Knee dislocation and tibial plateau fracture - a case presentation

This case presentation is of a patient who suffered a traumatic knee dislocation of his right knee, with multiligament injury as well as tibial plateau fractures on both the medial and lateral sides.

The injury had occurred a week before I saw him, and he was referred to me as a tertiary referral for complex reconstruction because of my special interest in multiligament instability.

The patient, a young man who was 19 years old at the time of injury, was engaged in a sport known as free running during which he ran against a wall and did a somersault - which went very wrong and he fell, twisting his right knee badly. The knee dislocated, rupturing the posterior cruciate ligament (PCL) and other structures in the posterolateral corner (PLC), and rupturing both the medial cruciate ligament (MCL) and lateral cruciate ligament (LCL). The anterior cruciate ligament was intact and so were the nerves.

 

The challenge

This was really a terrible injury - just awful! The most common kind of dislocation one comes across in the knee is dislocation of the patella (kneecap), but that only affects the one compartment of the knee, the anterior compartment. An injury like this with rupture of the major ligaments affects the medial and the lateral compartment, and the added complication of the tibial plateau fractures made it a huge challenge. To be able to deal with such cases one has to build up one's expertise and also the expertise of your surgical and rehab team. A difficult case like this is really challenging, but you have to rise to the challenge, think clearly and apply the basic principles

In a standard ligament injury like a football injury one can be unlucky and rupture one ligament or even two. This young man was very fit, and his sport involved extreme actions like flipping and jumping over walls and doing somersaults - and he did not just rupture on ligament, he ruptured all his ligaments except one!

In the old days before reconstructive surgery, he probably would have had the tibial plateau fracture seen to and then the knee would have been put in a plaster for 6 weeks and immobilised, by which time structures would have gummed up, and then one would have tried to rehabilitate him. These days there is a very different approach, and one would expect ligament reconstruction to be done within two weeks. Three weeks is pushing it because after that it is hard to identify the anatomy properly because by this time all the tissues look macerated. His knee was very swollen even at one week and the surgery took 4 or 5 hours.

 

Surgery

Although I had MRI scans pre-op, the full extent of the tibial plateau fracture only became evident during surgery, so I decided to perform the reconstruction in two stages because of the complexity, doing the most difficult ligament reconstructions first. I reconstructed the posterior cruciate ligament and posterolateral corner. The following week i brought him back to the operating theatre (OR)and reconstructed the medial collateral ligament and fixed the tibial plateau fracture with a medial plate.

 

Outcome

He has done really well!! It demonstrates how well people can do after these horrendous injuries. He was immobilised for a while, and then gently mobilised for the first six weeks. He was a bit slow regaining full extension as we wanted to protect the grafts. He was very motivated. Now at five months after the procedures were completed he has very little pain and almost full function. The PCL is a little slack but this is a good result with only slight residual laxity.