At Least It’s Not Your ACL
Transcript of At Least It’s Not Your ACL
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At Least It’s Not Your ACLObjectives
• Review anatomy of the knee
• Identify tendon injuries around the knee
• Discuss management of patella fracture and dislocation
• Review post-op management of the injured knee
Types of Knee Injuries
• Ligament Injuries
• ACL, PCL, MCL and LCL
• Bony Injuries
• Cartilage injuries
• Meniscus and Articular Cartilage
• Tendon Injuries
• Quad tendon and Patellar tendon
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Patella Fractures
Mechanism of Injury• 1% of all fractures
• Usually the result of a direct blow or fall
• Most are transverse fractures
• Men twice as likely as women
• Most require surgery
Diagnosis of Patella Fracture• Anterior knee pain
• Swelling
• Inability to straight leg lift
• Defect in the patella
• X-ray confirmation
Treatment Options
Non surgical
• Cast
• Brace
• Crutches
Surgical
• ORIF with screws
• Tension Band
• Partial patellectomy
• Total patellectomy
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Post-op Management
• Admit for pain control
• WBAT with crutches
• Knee brace
• Ice for comfort
• Shower 3 days
• Stitches out 10-14 days
Rehabilitation
• Based on injury and repair performed
• Straight leg raise at 1 week
• Passive ROM at 3 weeks
• Resistive exercises at 6 weeks
• Brace for support for 3 months
• Partial patellectomy held for 4 weeks to allow soft tissue healing
Patella Instability
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Patella Instability
• Generic TermA) Patella dislocation
B) Patella subluxation
• Affects between 7-49/100,00
• 11% of musculoskeletal symptoms seen in office
• 16 – 25% of all injuries in running
• Higher incidence in females
A) BONY
• Patella
• Femur (Trochlea)
B) SOFT TISSUE
1. Medial Retinaculum
2. Quads (VMO)
3. MPFL
Anatomy
Stability in Motion
EARLY FLEXION• Distal patellar engages superior aspect trochlear
groove• Quads are dynamic stabilizer • MPFL 1° static soft tissue restraint • ˃ 50% of medial restraint forces in cadaver study • ↑Flexion contact area of patella moves proximally
MID FLEXION 90°
• Proximal pole contacts distal aspect
trochlear groove
• Deeply engaged in groove
• ↑ Flexion causes contact with MFC/ medial
facet patella and LFC with lateral facet
PAST 90° FLEXION
• Smaller third facet engages MFC
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THE STAR OF
OUR SHOW
MPFL
MPFL
• Inserts sup/medial border of patella 6
mm below superior pole
• Origin - entire length of medial femoral
epicondyle
• Average length 5 and 6 cm
• Insertion broader than origin
• Also sends branches to VMO / Medial
retinaculum
Classification of Patellar
Instability
• Congenital
• Traumatic
• Developmental
ETIOLOGY
• Multifactorial
Can be traumatic from direct blow
• Developmental as a result of patella alta and
dysplasia
• Delayed engagement in shallow trochlea
• Tibial tubercle placement
HISTORY
• Anterior knee pain
• Giving way, going out
• Determine if specific event
• What previous treatment?
Successful?
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EXAM:
Inspect
• Bruising
• Swelling
Palpate
• Medial facet
• Lateral femoral condyle
• Thorough leg exam
٭ MCL
٭ Mimic ACL (history)
• Moving Patella Apprehension Test
MOVING PATELLAR APPREHENSION TEST
Knee 20 – 30° flexion
• Lateral pressure on patella
• ↑ bend, may ↑ apprehension = positive test
• Repeat with medial direction pressure
better = positive test
Q ANGLE
• Angle between ASIS and Patellar Tendon
• Males 8 - 10°
• Females 15 - 20°
Factors that ↑ Q Angle
• External tibial torsion
• Laterally positioned TT
• Genu valgum
• ↑ Femoral anteversion
PATELLAR TILT TEST
• Patient supine, knee flexed 20°
• Attempt to elevate lateral facet by pushing down
medially
• Elevation to less than neutral means tight lateral
tissue
• 0-20° Elevation is normal
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• X-Rays - Fleck of Bone medially
• CT scan • TT – TG - 90° - TT ˂20mm lateral to mid trochlea
of femur
• MRI• Bone contusion LFC
• MPFL tear
• Articular damage
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COLLATERAL DAMAGE !
