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Prioritised challenges in the management of acute knee dislocations are stiffness, obesity, treatment delays and associated limb-threatening injuries: a global consensus study
  1. Michael Held1,
  2. Robert C Schenck2,
  3. Vikas Khanduja3,
  4. Túlio Vinícius de Oliveira Campos4,
  5. Sachin Tapasvi5,
  6. Andy Williams6,
  7. Wai Pan Yau7,
  8. Christopher Harner8
  9. Authorship group ‘Knee surgery in LRS’
    1. 1Orthopaedic Surgery, University of Cape Town, Rondebosch, South Africa
    2. 2Orthopaedic Surgery, University of New Mexico - Albuquerque, Albuquerque, New Mexico, USA
    3. 3Orthopaedic Department, Addenbrooke’s Hospital, University of Cambridge, Cambridge, Cambridgeshire, UK
    4. 4Orthopaedic Department, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
    5. 5Orthopaedics, The Orthopaedic Speciality Clinic, Pune, Maharashtra, India
    6. 6Fortius Clinic, London, UK
    7. 7Department of Orthopaedics and Traumatology, University of Hong Kong, Hong Kong, Hong Kong
    8. 8University of Texas McGovern Medical School, Pittsburgh, Pennsylvania, USA
    9. 9University of Cape Town, Rondebosch, Western Cape, South Africa
    1. Correspondence to Dr Michael Held, Orthopaedic Surgery, University of Cape Town, Rondebosch, South Africa; michael.held{at}


    Objectives Heterogeneous patient factors and injury mechanisms result in a great variety of injury patterns encountered in knee dislocations (KD). Attempts to improve outcome can focus on a wide range of challenges. The aim of this study was to establish and prioritise a list of challenges encountered when treating patients with acute KD.

    Methods A modified Delphi consensus study was conducted with international knee specialists who generated a prioritised list of challenges. Selected priorities were limited to half of the possible items. Agreement of more than 70% was defined as consensus on each of these items a priori.

    Results Ninety-one international surgeons participated in the first round. The majority worked in public hospitals and treated patients from low-income and middle-income households. Their propositions were prioritised by 27 knee surgeons from Europe, Africa, Asia, as well as North and South America, with a mean of 15.3 years of experience in knee surgery (SD 17.8). Consensus was reached for postoperative stiffness, obesity, delay to presentation and associated common peroneal nerve injuries. Challenges such as vascular injuries, ipsilateral fractures, open injuries as well as residual laxity were also rated high. Most of these topics with high priority are key during the initial management of a patient with KD, at presentation. Topics with lower priority were postsurgical challenges, such as patient insight, expectations and compliance, rehabilitation programme, and pain management.

    Conclusion This consensus study has a wide geographical footprint of experts around the world practising in various settings. These participants prioritised stiffness, obesity, treatment delays and associated limb-threatening injuries as the most important challenges when managing a patient with acute KD. This list calls for applicable and feasible solutions for these challenges in a global setting. It should be used to prioritise research efforts and discuss treatment guidelines.

    Level of evidence V.

    • knee injuries
    • joint dislocations

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    • Collaborators Richard von Bormann, David North, Dustin Richter, Hasan Alizayagam, Carlos Mourao, Diogo Mesquita, Soliudeen Arojuraye, Ednei Freitas, Rtesh Patel, S Deepak, Fernanda Nahas, Paulo Fontes, Gabriel M Miura, Gian Du Preez, Guilherme F Simoes, Leandro Marinho, Roberto Cunha Luciano, Yogesh Gowda, Bernardo Ribeiro, Constantino Calapodopulos Jr, Ennio Coutinho, Weili Fu, Frederico Ferreira, Clauco Passos, Hannes Jonker, Hayden Hobbs, John Grant, Sebastian Magobotha, Marcos Alves, Marcelo Amorim, Marcelo Denaro, Marc Safran, Marcelo Moraes, Dinshaw Pardiwala, Rodrigo Lazzarini, Seth Sherman, Saseendar Shanmugasundaram, Sundararajan Silvampatti, Wagner Lemos, Jose M Juliano Eustaquio, Peter Venter.

    • Contributors All authors have made substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work. They also participated in drafting the work or revising it critically and provided final approval and agreed to be accountable for all aspects of the work to be published. Contributors from the ‘Knee surgery in LRS’ were participating investigators.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

    • Competing interests AW receives research funding and part-funding of a clinical fellow from Smith and Nephew. He is a shareholder and board member of Fortius Clinic, London and Innovate Orthopaedics. He owns shares in DocComs, a digital start-up providing a secure platform for medics to exchange patient information.

    • Patient consent for publication Not required.

    • Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (HREC 591/2018) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement De-identified participant data are available upon reasonable request from the authors (ORCID identifier: 0000-0002-0671-0439).

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