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59 (); 8-12
doi:
10.1016/j.jor.2024.07.006

The current epidemiology of vascular injuries associated with knee dislocation in the United States from 2010 to 2022

, , , , , , , ,
LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA

⁎Corresponding author: Ronald E. Delanois. delanois@me.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Despite the recognized importance of managing vascular injury associated with knee dislocation, studies have been limited by small patient sizes, data older than five years, and lack of inclusion of newer procedural and diagnoses codes. This has been reflected in the reported frequency of knee dislocation associated with vascular injury ranging from 1.6 % to 64 %. As such, we sought to determine: (1) the frequency of knee dislocations associated with vascular injuries; (2) the frequency of knee dislocations associated with vascular injuries that required repair; as well as (3) independent risk factors for knee dislocation with vascular injury that require repair, across different age groups, sexes, and United States geographic regions.

A national, all-payer database was queried from January 1, 2010 to June 31, 2022. The frequency of a vascular injury was calculated by dividing the number of vascular injuries within 30 days of all knee dislocations by the total number of knee dislocations in each category. The frequency of a vascular injury that required repair was calculated by dividing the number of vascular injuries that required repair associated with knee dislocation by the total number of vascular injuries associated with knee dislocations. Patients were categorized by year of diagnosis, age, sex, and US geographic region. Multivariable logistic regressions were calculated to determine independent risk factors for knee dislocation with vascular injury.

From 2010 to 2022, there were 99,688 knee dislocations. Of the total knee dislocations, there were 1066 (1.1 %) vascular injuries associated with knee dislocations, 96,530 (96.8 %) were closed dislocations, and 3158 (2.2 %) were open dislocations. Of the 1066 vascular injuries associated with knee dislocations, 262 (24.6 %) vascular injuries required repair. Male sex (P < 0.001), Elixhauser Comorbidity Index (ECI) > 3 (P < 0.001), alcohol abuse (P = 0.006), congestive heart failure (P = 0.01), hypothyroidism (P = 0.003), and obesity (P < 0.001), were independent risk factors for knee dislocation with vascular injuries.

Our study provides a refined understanding of the historically low incidence of knee dislocation with vascular injury as well as an increase in vascular injuries requiring repair from 2010 to 2022. Given the large expense of irreversible injury in these patients, vulnerable patient populations identified in our study, such as obese patients with additional comorbidities, should be a focus of future intervention. These findings can guide physicians in a clinical setting to appropriately manage the expectations of patients as well as minimize the morbidity and mortality associated with this presentation.

1

1 Introduction

Although tibiofemoral knee dislocations are exceedingly rare, comprising only 0.001 %–0.013 % of all orthopaedic injuries, they can result in a combination of ligament, meniscal, fracture, or neurovascular injuries.1–3 Timely identification and treatment of vascular injury are crucial to mitigate the risk of irreversible damage, such as limb loss and the need for amputation.4 Research indicates that one in five patients presenting with a dysvascular limb associated with knee dislocation may require amputation, often due to factors like restricted motion of the popliteal artery, inadequate collateral circulation of the knee, and prolonged warm ischemia.5–8

Despite the recognized significance of managing vascular injuries linked with knee dislocation, studies have faced limitations such as small sample sizes, outdated data, and omission of newer procedural and diagnostic codes.9–12 Consequently, reported rates of knee dislocation associated with vascular injury have varied widely, ranging from 1.6 % to 64 %.13–16 For instance, a systematic review involving 862 patients with knee dislocations revealed that 171 (18 %) sustained vascular injuries, with 80 % of these injuries undergoing repair.17 Conversely, a large database analysis of 8050 limbs identified 267 vascular injuries (3.3 %), of which only 13 % underwent repair.10 Discrepancies in outcomes may stem from differences in patient characteristics studied, such as obesity, male gender, and younger age, which have been linked to an elevated risk of knee dislocations with vascular injuries.12,18,19

Given that diagnosing knee dislocations heavily relies on clinical suspicion, accurately assessing the true incidence of knee dislocation associated with vascular injury can greatly benefit clinicians in practice.9 Therefore, we aimed to determine: (1) the prevalence of knee dislocations associated with vascular injuries; (2) the prevalence of knee dislocations associated with vascular injuries requiring repair; and (3) independent risk factors for knee dislocation with vascular injury necessitating repair, considering various age groups, genders, and geographic regions within the United States.

