**5. Discussion**

## **5.1 Methods of surgical treatment**

Knee joint dislocations account for fewer than 0.2% of all orthopedic injuries [19]. Collecting a numerous group of participants which would be homogeneous in terms of treatment methods in order to perform a detailed analysis is extremely difficult. Most studies have analyzed small groups of patients, which prevent from finding the best treatment options for knee joint displacement [20].

The doubts during the choice of the treatment method concern mainly the timing and stages of the interventions. Most studies that have demonstrated the advantage of sutures or ligament reconstruction in the acute phase (first 2–3 weeks following the injury) have examined only the anterior cruciate ligament. In the case of dislocation, Liow et al. [21] compared ACL and PCL stability and range of motion of the knee joint between two groups of patients: one group with the intervention in the acute phase (up to 2 weeks following the injury) and the other with the reconstruction performed following at least 6 weeks. The authors documented improved ACL stability for the intervention in the acute phase (first 2 weeks) and

**43**

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament…*

no significant differences in PCL stability. No differences were also found in mobility between both groups. In light of general knee function, the levels of activity and anterior tibial translation, the results were better in the knees reconstructed within 2 weeks from the injury [21]. Another problem concerning the acute phase of the dislocation is the decision on suturing or reconstruction of the ligament. Sutures should be placed within 3 weeks following the injuries since scarring make the operation more difficult. It would seem that a torn ligament with preserved insertions can be more advantageous situation than a graft fixed in the bone tunnel. Furthermore, Mariani et al., in a study of 23 patients, demonstrated better outcomes in patients following total reconstruction of ACL and PCL compared to those

The attempt to perform a longitudinal analysis (12 years) of the results of treatment of knee joint dislocations and determination of prognostic factors for the results was started by Hirschmann et al. [23]. In a study of 68 patients, the researchers demonstrated a high effectiveness of the on-stage ligament reconstruction and indicated the correlation of the results with the demographic factors (e.g. age, education, and social status), body build (BMI), injury pattern (number of torn ligaments, damage to other structures), and operating timing. The factors that predispose to worse results include damaged fibular collateral ligament, combined reconstruction of ACL and PCL (according to the authors, most patients did not need PCL reconstruction), and delayed interventions > days [23]. Bin and Nam [11] presented very good results concerning the range of motion and stability in patients who underwent two-stage ligament reconstruction. The first stage involved reconstruction of medial and lateral ligament complexes within 2 weeks following the injury. The second stage, 3–6 month later, after regaining full range of motion, consisted in ACL reconstruction and/or PCL reconstruction if the substantial

Fewer studies and, accordingly, fewer questions, were asked concerning postoperative procedures. The publications cited have discussed techniques of performing surgical interventions and final results concerning stability of ligaments and joint mobility. However, they failed to provide information about rehabilitation. Hirshmann et al. examined simultaneous reconstruction and emphasized the necessity of immediate mobilization in order to prevent arthrofibrosis. These authors recommended applying partial load to the orthosis with incomplete extension (10°) continued over 6 weeks. The limited passive and active movement was initiated immediately after the intervention, but the exercises of the first active flexion began following 6 weeks [23]. A very similar program was proposed by Robertson et al., who emphasized particular supervision and greater caution during knee mobilization following a complex reconstruction of several ligaments compared to that after isolated graft of a single ligament [19]. Ibrahim [24] encouraged to follow a more intensive rehabilitation program, recommending CPM movements in the rail within 0–30° and active knee flexion beginning as soon as 90° is reached. As emphasized by this author, this aggressive program, combined with early reconstruction of cruciate ligaments and repair of collateral ligaments, is highly effective in young

The above examples suggest an overall idea of therapy following the complex reconstruction. However, there are no detailed protocols described after the interventions. It is known that some elements of therapy following ACL reconstruction differ extremely from those following PCL reconstruction. They suggest posterior

*DOI: http://dx.doi.org/10.5772/intechopen.89649*

after direct repair of the cruciate ligaments [22].

instability was found [11].

and active patients [24].

