您的感受¶
多韧带膝关节损伤意味着维持膝关节稳定的多条强韧韧带中,不止一条发生了撕裂。这种情况通常发生在严重的扭转、跌倒或撞击之后,受伤时膝关节往往会完全失稳。
疼痛通常位于膝关节中央深处,并常沿内侧、外侧后角或两者同时出现。您的膝关节可能会感觉松弛或不稳定,仿佛在负重时可能会滑动或打软。肿胀会迅速出现且可能非常严重。行走困难,在楼梯或不平地面上时,您可能觉得膝关节不够安全,不敢放心承重。
完全伸直膝关节可能很困难且疼痛。弯腰捡东西、跪地或下蹲可能会加剧疼痛。从低矮的椅子上站起、上车或从马路牙子上迈下时,都可能感觉不稳。膝关节在活动后往往感觉更差,夜间可能出现酸痛,尤其是在受伤后的最初几天和几周。
由于这种损伤常伴随同一次事故造成的其他损伤,您可能还同时面临其他部位的疼痛或问题,例如头部、胸部或腹部。髌骨周围的肌腱和关节内的软骨垫也可能受损,这会增加疼痛和僵硬感。在某些情况下,膝关节附近的神经或血管也会受到影响,您的手术团队会仔细检查,并在必要时优先处理。
每个膝关节损伤都略有不同。哪些韧带撕裂、其他损伤的程度以及受伤的方式,都会影响您的感受以及适合您的治疗方案。
实际发生了什么¶
您的膝关节由四条主要韧带维系,这些韧带是连接骨骼的强韧带状组织。一条位于前方,一条位于后方,一条位于内侧,还有一组位于外侧后角。多韧带损伤意味着其中至少两条韧带已经撕裂。这种情况通常发生在膝关节在重大事故(如车祸或严重跌倒)中被强行脱位,随后自行复位或由急救人员复位时。
当膝关节脱位时,受损的不仅仅是韧带。关节内的缓冲垫(半月板)可能撕裂,关节面本身也可能出现挫伤或损伤。髌骨周围的肌腱也可能受到牵拉。这就是为什么您感受到的疼痛和僵硬来自同一膝关节的多个部位,而不仅仅是一个痛点。
膝关节附近的两个结构需要特别关注。一条大动脉紧贴关节后方走行,并被牢固地固定,因此在膝关节移位时可能被拉伸或撕裂。沿小腿外侧、靠近较细的小腿骨(腓骨)上端走行的神经也可能被拉伸。如果该神经受到影响,您向上抬起足部前侧的动作可能会变得无力或松弛。这就是为什么您的手术团队会仔细且尽早地检查您腿部的脉搏和神经功能。
您感受到的肿胀和关节失稳,是这些撕裂的韧带不再能维持关节稳定的直接结果。失去它们的约束,膝关节在您负重时可能会向前、向后或向侧方滑动。这种滑动还会牵拉缓冲垫和关节面,从而加剧疼痛。治疗的目标是恢复这种稳定性,使膝关节能够重新被信赖。
我们能做什么¶
首先进行普通 X 光检查。MRI 扫描可提供撕裂的韧带、缓冲垫(半月板)及关节面的详细图像。应力 X 光片是在对膝关节施加温和压力的情况下拍摄的,可显示关节的松弛程度,并帮助我们制定计划。
部分膝关节可通过非手术方式管理。如果其他健康问题使长时间手术不安全,或者您的膝关节在支撑下保持稳定,这可能适合您。治疗从使用支具固定膝关节开始,随后进行物理治疗以重建力量和活动能力。对于某些损伤模式,例如前韧带撕裂合并内侧韧带拉伸,仅使用支具和物理治疗即可取得良好效果。在一组采用此方式治疗的患者中,68% 的人恢复了之前的活动水平。当膝关节持续脱位、涉及开放性伤口或血管损伤,或儿童的生长板尚未闭合时,通常建议进行手术。
当需要手术时,撕裂的韧带将被重建,以便膝关节重新保持稳定。由于多个韧带同时撕裂,该手术比单韧带修复更大,且通常分阶段进行,期间保护膝关节。我们将与您详细讨论计划,包括用于新韧带的组织类型及其对康复的影响。这一选择是共同决定的,基于您的损伤、健康状况以及您对膝关节功能的期望。
无论采取何种治疗,康复都是结果的重要组成部分。手术后,膝关节通常先以伸直位用支具固定,然后逐渐弯曲。在一种常见的方案中,您需 6 周内避免负重,第 2 至 6 周弯曲至 70 度,之后自由活动。慢跑至少需等待 3 个月。大多数复杂重建手术需要 9 至 12 个月恢复,尽管有些人可在 6 个月时恢复重体力劳动或运动。
预期情况¶
多韧带膝关节损伤是一种严重的损伤,恢复需要时间。大多数接受手术重建撕裂韧带的人都能恢复一个稳定、可靠的膝关节。许多人对结果感到满意,并恢复日常活动。一些年轻运动员能够以某种程度重返运动,但并非每个人都能恢复到受伤前的确切水平。
恢复通常以月而非周为单位衡量。膝关节需要时间愈合,随后需要数月的物理治疗来重建力量和信心。您的恢复情况不仅取决于膝关节本身。同一事故造成的其他部位损伤,如头部、胸部或腹部,可能会减缓恢复进程并延长住院时间。年龄也很重要。30岁以上的人在术后几年内报告的膝关节评分往往略低于年轻人。其他健康因素,包括体重,也可能影响术后并发症的风险。
与常规单韧带手术相比,此类手术风险更高。在术后30天内,无论轻微还是严重,发生并发症的可能性均高于标准关节镜前交叉韧带重建术。手术过程中出现问题并不常见,但在术后早期几天和几周内可能性更大。您的外科团队会密切监测这些情况,一旦出现将及时处理。
