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Acute Knee InjuriesAcute Knee Injuries-- Controversies and Controversies and
ChallengesChallenges
Professor KM Chan OBE, JP President of FIMS
FIMS Ambassador Tour to Eastern Europe, 2004Belgrade, Serbia Montenegro
Belgrade
ACL ACL Athletic Career
ACL Rupture ACL Rupture -- Warning FeaturesWarning Features
• Intensive pain
• Immediate swelling
• Locking
• Feel a “Pop”
• “Dead” leg
• Cannot continue to play
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Acute SymptomsAcute Symptoms
Acute SignsEffusion Haemarthrosis
painswellingon-set
moderatemoderatehours - days
intensehigh tensiona few hours
75% of ACL 75% of ACL InjuriesInjuries
Haemarthrosis
X-Ray
MRI
Lachman Test
Clinical ExaminationAnterior Drawer Test
Clinical Examination
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Arthroscopic AssessmentArthroscopic Assessment ACL Injury – Delay in treatment
Symptomatic Instability
Watch-dog ligament
Stability
Pivoting Cutting
Mechanical Stability +
Functional Stability +
Meniscal Injuries +
Osteoarthritis ?
Operative TreatmentOperative Treatment
• Restore ROM
• Muscle function
• Knee joint stability - No giving way
• Pre injury activity level
• Decrease risk for late sequelae
Main GoalsMain Goals
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Graft StrengthGraft StrengthTunnel PlacementTunnel Placement
SiteSiteStabilityStability
Fixation DeviceFixation DeviceAssociated PathologiesAssociated Pathologies
MeniscusMeniscusArticularArticular CartilageCartilage
Minimal Invasive Surgery
Patellar Tendon
Hamstring Tendon
Quadriceps Tendon
ACL Meniscus Tear
ACL RehabilitationEarly rehabilitationEarly rehabilitation•• Full range of motionFull range of motion•• At least 90% normal strength At least 90% normal strength
and enduranceand endurance•• Return to ADLReturn to ADL•• Return to sportsReturn to sports
ACL ACL RehabilitationRehabilitation
Accelerated ProgrammeAccelerated Programme
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Closed Chain
HAMSTRINGHAMSTRINGHAMSTRING
CLOSED CHAINCLOSED CHAIN
( ( COCO--CONTRACTION )CONTRACTION )
IsokineticTechnology
ACL ACL ProprioceptiveProprioceptiveTrainingTraining
6 6 -- 12 months after surgery12 months after surgeryNo swelling and giving wayNo swelling and giving wayNo painNo painROM 0 ROM 0 -- 140 degrees of 140 degrees of flexionflexionQuadriceps strength > 85% Quadriceps strength > 85% Hamstrings strength > 90%Hamstrings strength > 90%
Return to Sports Meniscus tearMeniscus tear
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Meniscus tearMeniscus tear• History
• Twisting and/or flexion injury; possible associated ligament rupture
• Swelling may be sudden or occur over 24 hours
• Exam• Focal joint line
tenderness• Pain with
compression/rotation test
• Full range of motion, able to meet demands of sports
Clinical Examination
McMurray test
Arthroscopy
Bucket-Handle Tear of Lateral Meniscus
MRI
• MeniscusRepair
Preserve the MeniscusPreserve the Meniscus
FIMS Team Physician Development Course
Partial Menisectomy
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Meniscal Transplant
Patellar dislocation
Patellar dislocationPatellar dislocation• History
• Sudden giving way sensation of kneecap going out of place
• May reduce spontaneously or remain locked in dislocated position
• Rapid, marked swelling
ExamExam•• Patella may still be dislocated, Patella may still be dislocated,
usually laterallyusually laterally•• Exquisite tenderness medial to Exquisite tenderness medial to
patella (patella (retinaculumretinaculum))•• Tender anterior lateral Tender anterior lateral
femoral femoral condylecondyle may may indicate indicate articulararticular fracturefracture
•• Possible associated ACL tear will Possible associated ACL tear will give positive give positive LachmanLachman
Patellar dislocationPatellar dislocation
Diagnostic Diagnostic ArthroscoscopyArthroscoscopy
TreatmentTreatment•• Early mobilizationEarly mobilization•• Possible arthroscopic surgery Possible arthroscopic surgery
for treatment of for treatment of articulararticularfracture and/or medial repairfracture and/or medial repair
Patellar dislocationPatellar dislocation
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Patellar dislocationPatellar dislocationReturn to actionReturn to action•• Full range of motionFull range of motion•• Normal muscle strength, Normal muscle strength,
especially medial quadricepsespecially medial quadriceps•• When athlete can meet demands When athlete can meet demands
of sportof sport
Medial Collateral Ligament Medial Collateral Ligament InjuryInjuryHistoryHistory•• ValgusValgus forceforce•• Minimal to significant swelling depending Minimal to significant swelling depending
on degreeon degree
•Exam• Local tenderness• Valgus stress test indicates severity
