Knee ligaments


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Knee ligaments

  1. 1. By M. Mounes Orthopedic Department Ain Shams University
  2. 2. It is loss of normal anatomical relationship of the knee component during the ROM.
  3. 3.  In this session we will discuss : - Bony Anatomy - Knee Functional anatomy - Knee Blood and Nerve Supply - Knee Kinematics
  4. 4.  The knee is formed from three bones : - Femur (Femoral Condyle) - Tibia (Tibial Plateau) - Patella (Articular surface)
  5. 5.  Femoral Part : - Medial femoral condyle: * Taller than the lateral femoral condyle * 25 degree convergent * It is longer by 1.7cm than the lateral condyle in the outer circumference * Asymmetry in length produces axial rotation of the tibia on the femur during flexion and extension - Lateral Femoral condyle: AP diameter more than the medial condyle 10 degree convergent
  6. 6.  Tibial Part : The medial plateau is nearly flat or concave and has a larger surface area than the lateral plateau. - The lateral plateau surface is slightly convex. - Both plateaus have a 10degree posterior inclination to the tibial shaft in the sagittal plane. - Convex Concave
  7. 7.  Tibial Part : - Tibial spines (or tubercles) are bony elevations, function to stabilize the condyles from side-to-side motion. - The interspinous area is void of hyaline cartilage, as are the insertion sites for the meniscal horns and cruciates.
  8. 8.  Patella: • Largest sesamoid bone in the body (usually 3 - 5cm in length) • Patella tendon to patella length usually ratio of 1:1 (+/- 20%) • 10% of patients have complete suprapatella membranes and 75% will have at least one of the 3 plica's even if only as a remnant (supra-patella, medial patella or infra-patella) • Ossification centre appears between 2 and 3 years of age but can be as late as 6 years
  9. 9.  Patella: It has 2 articular facets (Medial and lateral) But recently (7) According to the shape of the facet it is classified to :
  10. 10.  In this session we will discuss : - Bony Anatomy - Knee Functional anatomy - Knee Blood and Nerve Supply - Knee Kinematics
  11. 11. Knee Stabilizers are : -Extra-articular Stabilizers -Intra-articular Stabilizers -Bone congruity -Propioception --Medial Medial --Lateral Lateral --Postero-medial Postero-medial --Postero-lateral Postero-lateral --Antero-medial Antero-medial --Antero-lateral Antero-lateral --Arcuatecomplex Arcuate complex --ACL ACL --PCL PCL --MFL MFL --Menisci Menisci
  12. 12. It is formed from three layers (Warren Marshal): 1- First Layer: Crural fascia investing sartorius & gastroc + Sartorius 2- Second layer : - Superficial MCL. - Posterior Oblique ligament - Semi-membranosus 3- Third Layer: - Deep MCL - Coronary ligament - Medial capsule
  13. 13. -Is the primary static restraint to valgus stress at full ext. and at 30 degree flexion. Has two portions: * Superficial fibers (tibial collateral ligament) * Deep portion (medial capsular ligament) -Both portions originate from the medial femoral epicondyle.
  14. 14. -The superficial MCL has two bundles : The anterior bundle vertically oriented fibers inserts just posterior to the insertion of the pes anserinus; The posterior bundle oblique fibers insert inferior to the tibial articular surface. - The medial capsular ligament also has two bundles : The meniscofemoral The meniscotibial portions, which are attached to the medial meniscus through the coronary ligaments.