**5.2 Rehabilitation proceedings**

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament… DOI: http://dx.doi.org/10.5772/intechopen.89649*

no significant differences in PCL stability. No differences were also found in mobility between both groups. In light of general knee function, the levels of activity and anterior tibial translation, the results were better in the knees reconstructed within 2 weeks from the injury [21]. Another problem concerning the acute phase of the dislocation is the decision on suturing or reconstruction of the ligament. Sutures should be placed within 3 weeks following the injuries since scarring make the operation more difficult. It would seem that a torn ligament with preserved insertions can be more advantageous situation than a graft fixed in the bone tunnel. Furthermore, Mariani et al., in a study of 23 patients, demonstrated better outcomes in patients following total reconstruction of ACL and PCL compared to those after direct repair of the cruciate ligaments [22].

The attempt to perform a longitudinal analysis (12 years) of the results of treatment of knee joint dislocations and determination of prognostic factors for the results was started by Hirschmann et al. [23]. In a study of 68 patients, the researchers demonstrated a high effectiveness of the on-stage ligament reconstruction and indicated the correlation of the results with the demographic factors (e.g. age, education, and social status), body build (BMI), injury pattern (number of torn ligaments, damage to other structures), and operating timing. The factors that predispose to worse results include damaged fibular collateral ligament, combined reconstruction of ACL and PCL (according to the authors, most patients did not need PCL reconstruction), and delayed interventions > days [23]. Bin and Nam [11] presented very good results concerning the range of motion and stability in patients who underwent two-stage ligament reconstruction. The first stage involved reconstruction of medial and lateral ligament complexes within 2 weeks following the injury. The second stage, 3–6 month later, after regaining full range of motion, consisted in ACL reconstruction and/or PCL reconstruction if the substantial instability was found [11].

#### **5.2 Rehabilitation proceedings**

Fewer studies and, accordingly, fewer questions, were asked concerning postoperative procedures. The publications cited have discussed techniques of performing surgical interventions and final results concerning stability of ligaments and joint mobility. However, they failed to provide information about rehabilitation. Hirshmann et al. examined simultaneous reconstruction and emphasized the necessity of immediate mobilization in order to prevent arthrofibrosis. These authors recommended applying partial load to the orthosis with incomplete extension (10°) continued over 6 weeks. The limited passive and active movement was initiated immediately after the intervention, but the exercises of the first active flexion began following 6 weeks [23]. A very similar program was proposed by Robertson et al., who emphasized particular supervision and greater caution during knee mobilization following a complex reconstruction of several ligaments compared to that after isolated graft of a single ligament [19]. Ibrahim [24] encouraged to follow a more intensive rehabilitation program, recommending CPM movements in the rail within 0–30° and active knee flexion beginning as soon as 90° is reached. As emphasized by this author, this aggressive program, combined with early reconstruction of cruciate ligaments and repair of collateral ligaments, is highly effective in young and active patients [24].

The above examples suggest an overall idea of therapy following the complex reconstruction. However, there are no detailed protocols described after the interventions. It is known that some elements of therapy following ACL reconstruction differ extremely from those following PCL reconstruction. They suggest posterior

*Sports, Health and Exercise Medicine*

*Quadriceps femoris power (knee extension).*

Analysis of the jump height using the right (operated) limb and the nonoperated

**Intensity Power [W] Differences %**

**Intensity Power [W] Differences %**

10 kg 128 169 32 20 kg 196 231 17 30 kg 156 251 61

10 kg 77 78 1 20 kg 139 148 6 30 kg 137 157 15

**Left lower limb (healthy)**

**Left lower limb (healthy)**

limb revealed differences in rate of power development achieved in consecutive tests. The highest power was recorded for the operated limb during the first jump (19.5 cm; 70.6 W/s/kg), with power reducing for consecutive tests to 18.7 cm, (67.9 W/s/kg) and 16.3 cm (59 W/s/kg), respectively. During the examination of the healthy limb, the values obtained in the first and second tests were lower compared to the operated limb, with 16.5 (62.7 W/s/kg) and 17 cm (64 W/s/kg), respectively. The power similar to that of the operated limb was obtained only for the third