如果不进行治疗,不稳定的膝关节往往会持续打软,长期来看可能会使软骨垫和关节面承受过度应力。早期手术通常比等待或不处理膝关节带来更好的功能恢复。未治疗的膝关节在长期预后上也往往不如重建后的膝关节。
设定现实的目标。大多数人能恢复一个稳定的膝关节,足以应对日常生活、工作和许多活动。部分人有可能完全重返高水平运动,但并非对所有人都能保证。您的外科医生将根据您的损伤情况、年龄和健康状况,与您讨论治疗后膝关节实际能达到的功能水平。
何时就医¶
此类损伤发生时即为急症。若您的膝盖在跌倒、碰撞或其他重大撞击中被迫脱位,或外观严重变形,请立即前往急诊科。若您的腿部感觉发冷、苍白或麻木,踝部无脉搏,或无法向上抬起足部前侧,同样适用上述情况。这些症状可能提示膝盖后方的动脉或神经受损,需立即检查。
若数周后膝盖仍感觉松弛或持续打软,无法完全伸直,或休息和使用支具后肿胀与疼痛仍未缓解,请要求专科医生评估。同一事故造成的其他部位严重损伤可能会改变膝盖的治疗方式和时机,因此也请告知您的医疗团队任何头部、胸部或腹部损伤。
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology¶
Bony Anatomy¶
- The bones of the knee are the distal femur, the proximal tibia, and the patella [2].
- The medial femoral condyle is larger and projects farther posteriorly and distally than the lateral condyle [6].
- The lateral femoral condyle projects farther anteriorly and is wider in the medial-lateral direction than the medial femoral condyle [6].
- The tibial articular surface slopes 7° to 10° in the sagittal plane [6].
- The posterior slope of the medial tibial plateau averages 10.7° and the lateral plateau averages 7.2° [11].
- The medial tibial plateau is larger than the lateral plateau and is concave in its frontal and sagittal planes [6].
- The lateral tibial plateau is smaller, more circular, concave in the frontal plane, and convex in the sagittal plane [6].
- The patella is the largest sesamoid bone in the body with a mean thickness of 2.5 cm [6, 11].
- The patellar articular surface contains a vertical central ridge separating the broader lateral facet from the medial facet, plus a smaller medial odd facet [6].
- The fibular head is located a mean of 1.5 cm distal to the joint line, with a range of 6 to 32 mm [11].
Ligaments¶
- The anterior cruciate ligament (ACL) prevents anterior translation and rotation of the tibia on the femur [2].
- The ACL is composed of 90% type I collagen and 10% type III collagen [6, 7, 11].
- The mean length of the ACL is 33 mm and the mean midsubstance width is 11 mm [6, 11].
- The ACL femoral attachment is a semicircular area on the posteromedial aspect of the lateral femoral condyle [6, 7, 11].
