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Knee dislocation caused by violent trauma is a complex, severe injury. Disruption of at least three of the four major ligaments causes pronounced instability, and the condition is typically a limb-threatening injury because of the combination of vascular and neurologic damage.
Preoperative X-ray of dislocated knee
There is a lack of high-level evidence available on which to base a systematic approach to evaluation and treatment of knee dislocation patients with multiligament injuries, despite the fact that comprehensive centers of orthopedic excellence like Mayo Clinic regularly treat numerous patients with traumatic knee dislocation. For example, a single orthopedics practitioner at Mayo Clinic has performed 91 cases in the past 3 years.
The unsettled questions and controversies these cases present center on several factors:
Each case is highly individual and the surgical procedures are complex.
ACL and PCL grafts before tibial fixation
Arthroscopic view of the ACL and PCL grafts after fixation
X-ray after fixation
To fill the evidence gap and create better outcomes for more patients by achieving a consensus on best practices, a group of eight knee surgery specialists from the United States and Canada formed the Knee Dislocation Study Group.
The impetus for this international effort came from Mayo Clinic's Bruce A. Levy, M.D., an orthopedic surgeon on the Rochester, Minn., campus. Dr. Levy was inspired by the clinical successes that resulted after the Canadian Orthopaedic Trauma Group pooled experiences from multiple institutions. The Knee Dislocation Study Group convened its first working session in September 2007.
Explains Dr Levy, "No two knee dislocations are exactly alike, except that the decision making involved is always highly challenging. Because of this fact, I found myself reaching out to my mentors for guidance. It was immediately obvious that everybody involved benefits from such a group — all the orthopedic surgeons and all the patients. By pooling our experience and our data, we produce evidence that is more powerful for devising a systematic approach to obtaining optimal outcomes for knee dislocation patients."
Michael J. Stuart, M.D., Dr. Levy's Mayo Clinic collaborator, adds, "The power of the group is that we can accelerate and improve the problem-solving process. Right now, the orthopedic literature does not always provide a single, validated best approach. We hope to change that by creating evidence-based consensus."
The group corresponds regularly and meets approximately every six months, often in conjunction with an annual meeting of a professional society. Members work together in the cadaver dissection laboratory to share surgical techniques, publish papers in the peer-reviewed literature and design large multicenter research trials. The group is also laying the foundation for creating a standardized database in which all their knee dislocation patients may be followed as a means of assessing and predicting outcomes.
As an example of the clinical impact of such a study group, Dr. Levy cites the Canadian group's experience with clavicle fractures. Before the Canadian group's studies and published results, most of these fractures were treated nonoperatively. But through a randomized, prospective trial comparing operative and nonoperative management, the Canadians discovered that fractures with severe displacement experienced improved functional outcomes when treated operatively.
"This is tremendous work and an example of a study group that changed clinical practice," Dr. Levy says. "There really is strength in numbers. The more complex the surgery and the patient population, the more we need help from our colleagues and their pooled experience to guide our efforts to optimize patient care."
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