Knee joint dislocations account for fewer than 0.2% of all orthopedic injuries [19]. Collecting a numerous group of participants which would be homogeneous in terms of treatment methods in order to perform a detailed analysis is extremely difficult. Most studies have analyzed small groups of patients, which prevent from

The doubts during the choice of the treatment method concern mainly the timing and stages of the interventions. Most studies that have demonstrated the advantage of sutures or ligament reconstruction in the acute phase (first 2–3 weeks following the injury) have examined only the anterior cruciate ligament. In the case of dislocation, Liow et al. [21] compared ACL and PCL stability and range of motion of the knee joint between two groups of patients: one group with the intervention in the acute phase (up to 2 weeks following the injury) and the other with the reconstruction performed following at least 6 weeks. The authors documented improved ACL stability for the intervention in the acute phase (first 2 weeks) and

finding the best treatment options for knee joint displacement [20].

attempt, with its value reaching 19.5 cm (74 W/s/kg).

**Right lower limb (following the reconstruction)**

**Right lower limb (following the reconstruction)**

**42**

**5. Discussion**

**Table 7.**

**Table 6.**

*Hamstring power (knee flexion).*

**5.1 Methods of surgical treatment**

support of the lower leg after PCL reconstruction, with different ranges of motion, which must not be accessed during the exercises due to the highest shear forces in the joint or the necessity to evoke constant co-contraction of the hamstrings during exercises after ACL reconstruction. It seems to be impossible to develop an ideal therapeutic procedure to ensure protection of both ligaments following the simultaneous reconstruction. Therefore, an optimum is attempted to be found. However, it often leads to delayed onset of complications, for example, those concerning patellofemoral pain syndrome. If the patient's lower limb following the PCL graft is not adequately supported at the posterior part, the joint capsule contracture may occur in this region. Gravity force that acts on the lower limb during lying (e.g. sleeping) or activity of the hamstrings in the sitting position is among the causes of shrinking of the structures in the dorsal part of the joint. If the joint capsule shrinks, the lower limb will give way toward the posterior drawer, whereas fresh PCL graft will be unable to adapt to the new function in adequate conditions. Consequently, the biomechanical joint conditions will be changed and, despite the graft, the patella and its ligaments should overtake the function of preventing from posterior displacement of the tibia. This will lead to the progressing arthrosis of the patellofemoral and femorotibial joints, while efficiency of the quadriceps femoris muscle will be reduced [13]. Two-stage reconstruction that our patient underwent revealed differences in therapies following PCL and ACL reconstructions. The rehabilitation procedure discussed in detail takes into account the origin and quality of the graft (evaluated by the operating surgeon) and the gradual process of ligamentation (three periods: necrosis, collagen types I and II synthesis followed by collagen type III synthesis in the ligament, which is most similar to the primary ligament [25] and the meniscus which was additionally injured. Due to its damage, the first stage focused on creation of the conditions for the cartilage growth. As noted by Hwang and Kwoh, the best solution is to use less invasive methods, whereas correct rehabilitation leads to the desired treatment effects [26]. In turn, long immobilization of the limb in the third stage of rehabilitation was dictated by the force of the graft—determined by the thickness of the collected tendon, it was assessed as poor. It was recommended to immobilize the limb for 8 weeks in order not to apply load to the graft, because graft tissues are weaker during the first period (6–8 weeks) following the reconstruction. Infarction is observed, with the replacement tissue degenerated and disorganized. It is after 8 weeks (week 8–12) when the graft is revitalized and its mechanical value is improving. Therefore, in order to create optimal conditions for graft acceptance, the balance should be found between graft protection from the excessive tension and the movement that is needed for rehabilitation of any joint (it prevents arthrofibrosis, improves blood supply, and nutrition of the graft). It was demonstrated that insignificant joint tension is favorable since it stimulates formation of new collagen and arranges its fibers along the loading force, thus improving mechanical properties of the new ligament [16]. A large part of each rehabilitation stage was exercises in a closed kinetic chain. The characteristic pattern of CKC exercises is reflexive co-contraction of kneeflexing muscles and the quadriceps femoris muscle, with minimization of the shift of the tibia. Furthermore, during these exercises, the increase in the flexion in the knee joint leads to the increased contraction of the quadriceps femoris and higher contact surface of the patellofemoral joint, with the force acting on bigger surface, thus leading to lower pain in the joint [14]. Another typical element of rehabilitation after ligament reconstruction is proprioceptive training. Tearing the ligaments, which have numerous mechanical receptors, leads to substantial disturbances in proprioception. Only after reconstruction, the ligaments regain the sense of joint position (kinaesthesia) over the rehabilitation process, thus restoring the reflexive muscle stabilization [27].

