Transcript Knee Dislocation - Orthopaedic Trauma Association

Knee Dislocation and
Multiligamentous Injury
Utku Kandemir, MD
Revised 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 stability
May be cause of
additional
instability if
fractured
Stabilizers of the
Tibiofemoral
Soft tissues:
stabilize while Joint
allowing ROM
• Ligaments
• Joint capsule
• Menisci
• Musculotendinous units
(DYNAMIC)
Anatomy – 4 groups of
ACL
ligaments
PCL
MCL, posteromedial capsule
LCL & PLC (popliteofibular
ligament, popliteus,
capsule, ITB, biceps
femoris)
Anatomy
PoplitealVascular
artery at risk
for
being tethered
• Adductor hiatus
• Soleus arch
If blood flow through
popliteal artery disrupted
Inadequate blood supply
distally
Influences
LongTerm
Anatomy:
Outcome
Peroneal nerve
Nerves
• More commonly injured
• Tethered around the
fibular neck
• Mechanism of injury
• Tension (Varus ±
hyperextension,
Translation (Anterior
/Posterior dislocation)
• Direct impact
• Iatrogenic (aggressive
Knee Dislocation–
Disruption of
Multiligamentous
Injury
normal
relationship of
tibiofemoral
joint
Usually 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
Pathomechanics
Cadaveric
study
Progressive Hyperextension
model
Anterior
dislocation
@≈30 degrees: tear of posterior
CAPSULE
Followed by tear of PCL & ACL
DISLOCATION
@≈50 degrees: rupture of Kennedy JC. 1963
Pathomechanics
Cadaveric
study
Combined 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 femur
ACL: Mixed pattern of injury
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. 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. 1971
True incidence
is underreported
Epidemiology
• 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
Epidemiology
0.2 % of all orthopaedic
injuries
Young ♂
MVA, sports trauma
14-44 % associated w
multiple trauma
Bilateral 5 %
Robertson A et al. 2006
Ligamentous Injury in
Suspect & Examine
in any
Polytrauma
Patient
• 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%

If any of the following
present r/o
Diagnosis
Multiligamentous injury (Spontaneous
reduction UNDERDIAGNOSED)
Hyperextension
 Popliteal ecchymosis
 Vascular insufficiency
 Peroneal nerve deficit
 Diffuse tenderness but
Absence of hemartrosis
(capsular disruption)
 Obese pt low energy fall

Physical Examination
Evaluate soft tissues
• Open
• Puckering (irreducible dislocation)
Vascular Examination
Color, temperature, Pulses
Dorsalis 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
Vascular Examination
ABI ≥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
Mills WJ 2004, Stannard JP 2004
Vascular
ABI <0.9 ORExamination
Temperature, Color, OR
Expanding swelling
(hematoma) around the
knee
Arterial study
• Arteriography in OR ( on
table by surgeon)
• Angiography (radiology suite)
Vascular Injury
~20% (5-30%) of all
dislocations
EMERGENCY if NO distal
perfusion
Patterns of Vascular injury
• rupture
• incomplete tear
• intimal injury (may cause
Neurologic Examination
Peroneal 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
injury
Usually axonothmesis
PROGNOSIS is POOR
Complete recovery ~ 20%
Examination of Ligaments
Varus Stress test
(20-30°,
extension)
• Don’t overdo:
iatrogenic peroneal
nerve palsy !)
Valgus Stress Test
(20-30°,
extension)
Examination of Ligaments
Lachman Test
Examination of Ligaments
Posterior Drawer test
Examination of Ligaments
External Rotation
Recurvatum test
Dial test (at 30° and
90°) (positive if 1015° difference)
Examination
ofonLigaments
Injury
Severity: based
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
Varus
stress @ 30° Tests
• 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
Posterior
Drawer
or
Quad
Active
@
90°
Positive Ligamentous Tests
• 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°
Imaging
Plain X-ray
Arteriogram
• On OR table
• Angiography
• CT Angio
MRI
CT scan
• Avulsions ( better detail)
• Associated fractures
(distal femur, proximal
tibia)
Imaging - Plain X-ray
Plain x-ray : AP and Lateral
• Abnormal joint space
• Subluxation
• Associated Fractures (prox
tibia, distal femur)
Imaging - Plain X-ray
Avulsions
• Medial epicondyle (MCL)
• Lateral epicondyle (LCL)
• Fibular head (LCL)
• Tibial spine (ACL)
• Posterior tibial (PCL)
• Capsular – anteriolateral
(Segond)
Indicated
for ALL- MRI
Imaging
multiligamentous injury
Gives detail of all non-bony
structures
• Menisci
• Articular cartilage
• Ligaments
• Tendons (biceps, Popliteus,
ITB)
IdentifyImaging
ligament injury
- MRI
• 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.