- The ACL tibial attachment is a broad, irregular, oval-shaped area between the medial and lateral tibial spinous processes [6, 11].
- The ACL consists of an anteromedial bundle that is tight in flexion and a posterolateral bundle that is tight in extension [7, 8, 11].
- The posterior cruciate ligament (PCL) prevents posterior subluxation of the tibia on the femur [2].
- The PCL is the largest intra-articular ligament with an average length of 38 mm and a mean midsubstance diameter of 13 mm [11, 19].
- The PCL cross-sectional area is approximately 120% to 150% greater than that of the ACL [19].
- The PCL has two bundles: an anterolateral (AL) bundle comprising 85% of the cross-sectional area and a posteromedial (PM) bundle [19].
- The PCL AL bundle is tight in knee flexion, while the PM bundle is tight in knee extension [11].
- The PCL tibial insertion is located 10 to 15 mm distal to the joint line on the posterior tibia [11, 19].
- The medial collateral ligament (MCL) has superficial and deep portions that stabilize the knee against valgus stresses [2].
- The superficial MCL proximal division resists valgus tibial translation, while the distal division resists tibial external rotation in extension [7, 8].
- The lateral collateral ligament (LCL), or fibular collateral ligament, runs from the lateral femoral condyle to the head of the fibula and is the main stabilizer against varus stress [2].
- The LCL resists varus tibial translation and tibial external rotation, especially at 30 degrees of knee flexion [7, 8].
- The popliteofibular ligament is present in 90% of knees and runs from the popliteus tendon to the styloid on the posterior fibular head [2].
- The popliteofibular ligament resists tibial external rotation, especially in knee flexion, and posterior tibial displacement [7, 8].
- The oblique popliteal ligament resists knee hyperextension and varus tibial translation [7, 8].
- The meniscofemoral ligaments (Humphrey and Wrisberg) are present in 93% of knees and connect the posterior horn of the lateral meniscus to the intercondylar notch [11, 19].
- The anterolateral ligament (ALL) was demonstrated in 100% of 23 human cadaveric knees in a dissection study [29].
Menisci¶
- The menisci are C-shaped fibrocartilaginous disks that provide shock absorption, increase joint congruency, enhance stability, and aid in synovial fluid distribution [2].
- The medial meniscus is firmly attached to the joint capsule along its entire peripheral edge [2].
- The lateral meniscus is attached to the anterior and posterior capsule but has a region posterolaterally where it is not firmly attached [2].
- The medial meniscus has less mobility than the lateral meniscus and is more susceptible to tearing when trapped between the femoral condyle and tibial plateau [2].
- The lateral meniscus is larger than the medial meniscus and carries a greater share of the lateral compartment pressure [2].
- The menisci consist of type I collagen fibers arranged obliquely, radially, and vertically [11].
- Vascular supply to the menisci penetrates 20% to 30% of the peripheral medial meniscus and 10% to 25% of the peripheral lateral meniscus [11].
Vascular and Neurologic Anatomy¶
- The blood supply to the knee is formed from an anastomosis including the descending geniculate, superior and inferior geniculate, middle geniculate, and anterior tibial recurrent arteries [6].
- The middle geniculate artery supplies both the anterior and posterior cruciate ligaments [6, 11].
- The popliteal artery travels through the adductor hiatus and distally through the fibrous arch deep to the soleus muscle, where it is relatively immobile [16].
- The common peroneal nerve travels along the posterior edge of the biceps femoris and continues distally around the fibular neck [16].
- The tibial nerve courses distally through the center of the popliteal fossa after branching from the sciatic nerve [16].
- The largest nerve providing innervation of the intra-articular knee is the posterior articular branch of the tibial nerve [6].
Kinematics and Biomechanics¶
- The knee is a hinge joint that incorporates gliding and rolling, with a "screw-home" mechanism where the tibia externally rotates 5 degrees in the final 15 degrees of extension [7, 8].
- The greatest range of motion occurs in the sagittal plane at approximately 160° [22].
- Knee rotation ranges from 45° in external rotation to 30° in internal rotation [22].
- In the frontal plane, the range of motion in both abduction and adduction reaches a maximum of 10° [22].
- Rupture of the cruciate ligaments or disruption of the tibiofemoral surface causes a major change in the path of the instant center, leading to articular dysfunction [22].
- The crossed four-bar linkage system describes the ACL and PCL as the central pivot and gear, while the menisci provide peripheral force control and braking [23].