**45**

the operated limb.

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament…*

In practice, the most often tools used to assess the knee after rehabilitation are: functional tests, examination of the range of movement in the joint, questionnaires or, less often due to the required equipment, joint stability tests on the arthrometer. In this case on the week 15 after the intervention, the following functional tests were performed: jumps on one leg over an obstacle (different directions), long jumps on one leg, climbing a step, and running with directional changes. Apart from the test results, the quality was also evaluated (joint control during the movement, maintaining joint axis at landing). The examination was mainly aimed to subjectively evaluate joint functioning and was not analyzed in percentage values. Eastlack et al. [28] presented similar activities as tests of functional evaluation. They used maneuverability test, with the patient running across a flat surface on the 6.3 m square envelope, shuttle run (running over a short section with rapid directional changes on the operated leg to the opposite direction), crossover running over the short distance, jumping on one leg and triple jump. The measure of the dysfunction depending on the test is time difference in performing the task or asymmetry of the distance of the jump compared to the other side [28, 29]. Previous activities at the same level of intensity can be restored at 85–90% efficiency, at good proprioception, coordination and muscle balance, and without hydrarthrosis and

An important condition is also return to the full range of motion. After completion of the therapy, the patient was able to make full extension and 150° flexion (examination of passive motion) in the knee joint. The attention was attracted to substantial differences in circumferences. Long immobilization at individual stages led to muscle atrophy, whereas performing isometric exercises is insufficient to prevent this phenomenon. In this specific case, immobilization resulted from the simultaneous injury to the meniscus and the necessity of protecting the graft (evaluated as poor). The solution to the problems of protection of the grafted ligament is artificial grafts. Bielecki et al. [30] described simultaneous reconstruction of only the side complex and revision of ACL using polyester grafts (LARS) that allowed for an early and intensive rehabilitation. Active joint mobilization was used on the first day, with full loading and exercises that strengthen muscles of lower limbs. This procedure offered very good short-term effects (full range of motion, stable knee joint, no differences in circumferences), whereas differences were observed between the imaging examination (tibia displacement during MRI and positive score in the Lachman test) and subjective patient evaluation using forms [30].

To monitor the results of treatment, special scales are commonly used to assess subjective complaints of patients. In the discussed case, the patient submitted the knee joint to subjective evaluation of functioning. Both on the IKDC scale and Lysholm scale, higher (better) results were obtained in the later evaluations. On the IKDC scale, in the section of activities of daily living, the patient indicated some limitations due to the inability of performing the complete squat (squat position) or sitting on the heels. These activities were improved with gradual increase in the range of motion. On the Lysholm scale, the deducted points concerned, among other things, the knee giving way–the patient claimed that she experienced such problems during practising sports. Better result in the second evaluation was probably obtained due to the substantial (but still not enough) rebuilding the muscles in

Half a year after completion of the rehabilitation, the significant muscle deficit

continued to have an effect on the evaluation of the peak power. The method proposed in this work is peak power test and the jump test on the force platform. Both in the case of flexion and extension, the value of peak power of the examined

*DOI: http://dx.doi.org/10.5772/intechopen.89649*

pain during and after the exercise [17].

