Knee Sports for PostGrad Orth Course 2017

POSTGRAD ORTH Deiary Kader

SPORTS INJURIES/ KNEE

FRCS(Tr&Orth) Revision Course

Professor Deiary F Kader Knee Surgeon

South West London Elective Orthopaedic Centre Epsom & St Helier University Hospitals

Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva)

Research/Training War Trauma Elective

Postgraduate Orthopaedics

CHARITY


PLAN1. MENISCUS

2. ACL

3. MCL

4. PCL

5. PLC

6. MULTI LEGAMENT

7. PFJ

CLINICALS ?


Nerve Supply-KneeTibial Nerve Medial and Middle GB Common Peroneal N Lateral & Recurrent GB Obturator N - GB


BLOOD SUPPLY- KNEEFemoral Popiteal A


MENISCAL RESECTION & REPAIR

Fibro-cartilaginous Type I collagen

POSTGRADORTH Deiary Kader

➢ Lateral Meniscus

–Circular

–Close insertions

–Posterior = Anterior width

–Loosely attached to capsule

➢ Medial Meniscus

– Semicircular

–Wider Posterior

–Firmly attached to capsule


Composed of 70% water - 30% organic matter (Collagen constitutes 75%)

Radial Fibres, serving as “ties” that resist shearing or splitting.

Circumferential Fibres run parallel to resist hoop stress during weight bearing.

8


Compression to radial to be contained by the Menx

Meniscus Vascular Supply

Red

Red-White White

At 10 years of age

What is the function of the Meniscus?

Meniscal FunctionLoad /transmission/ distribution

50% in extension

90% in flexion

Post.Horn in >90º flexion

Lateral > Medial

Joint stability

Congruity

Lubrication/ Nutrition

Proprioception

Increase contact area and reduce contact stresses


Meniscal Tear Management :-

Excision 60% of people over 65yrs have incidental tears

Repair

Transplant

Replacement

Traumatic tears & Degenerative tears


Arthroscopy Papers1- N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. Sihvonen R 2- CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. Khan M

3-BMC Musculoskelet Disord. 2013 Feb 25;14:71. doi: 10.1186/1471-2474-14-71. Arthroscopic partial meniscectomy in middle-aged patients with mild or no knee osteoarthritis: a protocol for a double-blind, randomized sham-controlled multi-centre trial. Hare KB

4-Am J Sports Med. 2013 Jul;41(7):1565-70. doi: 10.1177/0363546513488518. Epub 2013 May 23. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.Yim JH

5-Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):358-64. doi: 10.1007/s00167-012-1960-3. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Herrlin SV

6- N Engl J Med 2002; 347:81-88July 11, 2002DOI: 10.1056/NEJMoa013259 A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. J. Bruce Moseley

7- Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms, BMJ 2015; 350 doi: JB Thorlund

Moseley 2002 & Thorlund 2015

http://www.ncbi.nlm.nih.gov/pubmed/24369076

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sihvonen%20R%5BAuthor%5D&cauthor=true&cauthor_uid=24369076


http://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20M%5BAuthor%5D&cauthor=true&cauthor_uid=25157057


http://www.ncbi.nlm.nih.gov/pubmed/?term=Hare%20KB%5BAuthor%5D&cauthor=true&cauthor_uid=23442554



http://www.ncbi.nlm.nih.gov/pubmed/?term=Herrlin%20SV%5BAuthor%5D&cauthor=true&cauthor_uid=22437659

http://www.nejm.org/toc/nejm/347/2/

Repair

Excise


Horizontal cleavage tear

Pisani’s sign

The cyst size decrease

with knee flexion

knee flexed <45º


DD - Cyst • Ganglia: superficial, not as hard and unconnected to the joint

• Calcified deposits in the collateral ligament: show on radiographs

• Prolapsed torn meniscus (pseudocyst)

• Sebaceous cyst

• Bursitis

• Various tumours: sarcoma, lipoma, fibroma and histiocytoma

• PVNS


Snapping knee in deep

flexion


Snapping knee in deep flexion


Meniscal repairWhen would you repair a menx

Factors to consider


Meniscal repairFactors to consider:

