A case of medial knee dislocation:

surgical and post-operative

treatment
F. Saccia, G. Torri, M. Vaudetti, M. Falco
ASL TO2 - P. O. San Giovanni Bosco Torino
Juventus Soccer School Medical Area
Casa di Cura SantAnna Casale Monferrato



L.M., , 32 years old
Football player amateur level
Right knee injury during a football match
Mechanism: tackle received by two opponents
(defender + goalkeeper)
No previous right knee injuries
Transported to our Emergency Department


E.D. EVALUATION
Intense medial pain
Patellar dislocation (reduced before x-rays)
Mild emarthrosis
No fractures
No vascular injuries (angio-CT)
No peripheral nerve injuries

1 WEEK AFTER INJURY
FOLLOW-UP CHECK
Lachman test: +
Anterior drawer: +
Posterior drawer: +
Valgus test in extension: 3+
Valgust test 30: 3+
Increased external rotation at
30 of knee flexion


Cast substituted with a
knee hinged brace with
ROM 0- 30
No weight-bearing

Subjective IKDC: 9.2 Lysholm Knee Scale: 15
2 WEEKS AFTER INJURY
MAGNETIC RESONANCE IMAGING
Posterior root lateral meniscus tear in red zone
2 WEEKS AFTER INJURY
MAGNETIC RESONANCE IMAGING
Anterior cruciate ligament tear
2 WEEKS AFTER INJURY
MAGNETIC RESONANCE IMAGING
Posterior cruciate ligament tear
2 WEEKS AFTER INJURY
MAGNETIC RESONANCE IMAGING
Medial collateral ligament grade III lesion (femoral side)
2 WEEKS AFTER INJURY
MAGNETIC RESONANCE IMAGING
Medial patellofemoral ligament tear (femoral side)
2 WEEKS AFTER INJURY
CLASSIFICATION AND DECISION-MAKING
DIAGNOSIS: Medial knee dislocation (KDIIIM) + patella
dislocation + lateral meniscus posterior root tear
TREATMENT OPTIONS
1. Early surgery, one stage: early posteromedial corner repair
(+/- augmentation) + ACL and PCL allograft reconstruction
within 4 weeks
2. Early surgery, two stages: immediate posteromedial corner
repair (+/- augmentation), knee immobilization for 4 weeks,
then ACL and PCL reconstruction
3. Delayed surgery, one stage: rehabilitation, full ROM and
weight-bearing recovery, then posteromedial corner, ACL and
PCL reconstruction with allografts (6-8 weeks after injury)


DELAYED SURGERY ONE STAGE
ADVANTAGES
Full ROM and weight-bearing
recovered: lower risk of
stiffness
No need of prompt allografts
availability
Easier planning of daily life
activities for the patient
Patient psychologically
prepared for surgery (and
rehabilitation)

DISADVANTAGES
Need of more allografts than in
medial repair + bicruciate
reconstruction
Time of return to full activity
two months longer
Medial repair impossible

POSTEROMEDIAL REPAIR VS
POSTEROMEDIAL RECONSTRUCTION
71 patients, 73 PMC tears IN KNEE DISLOCATIONS
Group A: 25 knees treated with repair
Group B: 27 knees treated with autograft reconstruction (G-ST)
Group C: 21 knees treated with allograft reconstruction
Conclusions: Reconstruction of the PMC []
yielded better stability than repair in patients
with a knee dislocation that included PMC
instability.

8 WEEKS AFTER INJURY
FOLLOW-UP CHECK
Full active ROM
Walked with full weight-bearing
without crutches
Subjective IKDC: 54
Lysholm Knee Scale: 62

8 WEEKS AFTER INJURY
SURGICAL PLANNING
Posteromedial corner injury: LaPrade Anatomic Medial
Knee Reconstruction (2 ST allografts)
ACL + PCL tear: reconstruction with a splitted Achilles
tendon allograft
MPFL TEAR: no treatment, first episode of patella
instability, no anatomic primary elements of instability
Lateral meniscus tear: meniscal suture or no treatment,
decision based on arthroscopy (stable/unstable,
dimensions)




Copyright 2009, American Orthopaedic Society for Sports Medicine.
8 WEEKS AFTER INJURY
OPERATING ROOM PHYSICAL EXAM
Wide medial opening, MM lying on tibial surface
Stable LM tear
ACL tear
PCL tear




ARTHROSCOPIC FINDINGS
Medial drive-through sign
ARTHROSCOPIC FINDINGS
ARTHROSCOPIC FINDINGS
PCL tear
ARTHROSCOPIC FINDINGS
ACL + PCL reconstructed
POST-OPERATIVE X-RAYS
POST-OPERATIVE
REHABILITATION PROGRAM
Early ROM from day 1 in the safe zone determined
intraoperatively (in this case 0 - 90) for the first 2 weeks
Further knee flexion allowed after the first 2 weeks
No weight-bearing for the first 6 weeks
Weight-bearing, closed kinetic chain exercises (not beyond 70 of
flexion) and gait training at 6 weeks after surgery
Further strength training and proprioception exercises at 16/20
weeks

REHABILITATION PROGRAM
COMBINED WITH PCL PROGRAM
Early ROM from day 1 in the safe zone determined
intraoperatively (in this case 0 - 90) reduced to 0 - 60 to
protect the reconstructed PCL
Further knee flexion allowed after the first 2 weeks not beyond
90 before the end of the 4th week
No weight-bearing for the first 6 weeks
Weight-bearing, closed kinetic chain exercises (not beyond 70 of
flexion, reduced to 45 of knee flexion until the 8th week) and
gait training at 6 weeks after surgery
Further strength training and proprioception exercises at 16/20
weeks

1 YEAR AFTER SURGERY
FOLLOW-UP CHECK
Full ROM
Subjective IKDC: 90.8
Lysholm Knee Scale: 95
Resumed swimming, cycling, running
Doesnt want to resume football
Interrupted strength training at 9 months after surgery
(job, family)


1 YEAR AFTER SURGERY
FOLLOW-UP CHECK
1 YEAR AFTER SURGERY
FOLLOW-UP CHECK
1 YEAR AFTER SURGERY
VALGUS STRESS X-RAYS
1 YEAR AFTER SURGERY
ANTERIOR DRAWER X-RAYS
1 YEAR AFTER SURGERY
POSTERIOR DRAWER X-RAYS
1 YEAR AFTER SURGERY
MAGNETIC RESONANCE IMAGING
1 YEAR AFTER SURGERY
MAGNETIC RESONANCE IMAGING
1 YEAR AFTER SURGERY
RETURN TO FOOTBALL
Allowed at 1 year after surgery but with at least 90% of
thigh strength in respect to the controlateral, assessed
by the isokinetic test
He preferred to quit football (fear of a new injury)
He resumed cycling, jogging and swimming
No limitations, pain or giving-away in daily life activities

CONCLUSIONS
The medial reconstruction as described by LaPrade,
associated with a bicruciate reconstruction, proved its
efficacy in restoring knee stability
An aggressive post-operative rehabilitation program
with early ROM can prevent stiffness, but the program
must be adapted to the presence of a reconstructed PCL
The surgical decision-making and timing can be different
in professional than in amateur football players
In amateur players the return to football could be
affected by multiple constraints (job, family, fears and
wishes)







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