  15. 15. The five attachments of the The five attachments of the semimembranosus muscle :: semimembranosus muscle --Directhead to the postero Direct head to the postero medial part of proximal tibia medial part of proximal tibia (pars directa) (pars directa) --Deephead deep to MCL (Pars Deep head deep to MCL (Pars reflexa) reflexa) --Posterioroblique ligament Posterior oblique ligament --Opliquepoplitial ligament Oplique poplitial ligament --Expansionscovering the Expansions covering the popliteus fascia and the leg fascia popliteus fascia and the leg fascia
  16. 16. -POL Attaches to PHMM & femoral condyle. -Recently it is believes to be attached to SM and considered as one of its attachement Long Medial collater -It restraints Anterior tibial translation and external rotation through its attachment to the PHMM and Semimembrenosus
  17. 17. -POL rupture with the ACL when tibial anterior dislocation together with meniscal tear. -POL rupture with the ACL when tibia external rotation
  18. 18. -Due to its parallism to PCL it acts secondary restraint of PCL
  19. 19. It is formed of three layers : Arcuate Complex: Arcuate Complex: 1- First layer : 1]LCL 1]LCL Biceps femoris 2]. Arcuate lig (Y shaped 2]. Arcuate lig (Y shaped Iliotibial band condensation) condensation) 2- Second layer : 3]. Popliteus tendon 3]. Popliteus tendon Patellar retinaculum 4]. Biceps tendon 4]. Biceps tendon Patello femorla ligament 5]. Lateral head gastroc 5]. Lateral head gastroc 3-Third layer : LCL Popliteus tendon Popliteus Popliteofibular ligament Complex Popliteomeniscal fasicle Arcuate ligament Fabillofibular ligament Posterior capsule
  20. 20. 1st Layer Ilial Tibial Tract Bicep Femoris Peroneal Nerve
  21. 21. Exposing Layer 3 LCL LCL
  22. 22. LCL Deep Lamina of Layer 3 PF lig. PF lig.
  23. 23.  2° varus stabilizer  Superficial  Deep (Kaplan’s fibers)  Capsuloosseous (anterolateral sling)
  24. 24.  1° varus stabilizer  Proximal / posterior to lateral epicondyle  Midway along fibular head  Surrounded by the insertion of the Biceps muscle.
  25. 25.  Fabellofibular Ligament ula fi b te o t pli en Po gam Li r Popliteus Muscle Biceps Tendon Stabilizer to posterolateral rotation 1- Popliteus femoral attachement 2- Popliteomeniscal fascicles 3- Popliteofibular ligament 4- Popliteal aponeurosis to lateral meniscus
  26. 26.  Popliteus attachment on Femur  2 cm from FCL  Attaches on anterior fifth of popliteal sulcus
  27. 27.  Active internal rotator (unlocking)  Active antivarus joint coaptator  Passive control of external rotation  Passive control of hyperextension
  28. 28. Originates at musculotendinous junction  Anterior / Posterior divisions  Static stabilizer of ER  “Arcuate ligament” in old literature 
  29. 29. LCL LCL LM PT LM PM PFL Internal rotation tibia: lax PM PT PFL External rotation tibia: tense Fig. 8: Popliteofibular ligament, internal-external rotation (Karin Ullrich)
  30. 30. It is formed from : -Anteromedial capsule - Medial retinacula -Patelofemoral and patelotibial ligament It is formed from : -Anterolateral capsule - lateral retinacula -Iliotibial band
  31. 31. Knee Stabilizers are : -Extra-articular Stabilizers -Intra-articular Stabilizers -Bone congruity -Propioception --Medial Medial --Lateral Lateral --Postero-medial Postero-medial --Postero-lateral Postero-lateral --Antero-medial Antero-medial --Antero-lateral Antero-lateral --Arcuatecomplex Arcuate complex --ACL ACL --PCL PCL --MFL MFL --Menisci Menisci
  32. 32. Anatomy : Tibial origin : area approximately 11 mm X 17 mm located in front of, and lateral to, the medial intercondylar tubercle Femoral insertion : posterior part of the inner surface of the lateral femoral condyle Dimensions : 11 X33 mm The ultimate load for the young ACL was 1,725 ±±269 N. Since The ultimate load for the young ACL was 1,725 269 N. Since that study, the criteria for the strength of autograft, allograft, that study, the criteria for the strength of autograft, allograft, and synthetic substitutes have been set at 1,730 N. and synthetic substitutes have been set at 1,730 N.
  33. 33. Direction of fibers : Anteromedial taut in flexion Posterolateral taut in extension Named According to their insertion in the tibia fUNCTIONS: - Primary restrain to the anterior tibial displacement - Primary restrain for knee internal rotation - Secondary restrain to valgus and varus angulation at full extension -Propioception to the knee position -Screw home motion occurs around its axis The secondary restrains to the anterior tibial drawer are : Medial meniscus Collateral ligaments Joint capsule
  34. 34. AM taught in Extension AM taught in Extension AM taught in Flexion AM taught in Flexion
  35. 35. Anatomy : Tibial origin : Femoral insertion : Dimensions : The PCL averages in length between 32 and 38mm and has a cross sectional area of 31.2mm2 at its mid-substance level, which is 1.5 times that of the anterior cruciate ligament (ACL) crosssectional area. Named according to Femur
  36. 36. Direction of fibers : The PCL consists of two functional components referred to as the anterolateral (AL) and the posteromedial (PM) bundles It is the primary restraint to posterior tibial translation This is maintained throughout range of motion as the Anterolateral bundle is taught in flexion while the Posteromedial bundle is taught in extension.