2

2 Methods

2.1

2.1 Database

A national, all-payer database, PearlDiver Mariner Patient Claims Database (PearlDiver Technologies, Colorado Springs, CO, USA) was queried from January 1, 2010 to June 31, 2022. It includes over 120 million Health Insurance Portability and Accountability compliant records across the United States, which allows for more generalizable results in comparison to a single-institution analysis. It represents one of the largest aggregations of health care and tracks patients longitudinally. The cohorts were identified using International Classification of Disease (ICD)-10 procedural and diagnoses codes and Current Procedural Terminology (CPT) codes. Due to the inclusion of patient-protected information and the retrospective nature of the study, we received institutional review board exemption.

2.2

2.2 Patients

Our query identified 99,688 patients between January 2010 and December 2021 who had a knee dislocation using ICD-10 and CPT codes. Of those 99,688 patients, 1066 patients (1.1 %) had a vascular injury associated with a knee dislocation. This study used the Kennedy classification of knee dislocation based on the direction of tibial displacement relative to the femur.20 Only patients with noncongenital open or closed knee dislocations were included. Vascular injury included popliteal injury or other leg vessel injury.

2.3

2.3 Outcomes

The frequency of a vascular injury in Table 1 and Table 2 was calculated by dividing the number of vascular injuries within 30 days of all knee dislocations by the total number of knee dislocations in each category. In Table 3, the frequency of a vascular injury that required repair was calculated by dividing the number of vascular injuries that required repair associated with knee dislocation by the total number of vascular injuries associated with knee dislocations. Patients were categorized by year of diagnosis, age, sex, and US geographic region. The incidence of vascular injury secondary to knee dislocation, regardless of repair (Table 1), the incidence of vascular injury secondary to knee dislocation that required repair of all knee dislocations (Table 2), and the incidence of vascular injury that required repair secondary to knee dislocation of all vascular injuries (Table 3) were determined. Multivariable logistic regressions were calculated to determine independent risk factors for knee dislocation with vascular injury (Table 4) and knee dislocation with vascular injury that required repair (Table 5). In addition, multivariable logistic regressions were calculated to determine independent risk factors for knee dislocation with vascular repair based on age (Table 6) and independent risk factors for knee dislocations knee dislocation with vascular injury that required repair (Table 7).