1. Patient

2. Chronicity

3. Type

4. Location

5. Tissue quality

6. Stability of knee

7. Axial alignment


Meniscal repair Techniques

1. Inside-out vertical mattress suture (gold standard)

2. Outside-in

3. All-inside

4. Overall 75-90% success

5. New research

1. Better devices

2. Biologic healing/augmentation

3. Growth factors/Stem cell therapy


Partial Meniscal Substitutes Engineered constructs

Polyurethane polymeric implant (Actifit®)

Synthetic Scaffold

Collagen Meniscus Implant (CMI®)

Collagen(CMI®)


Collagen Menx implant

Rodkey et al


hydrogels knee

?


Total meniscal prosthesis

NUsurface

Synthetic implant

meniscus-like

Prof Zorzi from Verona


Menx Allograft IndicationsSymptomatic

Neutral alignment

Normal stability

No more than grade II-III Cartilage damage

Understand the risk of disease transmission

No knee abuser and

Not in BMI >35

Prof Deiary Kader

Traumatic Chondral Damage


Outerbridge Arthroscopic Grading System

Grade 0 Normal cartilage

Grade I Softening and swelling

Grade II

Partial thickness defect, fissures < 1.5cm diameter <50%

Grade III

Fissures down to subchondral bone, diameter > 1.5cm. >50%

Grade IV

Exposed subchondral bone


ICRS<1.5cm

>1.5cm

The modified International Cartilage Repair Society (ICRS)The Outerbridge classification

Prof Deiary Kader

Traumatic Chondral Damage

Treated with Microfracture


MACI

Microfracture

Effective in smaller lesions

Leads to fibrocartilage production,

ACI

Greater proportion of hyaline-like tissue

Effective in larger lesions.

MACI

Technically less challenging than ACI

For big lesions > 4 cm2

More effective than microfracture.

J Bone Joint Surg Br. 2005 May;87(5):640-5.

Autologous chondrocyte implantation versus matrix-induced

autologous chondrocyte implantation for osteochondral

defects of the knee: a prospective, randomised study

.Bartlett W1, Skinner JA, Gooding CR, Carrington RW, Flanagan AM, Briggs TW, Bentley G.

We conclude that the clinical, arthroscopic and histological outcomes are

comparable for both ACI-C and MACI. While MACI is technically attractive,

further long-term studies are required before the technique is widely adopted

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bartlett%20W%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Skinner%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Gooding%20CR%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Carrington%20RW%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Flanagan%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Briggs%20TW%5BAuthor%5D&cauthor=true&cauthor_uid=15855365

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bentley%20G%5BAuthor%5D&cauthor=true&cauthor_uid=15855365






ACL InjuriesFRCS(Tr&Orth) Revision Course


Anatomy➢33 mm long, 11 mm in diameter

➢Two bundles

➢AM bundle – tighten in flexion (Translation)

➢PL bundle – tighten in extension (Rotation)


ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the anterolateral ligament is a stabiliser of internal rotation

in >35º of flexion .

THE ACL Prevents Internal Rotation of th

e Tibia

Valgus + ER

POP

Causes of Injury

Mechanisms of Injury:

1) “plant-and-cut” manoeuvre

2) Knee Hyperextension (Fall backwards)

3) Landing on one leg following a jump

(Olsen et al 2004)


McDaniel – Rule of Thirds

One-third is able to compensate, and can

pursue normal recreational sports

One-third is able to compensate but will have to

reduce their sporting activities

One-third does poorly and develop instability

with simple activities daily living


Surgical TreatmentIndications:

1) Subjective instability (non-coper)

2) ACL tear in children and adolescents

3) Multiligament injury

4) Displaced meniscal tears


ACL Evidence-Based Review

Factors affecting results:

Patient Selection Tunnel placement Strong graft choices Solid fixation Rational rehabilitation


Surgical Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972) Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern regarding its effectiveness in addressing anterior translation

Intra-articular reconstruction. Current best practice

Intra + Extra articular reconstruction

Hamstring BTB

Grafts / Fixations

Quads

●Biologically inactive

●Slower incorporation

●Less stability in 6 months

●Risk of disease transmission

●Role in revision surgery

●Weaker after having been irradiated

Allograft


➢ ◊

Paul F. Segonda Paris surgeon

1879

Prof Deiary Kader

ANTEROLATERAL LIGAMENT

ALL


In 1972, D. L. MacIntosh In 1967,1975, M. Lemaire

Extra-articular reconstruction

Prof Deiary Kader

OPEN ALL Recon


Anatomic Single bundle recon


5mm +

What are the complications of ACL

reconstruction?