  37. 37. fUNCTIONS: oPrimary restraint to posterior tibial translation oSecondary restraint to varus and valgus forces. o Secondary restraint to torsional forces. o Interacts with the ACL to form “Four bar cruciate linkage system”. oPropioception
  38. 38. They are : Ligament of Humphery Ligament of Humphery Ligament of Wrisborg Ligament of Wrisborg
  39. 39. The ligament of Humphry is anterior to the PCL while the ligament of Wrisborg is posterior to it. Both arises from the posterior horn of lateral meniscus and attached anterior and posterior to the PCL attachment simultaneously. Ligament of Wrisborg Ligament of Humphery
  40. 40. Anterior meniscofemoral ligament PCL Posterior meniscofemoral ligament
  41. 41. PCL
  42. 42.     Elasto fibrocartilaginous Crescent shaped Medial meniscus is a small segment of a wide circle while lat. meniscus is a large segment of a smaller circle Ant. horns attached by a intermeniscal ligament
  43. 43. F is the highest vascular while A is the least vascular. 1 is the highest vascular while 3 is the least
  44. 44.    Popleteus muscle is attached to lateral meniscus Semimemb. Is attached to medial meniscus Through the POL attachemetn to PHMM Anterior horn of lat meniscus and post horn of both menisci attached to intercondylar eminence
  45. 45. Blood supply   From branches from lat,middle and medial genicular arteries Vascular synovial tissue from the capsule supplies the peripheral third of the meniscus
  46. 46. Circumferential and radial collagen fibre type I in 98%  Matrix: Proteoglycans glycoproteins and elastins 
  47. 47. At least 50% of the compressive load of the knee joint is transmitted through the meniscus in extension , and approx 85% of the load is transmitted in 90° flexion. Medial meniscus 85% LMM 75 %  Load bearing Total meniscectomy can cause a fourfold increase in articular surface stresses. Partial meniscectomy increases forces by 50%. When compressive force is applied to the knee joint, the anterior and posterior attachments of the meniscus resist extrusion . This converts compressive force into hoop stress, which the circumferential orientation of the collagen fibers is ideally suited to withstand.
  48. 48.  • Load bearing Shock absorption • Secondary stabilizer • Proprioception • Joint lubrication • Joint nourishment The shock absorbing capacity of normal knees is ~ 20% higher than in meniscectomised knees. It has a door stopper effect preventing This has been of the tibia anterior translation inferred from the The findingof a system totype 2 ability of type 1 and absorb nerve endings in the ant shock has been implicated in and development of OA menisci post horns of the
  49. 49. The knee joint is a modified hinge synovial joint. It is a combination of complex motion between rolling and gliding, ginglymus (hinge) and trochoid (pivot). Hence comes the recent name (bicondyloid joint)
  50. 50. Six degrees of freedom are described to show the relationship of the tibia and the femur to each other. These are broadly divided into: -Rotational - Translational. The 3 rotational degrees of freedom are : 1- Flexion-extension 2- Internal-external axial tibial rotation 3- Varus valgus (adduction-abduction). The 3 translational degrees of freedom are: 1- Anterior-posterior tibial displacement 2- Medial-lateral tibial displacement 3- Proximal-distal (joint distractioncompression). Constraints to excessive degrees of motion in these freedoms are provided by ligamentous structures around the knee.
  51. 51. How does the knee move ? Differs from How can the knee move ?
  52. 52. It is does not Roll
  53. 53. It is does not Glide
  54. 54. ROLLS GLIDES
  55. 55. KINEMATIC THEORIES 1) Rolling Back of the femur 2) Four-bar kinematic chain 3) Helical axis 4) Envelope of motion 5) Rotation with medial pivot 6) Screw Home motion
  56. 56. 1) Rolling Back of the femur MED LAT Roll-back of femoral condyles
  57. 57. 2) Four-bar kinematic chain Four-bar chain is rigid Zuppinger, Die active flexion, 1904 Four-bar chain is not rigid (PCL is lax in early flexion) Strasser, Lehrbuch der muskel, 1917 “Interactive knee”
  58. 58. (A) Model of the knee joint in full extension. (B) The interaction between these four bars can be used to describe the posterior migration of the tibiofemoral contact point that occurs with knee flexion. (C) Model of the knee joint in flexion.