Table 1 Incidence of knee dislocations with associated vascular injury.
Variable Total Number of Knee Dislocations Total Number of Vascular Injury Associated with Knee Dislocations Incidence of Vascular Injury Secondary to Knee Dislocation (%)
Total 99,688 1066 1.1
Year
2010 9902 57 0.6
2011 9520 63 0.7
2012 10,035 94 0.9
2013 9731 77 0.8
2014 10,218 102 1.0
2015 10,459 108 1.0
2016 6957 78 1.1
2017 5949 62 1.0
2018 5935 80 1.3
2019 6810 88 1.3
2020 6011 99 1.6
2021 6896 113 1.6
2022 2079 28 1.3
Total 100,502 1049 1.0
Age
≥19 25,288 119 0.5
20-39 24,700 408 1.7
40-59 25,770 307 1.2
≥60 24,003 0 0.0
Total 99,761 834 0.8
Sex
Male 38,628 575 1.5
Female 58,899 491 0.8
Total 97,528 1066 1.1
US Geographical Region
Midwest 25,027 305 1.2
Northeast 20,585 171 0.8
South 35,541 421 1.2
West 15,738 151 1.0
Unknown 638 0 0.0
Total 97,529 1048 1.1
Table 2 Incidence of knee dislocations that required repair of vascular injury.
Variable Total Number of Knee Dislocations Total Number of Vascular Injuries Requiring Repair Associated with Knee Dislocation Incidence of Vascular Injury Requiring Repair Secondary to Knee Dislocation (%)
Total 99,688 262 0.26
Year
2010 9902 11 0.11
2011 9520 11 0.12
2012 10,035 21 0.21
2013 9731 0 0.00
2014 10,218 26 0.25
2015 10,459 19 0.18
2016 6957 20 0.29
2017 5949 22 0.37
2018 5935 18 0.30
2019 6810 25 0.37
2020 6011 24 0.40
2021 6896 29 0.42
2022 2079 0 0.00
Total 100,502 226 0.22
Age
≥19 25,288 0 0.00
20-39 24,700 98 0.40
40-59 25,770 80 0.31
≥60 24,003 0 0.00
Total 99,761 178 0.18
Sex
Male 38,224 126 0.33
Female 58,550 118 0.20
Total 96,774 244 0.25
US Geographical Region
Midwest 24,818 77 0.31
Northeast 20,454 29 0.14
South 35,246 101 0.29
West 15,623 36 0.23
Unknown 638 0 0.00
Total 96,779 243 0.25
Table 3 Incidence of knee dislocation with vascular injury that required repair.
Variable Total Number of Vascular Injuries Associated with Knee Dislocations Total Number of Vascular Injuries Requiring Repair Associated with Knee Dislocation Incidence of Vascular Injuries Associated with Knee Dislocations Requiring Repair (%)
Total 1066 262 24.6
Year
2010 57 11 19.3
2011 63 11 17.5
2012 94 21 22.3
2013 77 0 0.0
2014 102 26 25.5
2015 108 19 17.6
2016 78 20 25.6
2017 62 22 35.5
2018 80 18 22.5
2019 88 25 28.4
2020 99 24 24.2
2021 113 29 25.7
2022 28 0 0.0
Total 1049 226 21.5
Age
≥19 119 0 0.0
20-39 408 98 24.0
40-59 307 80 26.1
≥60 0 0 0.0
Total 834 178 21.3
Sex
Male 575 126 21.9
Female 491 118 24.0
Total 1066 244 22.9
US Geographical Region
Midwest 305 77 25.2
Northeast 171 29 17.0
South 421 101 24.0
West 151 36 23.8
Unknown 0 0 0.0
Total 1048 243 23.2
Table 4 Multivariable regression for knee dislocation with vascular injury.
OR 95 % CI p-value
Male 1.74 1.53–1.98 <0.001
Age 0.99 0.99–1.00 0.19
ECI >3 1.07 1.04–1.09 <0.001
Alcohol Abuse 1.44 1.20–1.73 0.15
CKD 0.72 0.57–0.91 0.06
COPD 0.61 0.53–0.71 0.85
HF 0.62 0.46–0.85 0.01
Diabetes 0.87 0.65–1.17 0.48
Hypertension 1.15 0.97–1.36 0.37
Hypothyroidism 0.71 0.59–0.86 0.02
Obesity 2.21 1.93–2.54 <0.001
Tobacco Use 1.26 1.10–1.44 0.12
Table 5 Multivariable regression for knee dislocation with vascular injury requiring repair.
OR CI p-value
Male 1.64 (1.27–2.12) <0.001
Age 0.99 (0.98–1.00) 0.11
ECI >3 1.07 (1.04–1.14) <0.001
Alcohol Abuse 1.31 (0.89–1.87) <0.001
CKD 0.63 (0.39–0.99) 0.01
COPD 0.97 (0.74–1.28) <0.001
CHF 0.44 (0.22–0.80) 0.002
Diabetes 0.80 (0.76–1.87) 0.35
Hypertension 1.20 (0.84–1.70) 0.11
Hypothyroidism 0.64 (0.44–0.92) 0.01
Obesity 1.68 (1.27–2.22) <0.001
Tobacco Use 1.25 (0.95–1.64) <0.001
Table 6 Risk factors for dislocations with vascular injury based on age.
Odds Ratio Confidence Interval p-value
Male 1.95 1.72–2.21 <0.001
ECI 1.04 1.02–1.06 <0.001
Alcohol abuse 1.37 1.14–1.64 <0.001
Diabetes 0.95 0.81–1.10 0.482
Tobacco use 1.02 0.89–1.17 0.732
agerange05-09 1.43 0.11–14.72 0.772
agerange10-14 1.03 0.17–6.33 0.975
agerange15-19 3.21 0.66–15.65 0.149
agerange20-24 5.15 1.32–20.12 0.018
agerange25-29 4.89 1.56–15.34 0.007
agerange30-34 3.67 1.45–9.31 0.006
agerange35-39 2.81 1.37–5.81 0.005
agerange40-44 2.05 1.20–3.49 0.008
agerange45-49 1.02 0.69–1.51 0.916
agerange55-59 0.67 0.46–0.98 0.040
agerange60-64 0.42 0.24–0.74 0.002
agerange65-69 0.38 0.18–0.80 0.11
agerange70-74 0.19 0.07–0.51 <0.001
agerange75-79 0.16 0.05–0.52 0.003
BMIBMI3040 1.55 1.18–2.05 0.002
BMIBMI4050 2.78 2.15–3.64 <0.001
Table 7 Risk factors for vascular repair based on age.
Odds Ratio Confidence Interval p-value
Male 1.78 1.38–2.30 <0.001
ECI 1.08 1.03–1.12 <0.001
Alcohol abuse 1.23 0.84–1.75 0.271
Diabetes 1.03 0.75–1.40 0.866
Tobacco use 1.06 0.81–1.39 0.686
agerange05-09 0.43 0.02–2.05 0.407
agerange10-14 0.15 0.04–0.44 <0.001
agerange15-19 0.55 0.30–1.00 0.049
agerange20-24 1.46 0.84–2.56 0.180
agerange25-29 1.35 0.76–2.39 0.302
agerange30-34 1.17 0.65–2.08 0.599
agerange35-39 1.44 0.83–2.50 0.189
agerange40-44 1.00 0.55–1.80 0.997
agerange45-49 0.61 0.31–1.16 0.140
agerange55-59 0.83 0.47–1.45 0.508
agerange60-64 0.55 0.28–1.02 0064
agerange65-69 0.53 0.25–1.03 0.068
agerange70-74 0.26 0.10–0.59 0.003
agerange75-79 0.43 0.17–0.95 0.051
BMIBMI3040 1.37 0.80–2.38 0.252
BMIBMI4050 2.57 1.57–4.35 <0.001
2.4

