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Letters to the Editor to:

Scientific Articles:
James P. Stannard, Todd M. Sheils, Robert R. Lopez-Ben, Gerald McGwin, Jr, James T. Robinson, and David A. Volgas
Vascular Injuries in Knee Dislocations: The Role of Physical Examination in Determining the Need for Arteriography
J Bone Joint Surg Am 2004; 86: 910-915 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Vascular injuries in knee dislocations: The role of physical examination
Athanasios V Papavasiliou   (14 December 2004)
[Read Letter to the Editor] Dr. Stannard responds to Dr. Papavasiliou
James P. Stannard   (14 December 2004)

Vascular injuries in knee dislocations: The role of physical examination 14 December 2004
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Athanasios V Papavasiliou,
Orthopaedic Surgeon
Oxford Radcliffe Hospitals NHS Trust

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Re: Vascular injuries in knee dislocations: The role of physical examination

PpvslA{at}aol.com Athanasios V Papavasiliou

To The Editor:

I read with interest the article by Stannard et al(1) In it, the knee dislocations were classified according to the anatomic system proposed by Schenck and modified by Wascher (2) (KD-I to KD-V) which was further expanded by the authors. This classification is based on MRI and surgical findings.

One of the conclusions of the study was that “Increased vigilance may be justified when treating a patient who has a KD-IV dislocation, and the data in the present series indicate that serial examinations should last for at least forty-eight hours”. Although there is a clear outcome in this study and the correlation between the type of knee dislocation (KD-I to KD-V) and arterial damage was not its purpose, I feel that the above conclusion has little clinical value.

Common clinical practice for uncomplicated knee dislocations does not involve immediate (48 hrs) MRI or surgical exploration so, it is very rare that you can classify (KD-I to KD-V) these knee injuries and actually employ the classification to correlate the injury with possible arterial damage.

- A.V. Papavasiliou BSc, MD, PhD

Oxford Radcliffe Hospitals NHS Trust

Oxford, UK

References: 1. Stannard J, Sheils T, Lopez-Ben R, McGwin G Jr, Robinson J, Volgas D. Vascular injuries in knee dislocations: The role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004;86:910-15 2. Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19:457-77
Dr. Stannard responds to Dr. Papavasiliou 14 December 2004
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James P. Stannard,
orthopaedic surgeon
University of Alabama at Birmingham

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Re: Dr. Stannard responds to Dr. Papavasiliou

james.stannard{at}ortho.uab.edu James P. Stannard

To the Editor:

I appreciate Dr. Papavasiliou's letter regarding our study. The primary point of the study was not whether one classification of knee dislocation determines a higher risk for vascular injuries, but rather that physical examination can safely be employed to screen patients regarding the need for arteriograms.

However, the data we collected is striking regarding the increased incidence of vascular injuries with KD-IV dislocations. We are able to get MRI's of the knee within hours of admission if we believe it is necessary. Additionally, we perform a physical examination as one of the first steps in evaluating patients. We are aware that rapid access to MRI scanning, including on nights and weekends is not universally available. However, a good physical examination of the knee can provide enough data to classify a patients injury as a probable KD-IV dislocation.

We believe it is valuable for orthopaedic surgeons to be aware that dislocations in which all four major ligament groups are torn may be associated with a higher risk of vascular injury. If Dr. Papavasiliou's point is that clinical vigilance is necessary for all dislocations, we agree. Despite the higher incidence of vascular injuries with KD-IV dislocations, our protocol advocates serial exams for all dislocations. However, we believe awareness of the potential increased risk with KD-IV dislocations is wise.

Thank you for your comments regarding our study.

Sincerely, James P. Stannard, M.D.