**5.3 Methods of joint functioning assessment**

*Knee Dislocation: Comprehensive Rehabilitation Program after Two-Stage Ligament… DOI: http://dx.doi.org/10.5772/intechopen.89649*

## **5.3 Methods of joint functioning assessment**

*Sports, Health and Exercise Medicine*

support of the lower leg after PCL reconstruction, with different ranges of motion, which must not be accessed during the exercises due to the highest shear forces in the joint or the necessity to evoke constant co-contraction of the hamstrings during exercises after ACL reconstruction. It seems to be impossible to develop an ideal therapeutic procedure to ensure protection of both ligaments following the simultaneous reconstruction. Therefore, an optimum is attempted to be found. However, it often leads to delayed onset of complications, for example, those concerning patellofemoral pain syndrome. If the patient's lower limb following the PCL graft is not adequately supported at the posterior part, the joint capsule contracture may occur in this region. Gravity force that acts on the lower limb during lying (e.g. sleeping) or activity of the hamstrings in the sitting position is among the causes of shrinking of the structures in the dorsal part of the joint. If the joint capsule shrinks, the lower limb will give way toward the posterior drawer, whereas fresh PCL graft will be unable to adapt to the new function in adequate conditions. Consequently, the biomechanical joint conditions will be changed and, despite the graft, the patella and its ligaments should overtake the function of preventing from posterior displacement of the tibia. This will lead to the progressing arthrosis of the patellofemoral and femorotibial joints, while efficiency of the quadriceps femoris muscle will be reduced [13]. Two-stage reconstruction that our patient underwent revealed differences in therapies following PCL and ACL reconstructions. The rehabilitation procedure discussed in detail takes into account the origin and quality of the graft (evaluated by the operating surgeon) and the gradual process of ligamentation (three periods: necrosis, collagen types I and II synthesis followed by collagen type III synthesis in the ligament, which is most similar to the primary ligament [25] and the meniscus which was additionally injured. Due to its damage, the first stage focused on creation of the conditions for the cartilage growth. As noted by Hwang and Kwoh, the best solution is to use less invasive methods, whereas correct rehabilitation leads to the desired treatment effects [26]. In turn, long immobilization of the limb in the third stage of rehabilitation was dictated by the force of the graft—determined by the thickness of the collected tendon, it was assessed as poor. It was recommended to immobilize the limb for 8 weeks in order not to apply load to the graft, because graft tissues are weaker during the first period (6–8 weeks) following the reconstruction. Infarction is observed, with the replacement tissue degenerated and disorganized. It is after 8 weeks (week 8–12) when the graft is revitalized and its mechanical value is improving. Therefore, in order to create optimal conditions for graft acceptance, the balance should be found between graft protection from the excessive tension and the movement that is needed for rehabilitation of any joint (it prevents arthrofibrosis, improves blood supply, and nutrition of the graft). It was demonstrated that insignificant joint tension is favorable since it stimulates formation of new collagen and arranges its fibers along the loading force, thus improving mechanical properties of the new ligament [16]. A large part of each rehabilitation stage was exercises in a closed kinetic chain. The characteristic pattern of CKC exercises is reflexive co-contraction of kneeflexing muscles and the quadriceps femoris muscle, with minimization of the shift of the tibia. Furthermore, during these exercises, the increase in the flexion in the knee joint leads to the increased contraction of the quadriceps femoris and higher contact surface of the patellofemoral joint, with the force acting on bigger surface, thus leading to lower pain in the joint [14]. Another typical element of rehabilitation after ligament reconstruction is proprioceptive training. Tearing the ligaments, which have numerous mechanical receptors, leads to substantial disturbances in proprioception. Only after reconstruction, the ligaments regain the sense of joint position (kinaesthesia) over the rehabilitation process, thus restoring the reflexive

**44**

muscle stabilization [27].