2.4 Statistical analyses

Descriptive analyses, including the number of patients in each category and respective percentages were performed. Multivariable logistic regressions were performed to calculate independent risk factors for knee dislocation with vascular injury. We performed all analyses using R Studio (R Foundation for Statistical Computing, Vienna, Austria) with significance set at P < 0.05.

3

3 Results

3.1

3.1 Incidence of knee dislocations with associated vascular injury

From 2010 to 2022, there were 99,688 knee dislocations. Of the total knee dislocations, there were 1066 (1.1 %) vascular injuries associated with knee dislocations, 96,530 (96.8 %) were closed dislocations, and 3158 (2.2 %) were open dislocations. Patients age 20–39 (1.7 %), males (1.5 %), and those in the Midwest (1.2 %) and South (1.2 %) had the highest incidences of vascular injury secondary to knee dislocation (Table 1).

3.2

3.2 Incidence of knee dislocations that required repair of associated vascular injury

Of the 99,688 total dislocations from 2011 to 2022, 262 (0.26 %) vascular injuries required repair. Patients age 20–39 (0.40 %), males (0.33 %), and those in the Midwest (0.31 %) had the highest incidences of knee dislocations that required repair of associated vascular injury (Table 2).

3.3

3.3 Incidence of required repair of total vascular injuries

Of the 1066 vascular injuries associated with knee dislocations, 262 (24.6 %) vascular injuries required repair. Of the vascular injuries associated with knee dislocations, 993 (93.2 %) were closed and 73 (6.8 %) were open. Of vascular injuries that required repair, 244 (93.1 %) were closed and 18 (6.9 %) were open. Patients age 40–59 (26.1 %), females (24.0 %), and those in the South (24.0 %) had the highest incidences of knee dislocations that required repair of the total vascular injuries (Table 3).

3.4

3.4 Risk factors for knee dislocation with vascular injuries

Male sex (P < 0.001), Elixhauser Comorbidity Index (ECI) > 3 (P < 0.001), alcohol abuse (P = 0.006), congestive heart failure (P = 0.01), hypothyroidism (P = 0.003), and obesity (P < 0.001), were independent risk factors for knee dislocation with vascular injuries (Table 4). Male sex (P < 0.001), Elixhauser Comorbidity Index>3 (P < 0.001), alcohol abuse (P = 0.01), chronic obstructive pulmonary disease (P < 0.001), congestive heart failure (P = 0.01), hypothyroidism (P = 0.01), obesity (P < 0.001), and tobacco use (P < 0.001) were independent risk factors for knee dislocation with vascular injuries requiring repair (Table 5). Ages 20–24 (Odds Ratio (OR), 5.15, 95 % Confidence Interval 1.32–20.12, P = 0.018) and ages 25–29 (Odds Ratio (OR), 4.89, 95 % Confidence Interval 1.56–15.34, P = 0.007) were the biggest risks for dislocations with vascular injuries based on age (Table 6). In addition, BMI 40–50 was the biggest risk factor for vascular repair based on age (all P < 0.05) (Table 7).