Diagnosis - EUA
Invaluable 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
- Positional
Tibial
position with respect
to
femur
Anterior (40%)
Posterior (33%)
Lateral (18%)
Medial (4%)
Rotational (5%)
Kennedy JC. 1963
Classification
- Positional
PROBLEMS
Spontaneous reduction:
Unclassifiable
The status of ligaments NOT
described
Dislocation with intact cruciate not
included
HELPFUL
Reduction maneuver
Kennedy JC. 1963
Classification - Fracture
Dislocations
Type I: Split
Type II: Entire Condyle
Type II: Rim Avulsion
Type IV: Rim Compression
Type V: Four-Part
“Fracture dislocation of the knee is much
more serious injury than a plateau
Moore TM. 1981
Classification – Anatomic
(Injured Structures)
KD-II
KD-III
KD-I Single cruciate + Collateral
Both cruciates TORN, Collaterals INTACT
Most Common pattern
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 Injury
N = Nerve Injury
Schenck RC et al. 1992
Classification – Injured
Structures
Anatomic Classification of Knee Dislocations
Schenck 1992
ACL + collateral
I
single cruciate + collateral
II
ACL / PCL
collaterals intact
III M
ACL / PCL / MCL
LCL+PLC intact
III L
ACL / PCL / LCL+PLC
MCL intact
IV
ACL / PCL / MCL / LCL+PLC
PCL + collateral
V
fracture dislocation
C
arterial injury
N
nerve injury
Schenck RC et al. 1992
Fracture Dislocations: KD-V
KD-V1
Dislocation without both
cruciates
involved
KD-V2 Bicruciate disruption
only
KD-V3M Bicruciate +
posteromedial disruption
KD-V3L Bicruciate +
posterolateral disruption
KD-V4
Bicruciate +
Posteromedial
AND
Classification -Anatomic
ADVANTAGES
Better DEFINITION of injuries
better communication
Guides TREATMENT i.e. what is torn
Helpful to COMPARE different types
of treatment, studies
Treatment
Treatment – Closed
Should
be done
Reduction
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)
Closed
Reduction
Maneuver
POSITION
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 Reduction
Irreducible by Closed methods
Rare
Typically 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 Stabilization
Depends on the STABILITY after reduction
Stability correlated with the extent of injured
structures
Complicated
Knee immobilizer
by Obesity
and Other
• If grossly stable
Injuries
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
Initial Stabilization-External
Indications:
Fixation
• 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)
TreatmentScenario
- Vascular
Injury
1:
ISCHEMIC LIMB after REDUCTION
EMERGENCY EXPLORATION
Location of injury predictable
On table Arteriogram can be done
Circulation has to be restored in 6-8 hrs
Treatment
Vascular
Injury
Repair vs. reversed saphenous vein graft
Prophylactic fasciotomy of leg
compartments
TreatmentScenario
- Vascular
Injury
2:
ABNORMAL VASCULAR EXAM –
perfused LIMB
URGENT ARTERIAL STUDY
CT- Angiogram
Angiography
3:
TreatmentScenario
- Vascular
Injury
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
4:
TreatmentScenario
- Vascular
Injury
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 POOR
Complete Recovery ~ 20%
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
Discuss Treatment
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
Nonoperative vs. Operative
No prospective
Randomized Clinical
Treatment
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
Engebretsen
L 2009,
Harner CD 2004, Liow RY
2003, Fanelli GC 2002,
Robertson A 2006
• Repair/reconstruction
of injured
Less
commonly recommended
as
Nonoperative
Treatment
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
Nonoperative
Treatment
Immobilization 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 Treatment
Timing (Early vs.Delayed)
Repair/reattachment vs.
Reconstruction
Simultaneous Reconstruction Cruciates
vs. STAGED (PCL 1st, ACL later)
Fractures
Operative Treatment MULTIPLY INJURED vs.
