knee dislocation and multiligamentous injury

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

Anatomy: Tibiofemoral Joint

Bones• femoral condyles• tibial plateau

Dissimilar surfaces Little/No inherent

bony stabilityMay be cause of

additional instability if fractured

Stabilizers of the Tibiofemoral JointSoft tissues: stabilize

while allowing ROM• Ligaments• Joint capsule• Menisci

• Musculotendinous units (DYNAMIC)

Anatomy – 4 groups of ligamentsACL

PCLMCL, posteromedial

capsuleLCL & PLC (popliteofibular

ligament, popliteus, capsule, ITB, biceps

femoris)

Vascular AnatomyPopliteal artery at risk for being tethered • Adductor hiatus• Soleus arch

If blood flow through popliteal artery disrupted

Inadequate blood supply distally

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

Knee Dislocation–Multiligamentous InjuryDisruption of

normal relationship of tibiofemoral

jointUsually requires the injury to 2 of

the 4 major groups of ligaments

Knee Dislocation–Multiligamentous Injury

Large Spectrum of injury

Increased severity with more structures involved

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

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

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

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

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

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

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

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)

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)

Physical Examination

Evaluate soft tissues • Open

• Puckering (irreducible dislocation)

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

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

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

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)

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

Neurologic Injury

Common peroneal nerve palsy

Incidence ~20% (10-40%)Most Common with varus

injuryUsually axonothmesisPROGNOSIS is POOR

Complete recovery ~ 20%

Examination of LigamentsVarus Stress test (20-30°, extension)

• Don’t overdo: iatrogenic peroneal

nerve palsy !)

Valgus Stress Test (20-30°, extension)

Examination of LigamentsLachman Test

Examination of LigamentsPosterior Drawer test

Examination of LigamentsExternal Rotation Recurvatum test

Dial test (at 30° and 90°) (positive if 10-

15° difference)

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

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

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

ImagingPlain X-rayArteriogram• On OR table• Angiography• CT Angio

MRICT scan

• Avulsions ( better detail)• Associated fractures (distal

femur, proximal tibia)• CT Angio

Imaging - Plain X-ray

Plain x-ray : AP and Lateral • Abnormal joint space

• Subluxation• Associated Fractures (prox

tibia, distal femur)

Imaging - Plain X-rayAvulsions

• Medial epicondyle (MCL)• Lateral epicondyle (LCL)• Fibular head (LCL)• Tibial spine (ACL)• Posterior tibial (PCL)

• Capsular – anteriolateral(Segond)

Imaging - MRIIndicated for ALL multiligamentous injury

Gives detail of all non-bony structures• Menisci

• Articular cartilage• Ligaments

• Tendons (biceps, Popliteus, ITB)

MR Angiogram (MRA)

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

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

Classification

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

Classification - PositionalPROBLEMSSpontaneous reduction: Unclassifiable

The status of ligaments NOT described

Dislocation with intact cruciate not included

HELPFULReduction maneuver

Kennedy JC. 1963Kennedy JC. 1963

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

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

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

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

Classification -Anatomic

ADVANTAGES

Better DEFINITION of injuries better communication

Guides TREATMENT i.e. what is tornHelpful to COMPARE different types

of treatment, studies

Treatment

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

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

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

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

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

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)

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

Treatment - Vascular InjuryRepair vs. reversed saphenous vein graft

Prophylactic fasciotomy of leg compartments

Treatment - Vascular InjuryScenario 2:

ABNORMAL VASCULAR EXAM – perfused LIMB

URGENT ARTERIAL STUDY

CT- AngiogramAngiography

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

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

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

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

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

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

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

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

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

Operative TreatmentTiming (Early vs.Delayed)Repair/reattachment vs.

ReconstructionSimultaneous Reconstruction

Cruciates vs. STAGED (PCL 1st, ACL later)

Fractures

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

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

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)

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

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

Operative TreatmentVariety of techniquesNo consensus on methods

Cruciates: Arthroscopic / Arthroscopic aided

Medial and lateral: Open

Allografts used for reconstructionsRepair capsule

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

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?

Outcomes

Goal of Treatment

Stable kneePainless knee

Full ROMReturn to preinjury level of activity

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

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

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

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.

Case Examples

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

KD-I: ACL + MCL

MRI consistent with PE: • midsubstance MCL• Midsubstance ACL

KD-I: ACL + MCLMCL grade III does not heal when it is

midsubstance and associated with ACL

EUA confirms the degree of instability

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

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

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

KD-I: PCL + LCL + PLC

MRI: Extensive Lateral midsubstance injury PCL midsubstance injury

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

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

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

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

KD-IIIL: ACL + PCL + LCL + PLC

MRI: ACL + PCL + Lateral side injury

KD-IIIL: ACL + PCL + LCL + PLCEUA: all tests

positive except valgus stress

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

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

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

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

KD-IV: ACL+PCL+MCL+LCL+PLC

ALL torn

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

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

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

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

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.

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.

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)

Thank You

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