma 2004;56(6):1261-5.Moore TM. CORR 1981; ;(156):128-40.
Niall DM et al. JBJS Br 2005: 87(5):664-7.
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Bibliography Ohkoshi Y et al. CORR 2002;Ohkoshi Y et al. CORR 2002; ;(398):169-75.
Robertson A et al. JBJS Br 2006; 88;706-11. Schenck RC et al. South Med J 1992; 85(3S): 61.
Schenck RC et al. Arthroscopy 1999; 15(5):489-495. Shelbourne KD et al. Orthop Rev 1991;20:995-1004.Shelbourne KD et al. Orthop Rev 1991;20:995-1004.
Stannard JP et al. JBJS 2004 86:910-915, 2004. Szalay MJ et al. Injury. 1990;21(6):398-400.
Templeman DC et al. JBJS 1989;71(9):1392-5. vanRaay JJ et al. AOTS 1991 ;110(2):75-7. Walling AK et al. JBJS 1982;64(9):1324-7.
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Acknowledgement
William R. Creevy, MS, MD Mark A. Neault, MD
Brian D. Busconi, MD (Version 1, March 2004)
AND
Robert P. Dunbar, Jr., MD(Version 2, Jan 2007)
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Thank You
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