Pathophysiology of Knee Dislocation¶
- Knee dislocations represent less than 0.2% of all orthopaedic injuries [16].
- 20% to 50% of knee dislocations spontaneously reduce in the field, leading to underreporting of true incidence [16].
- The four major ligamentous stabilizers of the knee are the ACL, PCL, MCL, and fibular collateral ligament [16].
- The posterolateral corner (PLC) consists of the FCL, iliotibial band, popliteofibular ligament, biceps femoris, and popliteus tendon [16].
- Associated fractures occur in 57% of knee dislocations, with multiple fractures in 41% and open fractures in 27% [34].
- Damage to cartilage and menisci occurs in at least one-third of patients with traumatic knee dislocation [34].
- Popliteal artery compromise following multiligament knee injury is estimated to occur as high as 50% [34].
- Peroneal nerve palsy complicates knee dislocations at a frequency of approximately 25% [34].
- Recovery of antigravity ankle dorsiflexion strength was observed in 38% of patients with complete peroneal nerve palsy compared to 83% with partial palsy [34].
- High-energy knee dislocations are associated with life-threatening injuries in 27% of patients [34].
Clinical Presentation¶
- Acute knee dislocation is described as an elusive entity [1].
- Knee dislocations can occur in overweight patients [1].
- Knee dislocations can be associated with vascular injury [1].
- Low-velocity mechanisms can result in knee dislocation [1].
Investigations¶
Plain Radiography¶
- Plain radiographs are appropriate initial imaging studies for most knee conditions because they allow the assessment of traumatic injury, arthritis, patellofemoral alignment, osteochondral injury, bone neoplasm, and surgical implants [4].
- Imaging studies should include at least two perpendicular views: AP and lateral [4].
- Non–weight-bearing radiographs may identify acute injury without the risk of fracture displacement [4].
- Lateral capsular avulsion (meniscotibial ligament) is pathognomonic but not essential for ACL injury [4].
- Avulsion of the medial femoral epicondyle (Pellegrini-Stieda lesion) may appear within a few weeks of proximal MCL avulsion injury [4].
- Weight-bearing AP and lateral views are standard for initial evaluation [24].
- A view of the weight-bearing knee flexed at 45-degree angle, imaged posterior to anterior, is included in standard imaging [24].
- A standing full-length AP radiograph from hip joint to ankle joint is used to evaluate limb alignment and knee deformity [24].
- Supine AP knee radiographs do not adequately estimate the joint space width [28].
- Plain frontal radiographs of the knee may not accurately display the actual joint space due to different cartilage wear patterns, meniscal integrity, or variances in tibial slopes [28].
- A 45° standing flexion view was introduced to improve evaluation of the joint space [28].
- A fixed flexion view (FFV) technique has been introduced with improved reproducibility and good evaluation of the joint space [28].
- Goniometer readings of long limb alignment or measured on an FFV correlated well with the angle measured on long limb radiographs, providing an alternative imaging source if long limb radiographs are not available [28].
Computed Tomography¶
- Computed tomography provides enhanced bone detail [4].
- Three-dimensional CT reconstructions may help with preoperative planning for complex intra-articular fractures, multiplanar osteotomy for limb malalignment, and reconstitution of bone loss in joint arthroplasty [4].
- Three-dimensional CT with remodeling is used for preoperative planning for reconstruction associated with dysplasia, post-trauma planning, and complex total knee arthroplasty planning [24].
Magnetic Resonance Imaging¶
- MRI may help assess overall limb alignment and further delineate intra-articular and extra-articular soft tissues, including cartilage, menisci, ligaments, tendons, muscles, and nerve and vascular structures [4].
- The presence of edema, intra-articular fluid, disruption of ligament fibers, and an atypical ligament contour may suggest cruciate ligament injury [4].
- Patterns of meniscal injury can be identified by location (anterior, midbody, posterior, peripheral, articular), pattern (horizontal, longitudinal, radial, complex), and displacement [4].
- MRI may identify the degree of articular cartilage injury (chondrosis, full-thickness cartilage loss), the presence of associated bone marrow edema, and the location [4].
- Edema, avulsion, or discontinuity may be identified for the MCL/LCL or associated posteromedial and posterolateral ligamentous complexes [4].
- MRI may be used to assess the continuity of the quadriceps or patellar tendon [4].
