Objectives. Mechanism of Injury. Traumatic Knee Dislocations. Initial Exam Xrays MRI CT scan. Work up

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1 Case Study: Intercollegiate Football Running Back with Traumatic Knee Dislocation and Multiple Ligament Injury Ron Courson, ATC, PT, NRAEMT, CSCS Senior Associate Athletic Director Sports Medicine University of Georgia Athletic Association Athens, GA Objectives Review mechanism of injury and on-field clinical findings with knee dislocation Discuss emergency care considerations Review role of diagnostic testing with knee dislocation Review surgical considerations with multiple-ligament injury Discuss coordination of pre- and post-op rehabilitation and use of novel techniques within rehabilitation Traumatic Knee Dislocations Mechanism of Injury Traumatic knee dislocations leading to multiple ligament injury are relatively uncommon but not rare injuries These injuries demand prompt and appropriate attention Knee dislocations represent one of the few true orthopedic emergencies due to potential limb-threatening nature Post-operative management must be carefully coordinated with early ROM to restore functional motion without compromising knee stability NV check (serial exams) Stabilize extremity Thorough exam Appropriate supporting studies Initial Exam Xrays MRI CT scan Work up 1

2 5/8/2017 Selective Arteriography (CTA) Surgical Plan Serial Physical Exam (6, 24, 48hrs) Equal pulses ABI <0.9 Expanding hematoma Hx dysvascular foot 90% positive predictive value 100% negative predictive value Multiple surgeons Multiple injuries Multiple scenarios Multiple options Stannard 2004 Case Study Plan Scope, I & D Open Lateral repair +/reconstrxn Scope repair PCL, MMT s Lateral Approach Post-Operative Diagnosis: PCL tear Posterior lateral corner tear LCL tear Biceps femoris tear Medial mensicus tear both anterior and posterior horns Procedure: Arthroscopically assisted PCL repair Medial meniscus repairs anterior and posterior with debridement Open LCL, posterolateral corner and biceps femoris repairs with peroneal nerve neurolysis and allograft figure-ofeight posterolateral corner reconstruction 3 Working Windows 2

3 5/8/2017 Bony Preparation Arthroscopic Portion Fibular-Based PLC Recon Controlled Arthrofibrosis Hinged knee brace locked in full extension for 1st 2 wks Immediate Postop Proximal PCL Repair Ant and Post horn MMR Rehab Program Considerations Problem-solving approach physiologic healing constraints pain swelling ROM restrictions muscle atrophy decreased balance/proprioception DVT/PE prophylaxis deconditioning/weight loss Rehab Program Considerations Is rehabilitation program: evidence based? communicated with all parties? challenging/fun? Does rehabilitation: avoid redundancy? vary rehab activities? utilize all available resources? Is progression based upon: physiologic healing constraints? achieving rehab goals? MD direction? 3

4 Acute Rehab Phase NWB x 6 weeks Dynamic PCL brace locked in full extension x 2 weeks Pain/Swelling control DVT/PE prophylaxis: Xarelto VenoPro ROM: started prone PROM at 2 weeks started CPM with posterior strap on proximal tibia to prevent sag opened brace at 2 weeks with 0-90 degree motion restrictions Acute Rehab Phase PRE: quad sets/slr isometrics active assisted with ESC biofeedback no isolated active hamstring PRE x 4 months 6 weeks post-op deep-water running in pool KAATSU blood flow restriction therapy 7 weeks post-op Flexinator (knee ROM) 8 weeks post-op full weight-bearing 8 weeks post-op: CKC exercise progression squat variations step-up variations leg press (single and double) lunges Gait training hurdle stepping forward, back, side Basic balance/proprioception 10 weeks postop: Eccentron eccentric quadriceps training with emphasis on both strength development and force control 12 weeks post-op: OKC knee extensions running on underwater treadmill 4

5 14 weeks post-op: began walking stadium steps gradual progression in time and number body weight initially with progression over time to 20 lb. weight vest Advanced Rehab Phase 15 weeks postop: advanced balance/proprioc eption activities Advanced Rehab Phase 16 weeks post-op: straight ahead running on land 18 weeks post-op: began jumping 20 weeks post-op: began change of direction drills L drill drill Hoop drill LEFT test (Davies) Reaction drills Form running drills: Dynamic flexibility High knees Kick backs Skipping A, B, C skips Backpeddle Lateral slide Carrioca Ladder drills flat Raised Sled push/pull Progression to noncontact football drills: QB/RB ball exchange pitches passes out of backfield simulated plays Tae Kwon Do: 22 weeks post-op Performed under strict Emphasis on kicking to quadriceps development, and confidence in planting on foot Ground based fighting to 5

6 Tae Kwon Do: Performed under strict Emphasis on kicking to quadriceps development, and confidence in planting on foot Ground based fighting to Tae Kwon Do: Performed under strict Emphasis on kicking to quadriceps development, and confidence in planting on foot Ground based fighting to Tae Kwon Do: Performed under strict Emphasis on kicking to quadriceps development, and confidence in planting on foot Ground based fighting to Sprint training: 24 weeks post-op Curved treadmill Keiser resistance runner Track practice under supervision of sprint coach 26 weeks post-op: progressed to full S&C activities without restrictions 30 weeks post-op: summer football workouts without restrictions 40 weeks post-op: pre-season FB camp without restrictions (29 practices) 40 weeks post-op: pre-season FB camp without restrictions (29 practices) 42 weeks post-op: 1 st scrimmage wearing brace limited snaps 43 weeks post-op: 2 nd scrimmage lighter brace full snaps 6

7 45 weeks post-op: 1 st game returning from injury vs. UNC 32 rushing attempts 222 yards 2 TDs 2016 Season Statistics 224 rushes 1130 yards 8 TDs 5.0 avg. yds/rush long rush 55 yds. 5 receptions for 86 yds. and 1 TD Follow-Up 7