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Knee soft tissue postgraduate orthopaedic 2016

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Knee soft tissue postgraduate orthopaedic 2016

  1. 1. 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)
  2. 2. POSTGRAD ORTH Deiary Kader PLAN 1. MENISCUS 2. ACL 3. MCL 4. PCL 5. PLC 6. MULTI LEGAMENT 7. PFJ
  3. 3. MENISCAL RESECTION & REPAIR
  4. 4. POSTGRADORTH Deiary Kader Meniscal Anatomy
  5. 5. Radial Fibres, serving as “ties” that resist shearing or splitting. Fibres run parallel or circumferentially to resist hoop stress during weight bearing. 5
  6. 6. POSTGRADORTH Deiary Kader Composed of 70% water 30% organic matter Collagen constitutes 75%
  7. 7. Meniscus
 Vascular Supply Peripheral Vascularity 25-30% Medial and Lateral Geniculates Zones Red Red-White White Red Red-White White
  8. 8. Meniscal Function ➢ Load distribution •50% in extension •90% in flexion –PH in >90o flexion •Lateral > Medial ➢ Joint stability ➢ Congruity ➢ Lubrication ➢ Proprioception
  9. 9. Meniscal Tear 
 Management :- ➢ Excision – 60% of people over 65yrs have incidental tears ➢ Repair ➢ Transplant ➢ Replacement
  10. 10. Repair Excise
  11. 11. POSTGRAD ORTH Deiary Kader Arthroscopy Papers 1- 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
  12. 12. Snapping knee in deep flexion
  13. 13. POSTGRADORTH Deiary Kader Meniscal repair Factors to consider When would you repair a menx?
  14. 14. POSTGRADORTH Deiary Kader Meniscal repair Factors to consider: Patient Chronicity Type Location Tissue quality Stability of knee Axial alignment
  15. 15. 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
  16. 16. POSTGRADORTH Deiary Kader ??????
  17. 17. POSTGRADORTH Deiary Kader Meniscal Substitutes ➢Engineered constructs – Collagen Meniscal Implant – Synthetic Scaffold (Actifit) – Hydrogels Collagen
  18. 18. POSTGRADORTH Deiary Kader Menx Allograft 
 Indications
  19. 19. 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
  20. 20. POSTGRAD ORTH Deiary Kader ICRS <1cm >1cm The modified International Cartilage Repair Society (ICRS) The Outerbridge classification
  21. 21. MACI
  22. 22. 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.
  23. 23. POSTGRAD ORTH Deiary Kader ACL Injuries
 FRCS(Tr&Orth) Revision Course
  24. 24. Anatomy ➢33 mm long, 11 mm in diameter ➢Two bundles ➢AM bundle – tighten in flexion ➢PL bundle – tighten in extension ➢
  25. 25. 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. Cavanagh
 The Biomechanical Function of the Anterolateral Ligament of the Knee
 Am. J. Sports Med. Jan 2015
 Prevent Internal Rotation of the Tibia
  26. 26. POSTGRAD ORTH Deiary Kader
  27. 27. 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
  28. 28. POSTGRAD ORTH Deiary Kader Paul F. Segond
 a Paris surgeon
 1879
  29. 29. POSTGRAD ORTH Deiary Kader ACL Evidence-Based Review Factors affecting results: ➢ Patient Selection ➢ Tunnel placement ➢ Strong graft choices ➢ Solid fixation ➢ Rational rehabilitation
  30. 30. Surgical Treatment Indications: 1) Subjective instability (non-coper) 2) ACL tear in children and adolescents 3) Multiligament injury 4) Displaced meniscal tears
  31. 31. 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
  32. 32. Hamstring BTB Grafts / Fixations Quads
  33. 33. In 1972, D. L. MacIntosh
 In 1967,1975, M. Lemaire Extra-articular reconstruction
  34. 34. POSTGRAD ORTH Deiary Kader ANTEROLATERAL LIGAMENT
  35. 35. Anatomic Single bundle recon
  36. 36. 5mm +
  37. 37. ACL Tunnels
  38. 38. Meyers and McKeever classification (1959)
  39. 39. Postgraduate Orthopaedics 
 FRCS(Tr&Orth) Revision Course MCL 

  40. 40. Medial Collateral Ligament Exam 25-30° of flexion, the MCL provides 80% of the support to valgus stress
  41. 41. 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
  42. 42. MCL Reconstruction with AT + Revision ACLR Chronic MCL Injury
  43. 43. 
 
