This is a very interesting case and took a lot of organising. This gentleman was involved in a very nasty road traffic accident approximately two years ago, and he sustained a knee dislocation when he was struck by a car.
He ended up having significant neurological damage (nerve damage) at the back and the side of the knee in association with a rupture of his PCL and a rupture of the lateral ligament complex.
He underwent an immediate repair of the lateral side, which sadly failed, and subsequently went on to have a PCL reconstruction, which also failed and became infected. He had to undergo excision of all the fixation material and the graft.
He was referred to me because of my interest in complex ligament reconstructions and he really did represent a very challenging case.
He couldn't really walk more than a few yards because he dragged his foot, and had severe discomfort and odd sensations as a result of the nerve lesion and also his knee was grossly unstable because of it being PCL and lateral-side deficient. He was using crutches and life had really come to a standstill and what little life he was enjoying was accompanied by a significant amount of pain.
What was quite exciting was that I contacted Mr Mike Fox - lead surgeon at the peripheral nerve injury unit at Stanmore - and discussed the case with him. Mike and I trained together on the North West Thames rotation and I first met him when I was working at Stanmore. He was training to be a hip arthroplasty surgeon but when he worked on the peripheral nerve injuries unit at Stanmore he became enlightened about the way to go in his career, and went on to become the lead nerve surgeon for the peripheral nerve injuries unit.
Mike felt that the best thing to do was to approach this as a joint case, so he - to my amazement - gave up an entire day and came down to Basingstoke, and we spent the morning reconstructing this gentleman's knee.
We first had him on his tummy and Mike did a beautiful dissection of the nerves, finding the sciatic nerve and its division and the tibial nerve - and found the lesion (area of damage) which was causing this gentleman's problem - which was a tethering of the common peroneal nerve and sural nerve, which tethering he released.
We then closed him up and re-prepped and re-draped the patient and I then carried out a revision PCL reconstruction using my internal brace reinforcement technique (FiberTape) with an allograft. We also did a posterolateral corner and lateral side reconstruction using the so-called laPrade technique again with allografts.
The surgery went extremely well. I was delighted with the outcome on the operating table.The patient only spent a short time in hospital convalescing, and the minute he woke up all of his nerve pain had gone!
I'm absolutely delighted with how he has done with the knee. He is now 6 months down the line, and he is completely different to how he was at presentation when he had looked really quite depressed and was really disabled, walking slowly and in pain and with a very unstable knee.
We carried out the combined PCL and posterolateral corner reconstruction, together with the neurolysis by Mike Fox and I am delighted to say that at six months he walked in without crutches and with a normal gait pattern. He has been off his crutches for two months now and out of the brace for a month. He bent the knee to 125 degrees and it felt beautifully stable. He is getting some very mild discomfort, which he rated 2/10 on a visual analogue scale.
It really looks like he has got his knee back and this is getting him back on track in terms of his life.I am so delighted that he has had such a fantastic result after this complex knee dislocation, and it is just a testament to the new techniques that have been developed recently that we have been able to get such a great result with this very difficult case.
COMBINED LIGAMENT AND NERVE SURGERY
I think this is a very interesting case for many reasons, not only because of the challenging nature of the nerve and ligament surgery, but also because we could collaborate and do two complicated procedures in a great setup with a great team.
Adrian Wilson (L) with Mike Fox (R)
The sural nerve at the back of the knee is derived from branches of the tibial nerve medially and common peroneal nerve laterally.