In practice, the most often tools used to assess the knee after rehabilitation are: functional tests, examination of the range of movement in the joint, questionnaires or, less often due to the required equipment, joint stability tests on the arthrometer. In this case on the week 15 after the intervention, the following functional tests were performed: jumps on one leg over an obstacle (different directions), long jumps on one leg, climbing a step, and running with directional changes. Apart from the test results, the quality was also evaluated (joint control during the movement, maintaining joint axis at landing). The examination was mainly aimed to subjectively evaluate joint functioning and was not analyzed in percentage values. Eastlack et al. [28] presented similar activities as tests of functional evaluation. They used maneuverability test, with the patient running across a flat surface on the 6.3 m square envelope, shuttle run (running over a short section with rapid directional changes on the operated leg to the opposite direction), crossover running over the short distance, jumping on one leg and triple jump. The measure of the dysfunction depending on the test is time difference in performing the task or asymmetry of the distance of the jump compared to the other side [28, 29]. Previous activities at the same level of intensity can be restored at 85–90% efficiency, at good proprioception, coordination and muscle balance, and without hydrarthrosis and pain during and after the exercise [17].

An important condition is also return to the full range of motion. After completion of the therapy, the patient was able to make full extension and 150° flexion (examination of passive motion) in the knee joint. The attention was attracted to substantial differences in circumferences. Long immobilization at individual stages led to muscle atrophy, whereas performing isometric exercises is insufficient to prevent this phenomenon. In this specific case, immobilization resulted from the simultaneous injury to the meniscus and the necessity of protecting the graft (evaluated as poor). The solution to the problems of protection of the grafted ligament is artificial grafts. Bielecki et al. [30] described simultaneous reconstruction of only the side complex and revision of ACL using polyester grafts (LARS) that allowed for an early and intensive rehabilitation. Active joint mobilization was used on the first day, with full loading and exercises that strengthen muscles of lower limbs. This procedure offered very good short-term effects (full range of motion, stable knee joint, no differences in circumferences), whereas differences were observed between the imaging examination (tibia displacement during MRI and positive score in the Lachman test) and subjective patient evaluation using forms [30].

To monitor the results of treatment, special scales are commonly used to assess subjective complaints of patients. In the discussed case, the patient submitted the knee joint to subjective evaluation of functioning. Both on the IKDC scale and Lysholm scale, higher (better) results were obtained in the later evaluations. On the IKDC scale, in the section of activities of daily living, the patient indicated some limitations due to the inability of performing the complete squat (squat position) or sitting on the heels. These activities were improved with gradual increase in the range of motion. On the Lysholm scale, the deducted points concerned, among other things, the knee giving way–the patient claimed that she experienced such problems during practising sports. Better result in the second evaluation was probably obtained due to the substantial (but still not enough) rebuilding the muscles in the operated limb.

Half a year after completion of the rehabilitation, the significant muscle deficit continued to have an effect on the evaluation of the peak power. The method proposed in this work is peak power test and the jump test on the force platform. Both in the case of flexion and extension, the value of peak power of the examined muscles was greater for the left (nonoperated) limb. In the case of flexion, the difference was so small that it did not necessarily result from the injury and immobilization. In the case of extension, the power of the right limb muscles was significantly lower, accounting for 76% of the left lower limb power, whereas for the loads of 20 and 30 kg, this was 85 and 62%, respectively. The relatively good results for the load of 20 kg are likely to have resulted from the warm-up or increased patient motivation. However, overall tendency of the examination is the increasing disproportion between the value of peak power and the load: with the increasing load, the patient experienced more difficulty to achieve the result for the right leg similar to the left leg. The weakening of the quadriceps femoris muscle in the operated limb can be additionally confirmed by comparison of the first and second tests of the performed movement. Better result for the right and left limbs was achieved in the first test. Furthermore, the differences between the tests were substantially greater in the case of the operated leg. This means that the leg is not able to perform the extension movement twice with the same peak power, as it is the case with the left limb. Interestingly, the result of the jumping on the platform was better for the operated limb. This can be explained by the fact that, apart from the muscle strength, jumping ability is determined by such components as coordination and muscle balance, which may have resulted from the rehabilitation process which largely consisted in stabilization and working on the improved joint proprioception.

The proposed method of peak power test may turn out to be valuable information for both the physiotherapist and the patient himself. In the case of a significant deficit in the operated limb, it will be advisable to extend the therapy or individual work of the patient focused mainly on the muscle rebuilding. Then, the jump test seems to be a good tool for the functional assessment of the limb in players returning to the sporting activity.