Timing
ISOLATED INJURY
 Risk of HO & Stiffness
– Polytrauma (ISS>26 : at least 2-system
injury)
– Early Open surgery
LIMITED early surgery ( fixation of
avulsions) recommended
Mills WJ, Tejwani N. 2003
DELAY reconstructive surgery
Operative Treatment TYPE of Timing
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
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 RECONSTRUCTION
Timing of
CRUCIATES
Recently, Good results reported with
COMBINED reconstruction of PCL
&ACL
STAGED reconstruction (PCL 1st,
ACL later) may DECREASE the
Engebretsen
L 2009,
Harner CD 2004, Fanelli GC 2002,
incidence
of stiffness
Ohkoshi Y 2002, Shelbourne KD 1991
FRACTURE
DISLOCATIONS
Operative
Treatment
STAGED Treatment
FIRST: Fracture fixation +
reattachment of avulsions
Reevaluate 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
Operative
Treatment
Variety
of techniques
No consensus on
methods
Cruciates: Arthroscopic
/ Arthroscopic aided
Medial and lateral: Open
Allografts used for
Complications
STIFFNESS
• 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
Instability Complications
– Residual Laxity
• Nonoperative tx
• Failure of reconstruction
• Easier to treat than stiffness
Compartment syndrome
• Capsule torn: Be very careful
with arthroscopy
Iatrogenic vascular /nerve
injury
Osteonecrosis
Outcomes
Goal of Treatment
Stable knee
Painless knee
Full ROM
Return to preinjury level of activity
35 patients, 2-10 yrs f/u
19 acute, 16 chronic
Reconstruction/repair of ALL injuries
Good outcomes (Lysholm, Tegner, HSS)
No difference between acute and chronic
Conclusion: Combined
repair/reconstruction provides reliable
outcome
Fanelli GC 2002
31 patients, 2-6 yrs f/u
Reconstruction/repair of ALL injuries
19 operated ≤3 weeks, 12 patients >3
weeks
Higher subjective scores and better
objective stability in acutely treated
group
Mostly uncomplicated LOW energy (!)
Harner CD 2004
85 patients, 2-9 yrs f/u
No difference acute vs. chronic
surgery
WORSE outcome in HIGH energy
WORSE outcome in KD-IV (all 4
ligaments Injured)
Selective arteriography based on
serial exam is SAFE
87% grade II-IV arthritis compared
to
Engebretsen L 2009
Outcome - Summary
Early Reconstruction with modern
Arthroscopic techniques results in a
better outcome
Return to preinjury level is UNCOMMON
Washer 1997, Liow 2003, Harner 2004,
• 40% nearly Normal
• 40% Abnormal
• 20% severely abnormal
Robertson A et al. 2006.
Case Examples
KD-I:
+ MCL
34 y/o
femaleACL
s/p PVA
Closed injury
Neurovascular intact
Lachman Grade III
Valgus stress Grade III
• @30° AND in extension
The rest of Lig. Exam WNL
KD-I: ACL + MCL
MRI consistent with PE:
• midsubstance MCL
KD-I:
ACLnot
+ MCL
MCL grade
III does
heal when it is
midsubstance and
associated with ACL
EUA confirms the degree
of instability
KD-I:
+ MCL
Arthroscopic
ACL 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+MCL
Hinged
knee
brace
• Locked in extension
• Molded in varus
NWB/TDWB for 8 weeks
Isometric 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 injury
Reduced in ED
Neurovascular intact
Posterior sag (+)
Posterior drawer grade III
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 + PLC
PCL 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
KD-I:
+ LCL + PLC
Hinged PCL
knee brace
• Locked in extension
• Molded in valgus
NWB/TDWB for 12 weeks
Isometric 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 downstairs
Closed injury
Vascular exam WNL
Hypoestesia on the dorsum of
the foot and weakness of
dorsiflexion (3/5)
Neuro deficit persistent after
reduction
KD-IIIL: ACL + PCL + LCL +
PLC
KD-IIIL: ACL + PCL + LCL +
EUA: all tests positive
PLC
except valgus stress
KD-IIIL: ACL + PCL + LCL
+ PLC
Surgery @ post-injury day 11
Combined arthroscopic ACL & PCL
reconstruction with allograft
Repair of LCL avulsion from
femoral origin, popliteaus,
Posterolateral capsule and IT
band
KD-IIIL: ACL + PCL + LCL +
Hinged knee brace
PLC
• Locked in extension
• Molded in valgus
NWB/TDWB for 12 weeks
Isometric quadriceps
exercises
Started ROM 0-30°@
postop week 2
• Advanced ROM 30° every 2
KD-IIIL: ACL + PCL + LCL +
9 months followPLC
up
Nerve recovered to 4+/5
strength and full
sensation
ROM : 0-95°
Physically less active
compared to preinjury
activity level
KD-IV: ACL+PCL+MCL+LCL+PLC
ALL torn
51 y/o cab driver
s/p MVA
Closed injury
Neurovascular intact
Reduced 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
Surgery
@ post-injury day 18
ALL torn
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
Hinged knee brace
torn
• LockedALL
in extension
NWB/TDWB for 12 weeks
Isometric quadriceps exercises @
day 1
Started ROM 0-30°@ postop week
2
• Advanced ROM 30° every 2 weeks
KD-IV:
ACL+PCL+MCL+LCL+PLC
1 year follow up
torn
ROM: lacking ALL
10°flexion
compared to
noninjured side
Back to work at 1 year
Take home Messages
Do not MISS Vascular Injury
Evaluate the severity of injury
ALL unstable knees are NOT the same
EUA is key in decision making for treatment
PLAN, PLAN, PLAN before surgery
Stiffness is major problem
Return to Previous Activity Level is
Bibliography
Bonnevialle 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.
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;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; ;(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.
 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
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