Complications

➢ Infection

➢ DVT and PE

➢ Osteoarthritis

➢ Cyclops lesion residual tissue anterior to

the ACL blocks extension


Complications

➢Failure of Fixation

➢Graft rupture from impingement

➢Flexion contracture and arthrofibrosis

➢Anterior placement of the femoral tunnel limits flexion

➢Anterior placement of the tibial tunnel limits extension


ACL Tunnels

Tibial Eminence Fracture Meyers and McKeever classification (1959)

❖ Type I: non displaced

❖ Type II: partially displaced or hinged

❖ Type III: completely displaced (Type III)

❖ Type IIIA (Zifko) involves the ACL insertion only

❖ Type IIIB (Zifko) includes the entire intercondylar eminence.

❖ Type IV (Zaricznyj 1977): comminution of the fracture fragment.


Meyers and McKeever classification (1959)

Treatment

• Casting in extension for type I

• Open reduction and internal fixation.

• Arthroscopic reduction and fixation

• Rarely ACL reconstruction is necessary


Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course

MCL


Medial Collateral Ligament

In 25-30° of flexion, the MCL provides 80% of the support to

valgus stress


MCLTreatment Acute isolated MCL tear I RICE, physiotherapy. 2 Wks II ?Hinged brace for symptom improves, WBAA,

2wks III Hinged brace 30-90 or Surgical 3-4 wks

Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III


Chronic MCL Injury

Patient A MCL Reconstruction with AT + Revision ACLR


PCL and PLC

Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course

drive thru”


PCL Average length of 38 mm and diameter of 13 mm

AL Bundle: Long, thick, Large part

Tightens in flexion

PM Bundle: Tight in extension

Meniscofemoral ligaments: mechanically very strong

Anterior: Humphrey’s ligament

Posterior: Wrisberg’s ligament


PMB tight in Extension

ALB

TIGHT IN FLEXION


a. Ant Meniscofemoral lig Humphrey

b. Post Meniscofemoral lig Wrisberg

Meniscofemoral ligaments: mechanically very strong

Anterior: Humphrey’s ligament

Posterior: Wrisberg’s ligament


PCL Diagnosis in MRI ?MRI & PCL

➡ Clinical examination is more reliable than MRI scan ➡ The PCL may be dysfunctional despite normal MRI ➡ Kneeling stress x-ray ➡ Measure the degree of translation


Surgical reconstruction 1. Indications

2. Acute combined injuries

3. Acute bony avulsion

4. Symptomatic chronic PCL


PCL Reconstruction

PTS BRACE POST OP-PCL

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What are the structures in the Posterolateral Complex of the Knee?


Posterolateral Complex

Posterolateral Complex Components:

– LCL, Popliteus, Popliteofibular ligament, arcuate ligament, ITB, Biceps

Function

– Resists External and Varus rotation

Mechanism of Injury

– Direct blow to anteromedial tibia

– Hyperextension/varus

82


What is the function of the Posterolateral

Complex of the Knee?


The Posterolateral Corner Summary

Primary stabilisers of external tibial rotation at all knee flexion angles

Secondary restraints to anterior and posterior translation

The Posterolateral Corner Resist Ext Rotation of Tibia

The LCL is a cord like structure 5-7 cm in lengthS

Primary static restraint to varus opening of the knee

Secondary restraint to posterolateral rotation

The popliteus is a static and dynamic external rotation stabiliser.

