Knee Dislocation with Ipsilateral Tibial Fracture Treated with an Intramedullary Locked Nail and Simultaneous Transtibial Tunnel Knee Ligament Reconstruction: A Case Report of Autografts and Limited Resources

摘要

Knee dislocations associated with ipsilateral tibial shaft fracture represent one of the most challenging injuries in trauma surgery. This injury occurs in only 2% of all tibial fractures in several series. With the use of intramedullary nail (IMN) of the tibia, current practice paraments suggest that transtibial tunnels should be avoided and ligamentous knee surgery be delayed until healing of the shaft fracture occurs. We report a novel case which was successfully managed by delayed IMN and multiligamentous transtibial posterior cruciate ligament (PCL) and posterolateral corner (PLC) autograft reconstructions. A 27-year-old male sustained a Gustilo-Anderson grade IIIa tibial shaft fracture and a Schenck IIIL knee dislocation (KD3L) in the ipsilateral knee. At 2 weeks, the patient was then taken back to the operating theater to undergo definitive bone fixation and ipsilateral simultaneous knee ligamentous reconstruction. The knee was stabilized by open reconstruction of the PCL under fluoroscopic control using an ipsilateral quadriceps autograft fixed with metallic interference screws. The PLC was reconstructed with ipsilateral semitendinosus autograft harvested through a separate 1.5-cm standard anteromedial incision using the technique described by Stannard et al. After graft fixation, the 90 degree posterior and posterolateral drawer and 0 and 30 degrees varus stress tests were negative. After 12 months follow-up, the patient had no complaints regarding pain or instability. The tibial fracture had healed and no knee axis deviation could be noted. The patient had returned to recreational low demand activities and motorcycle riding. Treatment of a combined tibial shaft fracture with an ipsilateral knee dislocation may be satisfactorily accomplished with an IMN for the tibia and transtibial tunnel fixation for knee ligament reconstruction allowing for a single rehabilitation course and a shorter recovery without having to use a third stage for knee ligamentous reconstruction.