Medial Collateral Ligament Injury
TreatmentTreatment•• For isolated rupture, protected For isolated rupture, protected
mobilization, weightmobilization, weight--bearing as bearing as toleratedtolerated
Return to actionReturn to action•• Pain free, full range of motion, Pain free, full range of motion,
at least 90% normal strength at least 90% normal strength and enduranceand endurance
Medial Collateral Ligament Injury
Posterior Posterior CruciateCruciate Ligament Ligament RuptureRupture
HistoryHistory•• Blow to proximal Blow to proximal
anterior tibia, usually anterior tibia, usually with hyper extended with hyper extended or flexed kneeor flexed knee
•• Extent of injury often Extent of injury often not apparentnot apparent
PCL Rupture
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Posterior drawer test
Posterior sag test
• Exam• Positive posterior sag test, positive
posterior drawer• Check for associated ligament/meniscus
injury
PCL Rupture PCL RuptureTreatmentTreatment•• Individualized as to operative/Individualized as to operative/
nonnon--operativeoperativeReturn to actionReturn to action•• Full range of motionFull range of motion•• Strength & endurance Strength & endurance
to meet demands of to meet demands of sportsport
Posterolateral Complex Injury Clinical ImportanceClinical Importance
Often associated with Often associated with CruciateCruciateligament injuriesligament injuriesOften missedOften missed and may be a cause for and may be a cause for failure of failure of cruciatecruciate ligament ligament reconstruction operationreconstruction operationLoss of knee stability with possible Loss of knee stability with possible dislocation of the knee & dislocation of the knee & Neurovascular injuriesNeurovascular injuries1212--29% associated with29% associated with PeronealPeronealnerve injuriesnerve injuries
How to make the How to make the diagnosis ?diagnosis ?
Are those specific Are those specific tests useful ?tests useful ?
External rotation recurvatum test
Posterolateraldrawer test
Reverse pivot shift test
Increase varus laxity
Dial Test
35% +ve in normal patient
Normal amountextremely variable !!!
Difficult to quantify
(Cooper DE; JBJSA 1991)
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Radiological Features Radiological Features
Avulsion # PCL Avulsion # PCL attachmentattachmentWidened lat. Joint Widened lat. Joint spacespacePosterior position of Posterior position of tibia relative to femurtibia relative to femurArcuateArcuate # fibular head# fibular headAvulsion of Avulsion of GerdyGerdytubercle / ITBtubercle / ITB
Goals of TreatmentGoals of TreatmentAim to restore anatomy to reduce abnormally Aim to restore anatomy to reduce abnormally high contact pressures and the chances of high contact pressures and the chances of early OAearly OARestore stabilityRestore stabilityIn acute injuries, surgical repair in 3/52In acute injuries, surgical repair in 3/52•• Direct repair ( ideal)Direct repair ( ideal)
In chronic injury (Difficult)In chronic injury (Difficult)•• Tissue advancement Tissue advancement •• TenodesisTenodesis
Tissue augmentation with Tissue augmentation with autograftautograft or or allograftallograft
(( Correct any Correct any varusvarus malalignmentmalalignment by by proximal proximal valgusvalgus tibialtibial osteotomyosteotomy before PLC before PLC reconstruction or simultaneously )reconstruction or simultaneously )
Patellar Tendinosis
UltrasoundUltrasound
Patellar TendinosisMRIMRI
Patellar Tendinosis
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Patellar Tendinosis Anterior knee pain, non-acute
Anterior knee pain, nonAnterior knee pain, non--acuteacuteHistoryHistory•• Gradual onset of painGradual onset of pain•• Single specific location, Single specific location,
multiple locations, or multiple locations, or diffusediffuse
•• Effusion suggests more Effusion suggests more serious problemserious problem
•• PrePre--disposing factor: disposing factor: previous injuries to any previous injuries to any portion of the limb portion of the limb
ExamExam•• Determine specific locations of Determine specific locations of
tendernesstenderness•• Patellar mobilityPatellar mobility•• Muscle flexibility and strengthMuscle flexibility and strength
Anterior knee pain, nonAnterior knee pain, non--acuteacute
TreatmentTreatment•• Make specific diagnoses where possibleMake specific diagnoses where possible•• Generally, stretching and strengthening Generally, stretching and strengthening
to correct deficitsto correct deficits•• NSAIDS, RICENSAIDS, RICEReturn to actionReturn to action•• Full range of motion, no effusion, and Full range of motion, no effusion, and
able to meet demands of sportable to meet demands of sport
Anterior knee pain, nonAnterior knee pain, non--acuteacute Athlete DialogueAthlete DialogueAthlete Dialogue