The popletiofibular ligament acts as

a primary restraint to external rotation of

the tibia on the femur at 30º of flexion85

The Posterolateral Corner (PLC)

Isolated PLC sectioning produce a maximal

Average increase of 13° of tibial ER at 30° of knee flexion

Average increase of 5.3° of tibial ER at 90°

Isolated PCL sectioning has no effect on external tibial

rotation

Combined injury to the PCL and PLC leads to ER of 20.9°

at 90° of knee flexion

86


DIAL TEST


Posterolateral Complex Injury

External rotation testDial Test

Increased External rotation (30º, 90º).

External rotation recurvatum


Posterolateral Complex Injury--Treatment

Partial

– Grade I & II Instability with a good end point

– Nonsurgical Treatment

– 1-3 week immobilisation in extension

Complete Acute

– Primary repair best

– Augment with allo/auto graft

Complete Chronic

– Reconstruct Popliteus and LCL


PLC Reconstruction The reconstruction can be:-

1. Fibula based such as modified Larson’s technique or

2. Combined tibia and fibula based such as LaPrade’s (anatomical reconstruction).


Knee dislocationAny triple-ligament knee injury constitutes a frank dislocation. This is relatively rare but a severe and potentially limb-threatening injury.

High-energy injury such as RTA Sporting accident

May be missed on initial assessment.


Vascular injury associated with fractures or dislocations – BOAST 6

ABCs, manage catastrophic haemorrhage

Re-align the pulseless, deformed limb

A de-vasularised limb requires surgical interventionWarm ischaemia time >3-4 leads to irreversible damageImaging options include duplex, angiography, CT angio, on-table angio

Sequence – temporary shunt, skeletal stabilisation then definitive reconstruction with autologous vein grafts

Note:- Reperfusion may lead to compartment syndrome and myoglobinuria

Vascular Injuries Previously it was thought there was a

50% incidence of vascular compromise

Now 3.3-18%

20%–30% incidence of nerve injury.

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Classification of Knee Dislocation Based on tibial displacement

➢Closed or open

➢High or low energy

➢Dislocation or subluxation

➢Neurovascular involvement

➢Anterior (common, associated with intimal tears)

➢Posterior; also medial, lateral (highest rate of peroneal

nerve injury) and rotatory (usually irreducible) or combined

➢ Hyperextension leads to anterior dislocation

➢ Dashboard injury leads to posterior dislocation95


Classification Classified on the basis on tibial displacement in respect to the femur

ExaminationValgus and varus laxity

Anteroposterior translation

Recurvatum

>10º hyperextension suggests ACL injury

>30º hyperextension indicates PCL injury

Rotation indicates MCL and LCL injury

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ManagementSurgical emergency

Deal with life-threatening injuries first

Circulation check in A&E

Serial examination for 48 hours.

Ankle brachial Index (ABI) <0.9 is suggestive of significant

arterial injury

98


Management Emergency

Deal with life-threatening injuries first

Serial examination for 48 hours.

Ankle brachial Index (ABI)

ABI <0.9 is suggestive of significant arterial injury

Involve the vascular surgeon

Radiography before manipulation

(assess direction and associated fracture)

Reduction as soon as possible in theatre


ManagementSurgery as soon as the vascular surgeon allows Most ACL/PCL/MCL can be treated with bracing the MCL followed by combined ACL/PCL reconstruction once range of movement is restarted, usually after 6 weeks.

ACL/PCL/posterolateral corner can be treated by repairing the posterolateral corner acutely (within three weeks) and delayed ACL/PCL reconstruction 8 weeks later. Or all in One

Open dislocation, fracture dislocation and vascular compromise require staged procedures.


Patellar DislocationRe-dislocation rate is very high

After First Time 17-20% (to 49%)

After Second Time 44%-71%

High dissatisfaction following conservative Rx

Can be confused with ACL rupture


MPFL

VMO

VMO

MPFL

VMO

Patella Quads TendonPatella

Tendon

Medial Knee

M.E

Add.Tub

Femur


Med Epicondyle

Add Tubercle

Patella

MPFL


Why the patella is unstableLower limb Malalignment?? Femur, tibia or foot pronation Osseous abnormalities?? Patella alta Increased Q angle Trochlea dysplasia Soft Tissue?? HMS MPFL Insufficiency Muscle or ITB

Gait ??