- MRI may be used to assess the margin of resection for a neoplasm, identify vascular malformation, or define the location of nerves or vessels relative to popliteal cysts [4].
- Increasing strength of the magnetic field (measured in Tesla units) increases the resolution of images [4].
- An injected contrast agent (intravenous or intra-articular) may help delineate specific tissues of interest [4].
- MRI is the most useful study for differentiating osteonecrosis from other conditions [30].
- Serpentine lesions within a well-demarcated border is a specific finding on MRI for osteonecrosis [30].
- Bone edema on MRI is a common feature of OA, osteonecrosis, cartilage injury, and transient regional osteoporosis [30].
- MRI is grossly overused in the arthritic patient population [24].
- If the joint space is significantly narrowed on radiograph, then MRI is not indicated [24].
- MRI is used when osteonecrosis is suspected [24].
- Radiographic evaluations are essential when diagnosing an OCD lesion of the knee and elbow; however, important aspects of the OCD lesions may be better seen with MRI [27].
Nuclear Medicine¶
- Nuclear medicine provides a nonspecific study that does not define the etiology of an abnormality but rather the presence of an abnormality that may correlate with a clinical concern [4].
- Increased radionuclide activity in bone may be a normal postoperative finding for up to 6 to 12 months after a fracture repair or arthroplasty [4].
- Technetium-99 (Tc-99) is a radionuclide that may help identify infection, neoplasia, occult fracture, bone healing, active phases of heterotopic ossification, implant loosening, or failure of osseointegration [4].
- Gallium-67 (Ga-67) is a radionuclide that may help differentiate between aseptic and septic prosthetic loosening; 24 to 72 hours are needed for a complete study [4].
Diagnostic Accuracy and Clinical Correlation¶
- A systematic review quantified the accuracy of MRI for detection of meniscal injury and ACL tear [21].
- Physical examination along with radiographic or advanced imaging findings must be used concomitantly to determine the source of each patient’s symptoms, and to determine appropriate surgical intervention when nonsurgical measures have failed [9].
- Assessment of the joint must combine physical examination along with radiographic (including full-length alignment views) and MRI findings [31].
Treatment¶
Non-Operative Management¶
- Nonoperative treatment of knee dislocations is indicated when comorbidity or concomitant injury is of sufficient severity to preclude extensive surgery or anesthetic [33].
- Skeletal immaturity is a relative indication for nonoperative treatment of knee dislocations [33].
- Open dislocations are a relative contraindication for nonoperative treatment of knee dislocations [33].
- Dislocations with associated vascular injury are a relative contraindication for nonoperative treatment of knee dislocations [33].
- Irreducible dislocations are a relative contraindication for nonoperative treatment of knee dislocations [33].
- Dislocations with associated compartment syndrome are a relative contraindication for nonoperative treatment of knee dislocations [33].
- Dislocations with subsequent multiligament laxity and joint subluxation are a relative contraindication for nonoperative treatment of knee dislocations [33].
- Life-threatening polytrauma is associated with high-energy mechanism knee dislocations in approximately 27% of cases [33].
- Multiligament knee injury can occur with minimal trauma in obese individuals, referred to as the “ultra-low” energy knee dislocation [33].
- In patients with significant open wounds, implantation of allograft tissue for reconstruction of torn knee ligaments may be too dangerous due to the risk of contamination and potential infection [33].
- The role of surgical reconstruction in skeletally immature and elderly patients with knee dislocations is unknown [33].
- In elderly patients with knee dislocations, comorbidity imposes an obvious risk for surgical intervention [33].
- Technical difficulties in elderly patients with knee dislocations are presented by poor bone quality and the unpredictability of surgical reconstruction of ligamentous injury in those with any degree of preexisting arthritis [33].
- Complex constructs described for reconstruction of multiligament injuries, especially those with several tibial tunnels, significantly increase the chance for growth disturbance in children with open growth plates [33].
Operative Management: Graft Selection¶
- Various combinations of different autografts and allografts, with various reconstruction techniques, are described in the multiligament injury literature [5].
- Attempts to differentiate outcomes between various graft combinations and reconstruction techniques in the multiligament injury literature have become nearly impossible [5].
- Most surgeons are hesitant to add further morbidity by harvesting autograft tissue from the injured knee due to the extreme insult to the joint and its soft tissue envelope at the time of dislocation [5].
- The integrity of autograft tissue may be compromised in the recently traumatized state [5].