 
 PCL and PLC 
 
 
 
 Postgraduate Orthopaedics 
 FRCS(Tr&Orth) Revision Course
  44. 44. 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
  45. 45. a. Ant Meniscofemoral lig Humphrey b. Post Meniscofemoral lig Wrisberg
  46. 46. 50
  47. 47. Diagnosis ?
  48. 48. Surgical reconstruction 
 Indications • Acute combined injuries • Acute bony avulsion • Symptomatic chronic PCL
  49. 49. 53 PCL Reconstruction
  50. 50. What are the structures in the Posterolateral Complex of the Knee? Function??? 54
  51. 51. Posterolateral Complex 55
  52. 52. What is the function of the Posterolateral Complex of the Knee? 56
  53. 53. The Posterolateral Corner (PLC) 57
  54. 54. 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 58
  55. 55. Posterolateral Complex Injury 59
  56. 56. 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 60
  57. 57. 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. 61
  58. 58. 62
  59. 59. Vascular Injuries 
 63
  60. 60. Classification 64
  61. 61. Examination
 Recurvatum 65
  62. 62. Management Emergency
 66
  63. 63. Management
 Surgery 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. 67
  64. 64. 68
  65. 65. 69
  66. 66. 70 MPFL VMO VMO MPFL VMO Patella Quads TendonPatella Tendon Medial Knee M.E Add.Tub Femur
  67. 67. 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 71
  68. 68. 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 ??
  69. 69. 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
  70. 70. PATELLA ASSESSMENT
 Beighton 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
  71. 71. IMAGING OF THE PATELLOFEMORAL JOINT ✦ AP and Lateral Knee x-ray ✦ Merchant’s view ✦ MRI Axial view ✦ CT Rotational Profile Merchant’s
  72. 72. 76 Trochlea dysplasia Blumensaat's line Normal Trochlea Depth NORMAL
  73. 73. MEASURING PATELLA HEIGHT Caton – Deschamps index =1.2 Blackburne-peel index = 1.12
  74. 74. 78 MPFL injury Patella pain Articular Damage MRI SCAN
  75. 75. 
 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)
  76. 76. 80 analysis Normal measure is 5° to 15° Femoral anteversion
  77. 77. 81 LATERAL PATELLAR TILT
  78. 78. 82 lateral trochlear tilt The pathologic measure is <14°
  79. 79. 83 Clinique de la analysis lateral tibia twisting slices n°3 and n°4 Normal Ext rotation is 25° to 30°
  80. 80. 
 TRUE Q ANGLE, MEASUREMENT OF THE TIBIAL TUBEROSITY-TROCHLEAR GROOVE (TT/TG) DISTANCE
 Normally TT/TG = 2-9 mm pathologic measure is > 19 mm
  81. 81. 85 TROCHLEAR DYSPLASIA Dejour classification of trochlear dysplasia on CT scans
  82. 82. 86 Shallow flat dome-shaped medial ‘‘cliff-face.’’ Dejour classification
  83. 83. NON-SURGICAL TREATMENT OF PATELLA INSTABILITY Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait
  84. 84. PFJ BIOMECHANICS Patellofemoral 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)
  85. 85. 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 89
  86. 86. TIBIAL TUBERCLE TRANSFER Patellofemoral Instability with Malalignment
  87. 87. FULKERSON'S TECHNIQUE OF ANTEROMEDIALIZATION A steeper osteotomy plane will produce more anteriorization along with medialization
  88. 88. PATELLA ALTA –Distal transfer (Distalization)
  89. 89. 93 1.4 cm Patella alta 

  90. 90. Med Epicondyle Add Tubercle Patella MPFL
  91. 91. 95
  92. 92. Our Dissection
  93. 93. 97
  94. 94. TROCHLEA DYSPLASIA TROCHLOPLASTY
  95. 95. 99
  96. 96. 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 100
  97. 97. 101 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

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