Clinical Review

Paraskiing Crash and Knee Dislocation With Multiligament Reconstruction and Iliotibial Band Repair

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We describe the diagnosis, treatment, rehabilitation, and complications of a 27-year-old male paraskiier who sustained a closed high-velocity knee dislocation after colliding with a tree at a speed of 45 mph and falling 40 feet to the ground. Extensive surgery to repair and reconstruct the knee included open lateral capsular repair, open anatomical posterolateral corner reconstruction with split Achilles tendon allograft, open iliotibial band reconstruction with Achilles tendon allograft, arthroscopic anterior cruciate ligament reconstruction with bone-patellar tendon–bone autograft, and double-bundle posterior cruciate ligament reconstruction with Achilles tendon allograft for the anterolateral bundle and tibialis anterior tendon allograft for the posteromedial bundle. Follow-up surgery was performed to treat arthrofibrosis. Postoperative stress radiographs and subjective outcomes demonstrated that stability was excellent overall.



Take-Home Points

  • Reconstruction of a torn ITB is important in restoration of native anatomy and function given its properties in anterolateral stabilization and resistance to varus stress and internal tibial rotation.
  • Restoration of posterolateral instability primarily involves reconstructing the FCL, PLT, and popliteofibular ligament.
  • For combined PLC injuries, concurrent reconstruction of the cruciate ligaments in one stage is highly recommended.
  • Post-surgery, a 6-week non-weight-bearing, limited flexion rehab protocol utilizing a dynamic PCL brace, such as the PCL Rebound brace, is recommended to prevent posterior tibial sag.
  • Arthrofibrosis and decreased ROM can be seen following a violent knee injury which requires extensive multiligament reconstruction surgeries, occasionally requiring a secondary surgery for further restoration of knee motion.

Tibiofemoral knee dislocations are uncommon injuries that have devastating complications and potentially result in complex surgeries. 1 Knee dislocations (KDs) can be classified with the Schenck system. 2 KD-I is a multiligament injury involving the anterior cruciate ligament (ACL) or the posterior cruciate ligament (PCL), and the scale increases in severity/number of ligaments involved, with KD-V being a multiligament injury with periarticular fracture. 2

In this article, we report the case of a complex multiligament knee reconstruction performed with a midsubstance iliotibial band (ITB) repair. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 27-year-old man presented 12 days after a paraskiing crash in which he collided with a tree at 45 mph and fell 40 feet before hitting snow. Physical examination revealed a large hemarthrosis of the left lower extremity and ecchymosis about the posterolateral aspect of the knee and popliteal fossa. Range of motion (ROM) was limited from 5° of hyperextension to 90° of flexion. Additional motion was deferred secondary to pain. Varus stress testing at 0° and 30° of knee flexion demonstrated significant side-to-side differences. The Lachman test, posterior drawer test, and posterolateral drawer test were all 3+. The dial test was 3 to 4+ compared with the contralateral knee. Valgus stress testing at 0° and 30° of flexion did not reveal any side-to-side laxity. The calf was nontender, and all compartments were soft. The patient reported no neurovascular symptoms and had no neuromotor deficits other than mild common peroneal nerve dysesthesias.

Varus stress radiographs showed increased side-to-side gapping (8 mm) of the lateral compartment of the injured knee. Kneeling posterior stress radiographs, limited because of the patient’s inability to apply full stress on the injured knee secondary to pain, showed a difference of 6 mm in increased posterior translation on the uninjured leg ( Figures 1A-1D ).

Figure 1.
Magnetic resonance imaging (MRI) showed tearing of all posterolateral corner (PLC) structures; specifically, the fibular collateral ligament (FCL) and the popliteus tendon (PLT) were completely torn, and the biceps femoris was partially torn ( Figures 2A-2C ).
Figure 2.
Also identified were a complete, retracted midsubstance tear of the ITB and a complete lateral capsule tear off of the femur. The ACL and the PCL were torn completely, but the menisci and common peroneal nerve were intact. Given the patient’s extensive pathologies and activity level, surgery was deemed the best treatment option. Findings of an examination with anesthesia were consistent with the clinical examination findings, and the decision was made to proceed with the surgery.

First Surgery

1. PLC Approach. A lateral hockey-stick skin incision was made along the ITB and extended distally between the fibular head and the Gerdy tubercle. The subcutaneous tissue was then dissected, and a posteriorly based flap was developed for preservation of vascular support to the superficial tissues. The ITB and the lateral capsule had completely torn off of the femur, allowing exposure directly into the joint. The long and short heads of the biceps femoris were exposed, with about 50% of the biceps attachment torn. The FCL was torn midsubstance, and the PLT had no remnant attachment left on the femur.

2. ITB and Lateral Capsule Tag Stitched. The torn ends of the ITB were dissected and tag stitches placed in each end. Tag stitches were also placed in the lateral capsule in preparation for a direct repair.

3. Neurolysis. The common peroneal nerve was found encased in a significant amount of scar tissue, and extensive neurolysis was required. Slow, methodical dissection was performed under the partially torn long head of the biceps femoris and was continued through the scar tissue and adhesions. Distally, 5 mm to 7 mm of the peroneus longus fascia was incised as part of the neurolysis in order to prevent nerve irritation or


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