- Concerns among surgeons who favor autograft harvest include the mechanical integrity of allograft, its sterility, and its ability to integrate into a foreign host [5].
- The debate over the optimal preparation of allograft tissue continues, with maintenance of structural integrity being weighed against the complete eradication of potential pathogens [5].
- Allograft is unavailable in many countries and centers [5].
- In some places, the cost of procuring allografts may be prohibitive [5].
- For surgeons who employ allograft in the treatment of multiple ligament knee injuries, a specific conversation with the patient outlining its necessity and potential risks is essential [5].
- The issue of autograft versus allograft is likely to be effectively answered only by a multicentered study [5].
Postoperative Rehabilitation¶
- Rehabilitation protocols described in the literature for knee dislocations following surgery vary [32].
- A systematic review by Mook et al. suggested that immobilizing knees after acute surgery for knee dislocation led to increased posterior instability versus a protocol of early mobilization [32].
- A systematic review by Mook et al. found that the trend of increased posterior instability with immobilization was also seen in the incidence of postoperative varus and valgus laxity [32].
- A systematic review by Mook et al. found that within chronic treatment groups, varus laxity was increased with early mobilization [32].
- A systematic review by Mook et al. showed that immobilization after acute surgical treatment of knee dislocations increased the incidence of both flexion loss >10 degrees and extension loss >5 degrees [32].
- A systematic review by Mook et al. found that patients were significantly more likely to have severely abnormal or poor outcomes with prolonged immobilization [32].
- A systematic review by Mook et al. found that patients were significantly less likely to return to work with prolonged immobilization [32].
- Richter et al. compared 6 weeks of immobilization to functional rehabilitation (flexion to 60 degrees allowed after 48 hours) in patients managed both operatively and nonoperatively [32].
- Statistically significant improvements were seen in the Lysholm and Tegner scores, but not the IKDC scores, in patients treated with functional rehabilitation compared to immobilization [32].
- Early results from a prospective randomized study suggest reduced instability and reduced surgical failure rates with the use of a hinged knee external fixation device compared to a hinged knee brace [32].
- A randomized comparison of early versus delayed rehabilitation protocols following acute (<3 weeks) multiligament surgery is subject to the issue of heterogeneity among patterns of injury and repair techniques [32].
- Early motion may be a more favorable option to surgeons who in the past had been hesitant to mobilize acutely repaired tissues, given the more recent popularity of combined early repair and reconstruction [32].
References¶
[1] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > DISLOCATIONS OF THE KNEE JOINT.
[2] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 3Sports Medicine > Image KNEE INJURIES.
[4] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > I. Radiographic Evaluation.
[5] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Autograft Versus Allograft Reconstruction for Knee Dislocations.
[6] Aaos Comprehensive Orthopaedic Review 3. Anatomy and Biomechanics of the Knee > I. Anatomy.
[7] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 1 KNEE > ANATOMY (FIG. 4.1).
[8] Miller S Review Of Orthopaedics. SECTION 1 KNEE > ANATOMY (FIG. 4.1).
[9] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Introduction.
[11] Aaos Comprehensive Orthopaedic Review 3. Radiographic Evaluation and Surgical Anatomy of the Knee > II. Surgical Anatomy of the Knee.
[16] Aaos Comprehensive Orthopaedic Review 3. Knee Dislocations and Patellar Fractures* > I. Knee Dislocations.
[19] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Posterior Knee Anatomy.
[21] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Annotated References.
[22] Aaos Comprehensive Orthopaedic Review 3. Biomechanics and Wear in Joint Arthroplasty > III. The Knee Joint.
[23] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Anatomy > Knee Kinematics.
[24] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 11 KNEE ARTHRITIS ASSESSMENT.
[27] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.
[28] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Anatomy > Imaging (Radiograph, MRI, CT Scan, Dynamic Versus Static) > Radiograph.
[29] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Anatomy > Annotated References.
[30] Aaos Comprehensive Orthopaedic Review 3. General Evaluation of the Knee Patient > III. Osteonecrosis.
[31] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Knee Arthroscopy and Preservation, Knee Reconstruction > Summary.
[32] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Postoperative Rehabilitation for Knee Dislocations.
[33] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Nonoperative Treatment of Knee Dislocations.
[34] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Assessment of Knee Dislocations > Injuries Associated with Knee Dislocations.