PFJ BiomechanicsPatellofemoral joint reaction force

WALKING 0.5xBW

STRAIGHT LEG RAISE 0.5xBW 0 DEG

CYCLING: 1.2 × BW

RISING FROM A CHAIR w ARMS: <3 × BW

STAIRS (UP OR DOWN) 3.3xBW 60 DEG

JOGGING & SQUAT–RISE 6xBW at 140 deg

SQUAT–DESCENT 7.6x BW at 140 deg

JUMPING UP TO 12 × BW

Ff

Ft

Fj

Trigonometry Fjf=Ff cos(angle/2)


Knee assessmentLeg Alignment Varus/valgus

Femoral neck anteversion

Tibial rotation

Ligament assessment (ACL,PCL, MCL, LCL)

Meniscal assessment

Medial/ Lateral compartment OA

Hip , Spine, peripheral pulses

Apprehension test


Patella AssessmentBeighton Score 0---9 Patella Alignment (Q Angle) Dislocation in extn (J Sign) Quads Bulk/ ITB (Ober's test) Hamstring Tightness Patella height Alta/Baja Patella Mobility (N@300=<1/2) Parapatellar tenderness Patella Apprehension PFJ Crepitus PFJ Compression (Clarke test) Trochlea Depth Normal (1380)

Shallow ,Flat , Convex , Cliff


Beighton Score 0---9


Imaging of the patellofemoral joint

✦ AP and Lateral Knee x-ray

✦ Merchant’s view

✦ MRI Axial view

✦ CT Rotational Profile

Merchant’s


Trochlea dysplasia

Blumensaat's line

Normal Trochlea Depth

NORMAL


Measuring patella HeightCaton – Deschamps index =1.2

Blackburne-peel index = 1.12


MPFL injury

Patella pain

Articular Damage


Rotational Profile CT Evidence based intervention

Femoral Anteversion N=50 -150 Knee rotation N=30 External Tibial torsion 250-300 TT:TG offset (N= 10-19mm) Patella index Patella Tilt (N=average QD&QC <200) Trochlea Tilt (N>130) Trochlea Depth Normal (1380+/- 60)


analysis

Normal measure is 5° to 15°

Femoral anteversion


LATERAL PATELLAR TILT


lateral trochlear tilt

The pathologic measure is <14°

POSTGRAD ORTH Deiary Kader Clinique de la Sauvegarde –

analysis

lateral tibia twisting

slices n°3 and n°4

Normal Ext rotation is 25° to 30°


True Q angle, Measurement of the Tibial Tuberosity-Trochlear Groove (TT/TG) distance

Normally TT/TG = 2-9 mm pathologic measure is > 19 mm


Trochlear Dysplasia

Dejour classification of trochlear dysplasia CT


Dejour classification of trochlear dysplasia on CT scansShallow flat

dome-shaped medial ‘‘cliff-face.’’

Dejour classification


Non-Surgical treatment of Patella Instability

Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait


Tibial Tubercle Transfer Patellofemoral Instability with Malalignment


Fulkerson's Technique of Anteromedialization

A steeper osteotomy plane will produce more anteriorization along with

medialization


PATELLA ALTADistal transfer (Distalization)


14 mm

Patella alta


Med Epicondyle

Add Tubercle

Patella

MPFL


Our Dissection


What are the complications of MPFL reconstruction?


Trochlea dysplasia

TROCHLOPLASTY


24 years old female doctor had a permanents dislocation of the patella Treated with 1. Lateral release 2. Tib Tub Medialisation 3. Tib Tub Distalisation 4. Trochleaoplasty 5. MPFL Reconstruction


Surgical OptionsInstability with Malalignment Tib Tub Medialisation

Instability without Malalignment MPFL Reconstruction

Instability with patella alta Tib Tub Distalisation

Trochlea Dyslpasia Trochleoplasty

Rotational problems Derotation Osteotomy


LONDON COURSE 2-7 OCTOBER 2017

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Knee Sports for PostGrad Orth Course 2017

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Transcript of Knee Sports for PostGrad Orth Course 2017