4

4 Discussion

The reported incidence rates of knee dislocation associated with vascular injury have exhibited considerable variation, raising concerns about the reliability of these studies in accurately determining the true prevalence of concurrent knee dislocation and vascular injury.10 Furthermore, given the potential for knee dislocations to result in limb-threatening associated injuries, a nuanced understanding of the actual occurrence of knee dislocation associated with vascular injury is imperative. Our study, leveraging a nationally representative database, unveiled a historically low incidence of vascular injury secondary to knee dislocation (1.1 %). Additionally, we identified male sex, ECI>3, congestive heart failure, hypothyroidism, and obesity as risk factors for knee dislocation with vascular injuries requiring repair.

However, our study is not devoid of potential limitations. While all patient records undergo review by a third-party source, the possibility of medical billing and coding errors persists, albeit mitigated by a reported nationwide billing/coding error rate of 1.0 %.21 We also did not factor in various outcomes such as ischemia duration or amputation, both crucial parameters in knee dislocations with associated vascular injuries. Moreover, the omission of spontaneously reduced knee dislocations in coding may lead to underestimation of frequency. Additionally, challenges in diagnosing knee dislocations may result in misclassification as cruciate ligament or collateral ligament injuries, further underestimating total frequency. Furthermore, elderly or obese patients with low-velocity knee dislocations may not be distinguishable from those with high-velocity dislocations, contributing to underestimation. Nevertheless, our inclusion of Medicare, Medicaid, and private insurance patients enhances the generalizability of our findings compared to previous studies utilizing the same database.9,10

Recent literature, including a meta-analysis and systematic review, highlights the wide variability in reported incidence rates of vascular injuries associated with knee dislocations.13,17 Notably, our study differs in its examination of both closed and open knee dislocations, encompassing patients under 60 years old from both trauma and non-trauma centers. This comprehensive approach offers insights into the epidemiology of knee dislocations with vascular injury over several years, incorporating updated ICD-10 codes and employing multivariable regression to assess associated risk factors.

Moreover, the absence of focus in prior studies on changes in incidence following new imaging protocols and management algorithms regarding knee dislocations underscores the significance of our investigation.15,22–26 Our study provides an update on incidences from 2010 to 2022, revealing minimal changes in the incidence of vascular injuries associated with knee dislocations over this period. However, there was a notable increase in the incidence of vascular injuries requiring repair, possibly reflecting a higher frequency of higher-energy injuries necessitating surgical intervention, particularly in younger, more active patient populations. These findings align with previous research utilizing the same national database, suggesting a consistent trend over time.9,10

Furthermore, our study fills a gap in the literature by identifying independent risk factors for vascular injury requiring repair, including male sex and obesity, which have been implicated in previous studies.18,24 These findings underscore the importance of proactive screening for vascular injuries in obese patients, while also highlighting the potential to address modifiable risk factors such as obesity to mitigate mortality rates and hospitalization costs associated with these injuries. In our study, obesity emerged as a risk factor not only for knee dislocations with vascular injury but also for those requiring vascular repair.

Our study provides a refined understanding of the historically low incidence of knee dislocation with vascular injury as well as an increase in vascular injuries requiring repair in a nationally, representative patient population from 2010 to 2022. Given the large expense of irreversible injury in these patients, vulnerable patient populations identified in our study, such as obese patients with additional comorbidities, should be a focus of future intervention. These findings can guide physicians in a clinical setting to minimize the morbidity and mortality associated with this presentation.

Ethical approval

IRB exemption due to retrospective nature and public database Authors’ contribution.

Funding

None.

Patient consent

No patient consent needed due to retrospective nature and public database.

Use of AI tool

No use of AI tool.

CRediT authorship contribution statement

Jeremy A. Dubin: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Sandeep S. Bains: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Ethan Remily: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Hytham Salem: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing, MM, Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Roles/. Oliver Sax: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Daniel Hameed: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. James Nace: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Philip K. McClure: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Ronald E. Delanois: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

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