CT SCAN with FRACTURE
TREATMENT
- Non-Surgical
- Surgical
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NON-SURGICAL TREATMENT
• PT is often successful
• Initially focus on VMO strengthening
• Stretching also important
٭ Achilles
٭ Hamstrings / Quads
٭ IT Band
٭ LAT Retinaculum
• Closed chain exercises
• Core stability
• Functional Alignment
• Braces, orthotics for pronation, taping
Surgical Treatment
Proximal Realignment
Distal Realignment
Trochleoplasty
SURGICAL CONSIDERATION
• Patient Age
• Level of Activity
• Condition of Joint
• Origin of Deficiency
- May be combination of alignment and soft tissue injury
PROXIMAL REPAIR AND
REALIGNMENT
• Repair ligament at point of injury
• Anchors used to fix ligament to femur or patella
• Recommended:
• 1) In chronic case with failed conservative Rx
• 2) Acute Instability with loose chondral fragment
• If combining with TT transfers; do transfer first, then tension
ligament
Reconstruction of MPFL
• Not for pain, arthritis, or to correct malalignment
• Do not over tighten; leads to more pain and arthritis
Procedure for MPFL
• Scope knee• Harvest graft • Place tunnels in patella• Secure graft to patella• Tension graft • Fix graft to femur
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MEDIAL IMBRICATION AND VMO
ADVANCEMENT
• First described procedure was huge
• Large lateral release
• Large lateral advancement
• Mini open with small lateral release proved more reliable
• Can now medially imbricate with scope
• Mention of lateral release
• Never isolated procedure
DISTAL REALIGNMENT
• Abnormal trochlea or patella alta
• Transfers tibial tubercle distally and medially
• Corrects Q-Angle
• TT / TG Index corrected
• Good results 89 – 93%
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Lift tubercle and shift medially
TROCHLEOPLASTY
• 1ST Described in 1915
• Modified over the years
• Results in arthritis
SUMMARY
Restore normal mechanics
Intact but attenuated MPFL – Imbrication
Reconstruct MPFL
• MPFL and retinaculum attenuated
• Congenital Dislocation
• Severe ligamentous laxity
Large Q Angle / Trochlea Dysplasia
Tibial tubercle transfer
Lateral release never isolated procedure
Cartilage Injury
• Meniscus Tears
• Articular Cartilage Injuries
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Mechanism of Injury
• Trauma
• Ligament / Fractures
• Twisting
• Squatting
Symptoms / Exam
• Intra – articular swelling
• Pain on joint line
• Lock / loss of extension
• Pain with McMurray’s
• Int/ext rotation of tibia
Knee X-Ray MRI Showing A Meniscus
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Treatment• Arthroscopy
• Debridement
• Repair
Meniscal Repair
• Location of tear critical
• White on red
• Red on red
Return to Sports
•Resect – 10 to 14 days
•Repair – 4 to 6 months
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Osteochondritis Dissecans
Definition
•Condition in Which Portion of Subchondral Bone Undergoes Partial or Complete Separation From Its Bony Bed
•Males/Females – 2/1
•Trauma Or Vascular Origin
Osteochondritis Dissecans (OCD)
Mechanism of Injury
- Lesion is Pre-Existing
- Twisting Injury Dislodges Piece
Osteochondritis Dissecans
Physical Exam
- Pain
- Swelling
- Locking Sensation, Popping
- Loose Body
Osteochondritis Dissecans
Radiology
•X-ray to Assess Location, Number of Fragment
•MRI Useful to Measure, Size, Depth, Condition of Articular Surface
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Osteochondritis Dissecans
Treatment
Postop
•NWB 6 to 8 weeks
•Gradual Return to WB Over 3 weeks
•Serial X-rays to Determine
Incorporation
•Return to Sports – 4 to 6 months
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Tendon Ruptures
Overview
- Quadriceps Tendon
- Patellar Tendon
Quad Tendon Rupture
Method of Injury
•Eccentric Contraction of Quad (i.e.
Recovering From Tripping)
•Rupture Intrasubstance or From Proximal
Pole Patella
•Increase Risk with D.M., Gout, Chronic
Steroids, Dialysis
Quad Tendon Rupture
Physical Exam
•Immediate Severe Pain and Swelling
•Persistent Buckling, Cannot Climbs
Stairs
•Palpable Defect
•Complete Tear – Cannot SLR
Incomplete – Extensor Lag
Quad Tendon Rupture
Radiology
•Low Patella, Patella Baja
•Avulsion Fracture
•Soft Tissue Swelling
•MRI Will Show Tear, Used in
Equivocal Cases
Quad Tendon Rupture
Treatment
•Rarely Non-Surgical
•Majority Require Surgery
•Slow Return to Full Motion
•Return to Sports 6 to 9 months
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Patella Tendon Rupture
Mechanism of Injury
•Similar to Quad Tendon
•Also Seen in Jumping Sports
•Bilateral Ruptures Seen in
Patients With Systemic Diseases
Patella Tendon Rupture
Physical Exam
•Defect Below Patella
•Cannot Extend Leg Actively
•Severe Pain, Inability to Walk
Patella Tendon Rupture
Radiology
•X-rays Reveal Patella Alta,
High Riding Patella
•MRI Only For Equivocal Cases or
Suspicion of Other Injuries
Patella Tendon Rupture
Treatment
•Incomplete Tear Rare, Could Immobilize
4 to 6 weeks
•Majority Require Surgery
•Auxiliary Wire to Protect Repair
•Begin Motion 3 Weeks Postop
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Patellar Tendon Rehabilitation
• Straight leg brace at discharge
• WBAT with crutches
• May begin early motion if good repair and auxiliary wire used
• Usually do not return to full sports activity for 6-9 months
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