knee soft tissue postgraduate orthopaedic 2016
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POSTGRAD ORTH Deiary Kader
KNEE 2
Postgraduate Orthopaedics 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)
Radial Fibres, serving as “ties” that resist shearing or splitting.
Fibres run parallel or circumferentially to resist hoop stress during weight bearing.
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MeniscusVascular Supply
Peripheral Vascularity 25-30%
Medial and Lateral Geniculates
Zones
Red
Red-White
White
Red Red-White White
Meniscal Function
➢ Load distribution •50% in extension •90% in flexion –PH in >90o flexion
•Lateral > Medial ➢ Joint stability ➢ Congruity ➢ Lubrication ➢ Proprioception
Meniscal Tear Management :-
➢ Excision – 60% of people over 65yrs have incidental
tears
➢Repair
➢ Transplant
➢Replacement
POSTGRAD ORTH Deiary Kader
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 Thorlund
POSTGRADORTH Deiary Kader
Meniscal repair
Factors to consider:
Patient Chronicity Type Location Tissue quality Stability of knee Axial alignment
POSTGRADORTH Deiary Kader
Meniscal repair Techniques
➢Inside-out vertical mattress suture (gold standard)
➢Outside-in
➢All-inside
➢Overall 75-90% success
➢New research
– Better devices – Biologic healing/augmentation – Growth factors/Stem cell therapy
POSTGRADORTH Deiary Kader
Meniscal Substitutes
➢Engineered constructs
– Collagen Meniscal Implant
– Synthetic Scaffold (Actifit)
– Hydrogels
Collagen
Outerbridge Arthroscopic Grading System
Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II Partial thickness defect, fissures < 1.5cm diameter
Grade III
Fissures down to subchondral bone, diameter > 1.5cm
Grade IV
Exposed subchondral bone
POSTGRAD ORTH Deiary Kader
ICRS<1cm
>1cm
The modified International Cartilage Repair Society (ICRS)The Outerbridge classification
Microfracture
Effective in smaller lesions
Leads to fibrocartilage production,
ACI
Greater proportion of hyaline-like tissue
Effective in larger lesions.
MACI
Technically less challenging
For big lesions > 4 cm
More effective than microfracture.
Anatomy➢33 mm long, 11 mm in diameter
➢Two bundles
➢AM bundle – tighten in flexion
➢PL bundle – tighten in extension
➢
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 . Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. CavanaghThe Biomechanical Function of the Anterolateral Ligament of the Knee
Am. J. Sports Med. Jan 2015
Prevent Internal Rotation of th
e Tibia
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
POSTGRAD ORTH Deiary Kader
ACL Evidence-Based Review
Factors affecting results:
➢ Patient Selection ➢ Tunnel placement ➢ Strong graft choices ➢ Solid fixation ➢ Rational rehabilitation
Surgical Treatment
Indications:
1) Subjective instability (non-coper)
2) ACL tear in children and adolescents
3) Multiligament injury
4) Displaced meniscal tears
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
Medial Collateral Ligament Exam
25-30° of flexion, the MCL provides 80% of the support to
valgus stress
Treatment Acute isolated MCL tear I RICE, physiotherapy. 2 Wks II ?Hinged brace for symptom improves, WBAA,2wks III Hinged brace 30-90/ Surgical 3-4 wks
Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III
MCL
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
Surgical reconstruction
Indications
• Acute combined injuries
• Acute bony avulsion
• Symptomatic chronic PCL
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
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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
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PLC Reconstruction The reconstruction can be:-
✴Fibula based such as modified Larson’s technique or
✴Combined tibia and fibula based such as LaPrade’s
anatomical reconstruction.
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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.
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PATELLAR DISLOCATION
➢Re-dislocation rate is very high
➢After First Time 17-20%
➢After Second Time 44%-71%
➢High dissatisfaction following conservative Rx
➢Can be confused with ACL rupture
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WHY THE PATELLA IS UNSTABLE
Lower 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 ??
KNEE ASSESSMENT
Leg 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
IMAGING OF THE PATELLOFEMORAL JOINT
✦ AP and Lateral Knee x-ray
✦ Merchant’s view
✦ MRI Axial view
✦ CT Rotational Profile
Merchant’s
ROTATIONAL PROFILE CT
EVIDENCE BASED INTERVENTION
1. Femoral Anteversion N=50 -150 2. Knee rotation N=30 3. External Tibial torsion 250-300 4. TT:TG offset (N= 10-19mm) 5. Patella index 6. Patella Tilt (N=average QD&QC <200) 7. Trochlea Tilt (N>130) 8. Trochlea Depth Normal (1380+/- 60)
83Clinique 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) DISTANCENormally TT/TG = 2-9 mm pathologic measure is > 19 mm
NON-SURGICAL TREATMENT OF PATELLA INSTABILITY
Conservative first Quads strengthening Core stability McConnell Taping Insoles 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)
SURGICAL OPTIONS
Instability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
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FULKERSON'S TECHNIQUE OF ANTEROMEDIALIZATION
A steeper osteotomy plane will produce more anteriorization along with medialization
SURGICAL OPTIONS
Instability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
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