  59. 59. Roll-back & Four-bar Axis of motion passes through the intersection of the bars
  60. 60. At the beginning the ratio of femoral to tibial motion is 2:1
  61. 61. At the end the ratio of femoral to tibial motion is 4:1
  62. 62. The angle of fixation of the four bar cruciate linkage system denotes the range of flexion and extension
  63. 63. Hyper extension by 50 degrees If axis of fixation (blumenstate line) to the femoral axis is 90 degree
  64. 64. Normal Range Of motion If axis of fixation (blumenstate line) to the femoral axis is 40 degree
  65. 65. Burmester Curve A third order curve defined by the four bar cross linkage system defines the position for most isometric ligaments.
  66. 66. Burmester Curve i.e. Points which make the external ligaments taught during flexion and extension thus maintaining its isometericity.
  67. 67. 3) Rotation with medial pivot External Femoral rotation Inteernal 10 5 0 5 10 15 20 25 0 25 50 75 100 Knee flexion – Squatting 125 (degrees) 150
  68. 68. MFC Does not move AP LFC Moves backward 19 mm Freeman, JBJS-B, 2000
  71. 71. “Mobility” of the LATERAL femoral condyle is due to: 1) High mobility of lateral meniscus
  72. 72. 2) Lateral tibial plateu convex and downsloped
  73. 73. “Stability” of the MEDIAL femoral condyle is due to: 1) Restraint of the fixed posterior horn of medial meniscus
  74. 74. 2) Medial tibial plateu cup-shaped & “upsloped” (≈5°)
  75. 75. PCL LFC MCL MFC 3) Ligament colums in constant tension on MFC
  76. 76. 4) Helical axis FLEX ROT COMBINED Flexion & rotation are combined resulting in an oblique axis.
  77. 77. 1 2 3 4 5 7 6 M L Obliquity and posterior shift produce an helical axis.
  78. 78. 5) Envelope of motion Within the envelope the knee is “free” (2 D.O.F.), but towards its limits the joint is restrained with rotations coupled to F/E (1 D.O.F.)
  79. 79. PCL restrains hams (rollback with flexion) Hams pull tibia back (rollforward) SWING PHASE Anterior Femoral translation 2 Posterior 1 0 STANCE PHASE 0 20 40 60 80 Knee flexion – Stair climbing 100 (degrees)
  80. 80. 6) Screw Home motion • It is the lateral rotation of the medial tibial plateau on femur during stance phase (extension), and internal rotation during swing phase (flexion). • 3 factors leads to this mechanism: 1]. The more distal alignment of the MFC 2]. The bigger radius of curvature of the MFC 3]. The cruciates crossing in-between; around which this rotation occur • Its significance it that it tightens both cruciates and locks the knee in the position of maximal stability
  81. 81. Valgus + External Rotation is the Valgus + External Rotation is the commonest medial side injury, commonest medial side injury, respectively; respectively; 1]. MCL then Medial capsule 1]. MCL then Medial capsule 2]. ACL 2]. ACL 3]. MM = “O'DONOGHUE UNHAPPY 3]. MM = “O'DONOGHUE UNHAPPY TRIAD” TRIAD” Varus + Internal injury of lat ligaments of Varus + Internal injury of lat ligaments of the knee; the knee; 1]. LCL then lateral capsule 1]. LCL then lateral capsule 2]. ACL 2]. ACL 3]. Arcuate complex 3]. Arcuate complex 4]. Popliteus tendon 4]. Popliteus tendon 5]. ITB 5]. ITB 6]. Biceps femoris 6]. Biceps femoris 7]. Common peroneal nerve, , 7]. Common peroneal nerve
  82. 82. HYPEREXTENSION mechanism: HYPEREXTENSION mechanism: 1]. ACL 1]. ACL 2]. PCL & posterior capsule 2]. PCL & posterior capsule ••ANTERO-POSTERIOR ANTERO-POSTERIOR DISPLACEMENT: e.g. dashboard DISPLACEMENT: e.g. dashboard accident: accident: 1]. ACL or 1]. ACL or 2]. PCL 2]. PCL
  83. 83.  A knee dislocation is an injury that involves the anterior curciate ligaments and the posterior curciate ligaments usually in combination with the medial collateral ligaments or the lateral collateral ligaments and associated soft tissue structures.  Recently knee dislocation can occur with one curciate in association with collaterals
  86. 86. KD I : One of the cruciates + one of the collaterals Knee fracture-dislocation (Fx-Dx) KDII: Both cruciates Knee fracture-dislocation (Fx-Dx) KDV.1 Fx-Dx ACL or PCL intact KDV.1 Fx-Dx ACL or PCL intact KDV.2 Fx-Dx with a bicruciate injury KDIIIL : Both cruciates +aLCL but MCLinjury KDV.2 Fx-Dx with bicruciate is Intact KDV.3 Fx-Dx, bicruciate injury, one corner KDV.3 Fx-Dx, bicruciate injury, one corner KDV.4 Fx-Dx, all four ligaments injured KDIIIM: Both cruciatesfour ligaments is intact KDV.4 Fx-Dx, all + MCL but LCL injured + N = Nerve injury + N = Nerve injury + C = Vascular injury KDVI:C = Vascular injury + LCL + Both cruciates + MCL KDV: Fracture Dislocation knee
  87. 87. History: 1- Ask about the traumatic knee event : •Clear pop + Non contact trauma : - ACL - Patellar Dislocation •Clear pop + contact trauma: - Collateral - Fracture - Meniscal •No clear ‘pop’ PCL 2- Ask about the ability to continue walking : • If the pt. can continue Meniscal injury / PCL •If pt. can not Other ligamentous injury
  88. 88. 3-Ask about Knee Swelling : • If immediate swelling •If late swelling Ligamentous injury Fracture meniscal injury 4-Locking: • Meniscal injury (Bucket hundle) •Lose body 5-Pseudo Locking: • Hamstring spasm •Hge + PF disorder
  89. 89. 6- Giving way: • Ligamentous injury •Patellar dislocation 7- Pseudo giving way: • Reflex inhibition of muscles due to ant. Knee pain
  90. 90.  Inspection & palpation : Knee swelling, bruising. - Varus or valgus malalignment - ROM - Gait abnormality -Wave test - Ballottement test - Quadriceps wasting and decrease in thigh girth -
  91. 91.  MCL and LCL: leg under arm, 2 hands, 30º flexion to relax pos capsule (careful not to rotate knee) • Valgus stress in flexion ........... MCL • Valgus stress in extension …... MCL + POL • Varus stress (taut in full ext) .... LCL (normally lax in flexion)
  92. 92. Grade 1 •Mild tendernes over the ligament. •Usually no swelling. •When the knee is bent to 30 degrees and force applied to the inside of the knee pain is felt but there is no joint laxity. Grade 2 •Significant tenderness on the lateral lig. •Some swelling seen over the ligament. •When the knee is stressed as for grade 1 symptoms,there is pain and laxity in the joint, although there is a definite end point. Grade 3 •This is a complete tear of the ligament. •When stressing the knee there is significant joint laxity. •The athlete may complain of having a very unstable knee.
  93. 93.  ACL: Laxity test Functional tests Anterior drawer test :: Anterior drawer test -Knee flexed at 90° -Anterior pull of the tibia. Lachman test :: Lachman test - At 15-30º (put patient's knee over your knee) - most sensitive
  94. 94. KT 1000 and KT 2000
  95. 95. Pivot Shift Tests: Pivot Shift Tests: 1- Mcintosh test 1- Mcintosh test Knee extended, valgus strain, foot internally rotated, if instability present, tibia is subluxed anteriorly. Now flex knee, clunk at 30º is +ve Normal MCLand iliotibial band and torn ACL 2- Lose test 2- Lose test knee & hip flexed 45º and the other hand thumb behind the fibula. ER and valgus the tibia + slow extension + push the fibula forward tibial condyle shifts or subluxes forwards in full extension.
  96. 96. Pivot Shift Tests: Pivot Shift Tests: 3- Slocum test 3- Slocum test Patient lies on unaffected side, with unstable knee up & flexed 10º. Medial aspect of foot rests on table. Patient maintains ipsilateral pelvis rotated posteriorly 30-50º. Knee pushed into flexion. Easier to do in heavy or tense patients. 4- Anterior jerk off test 4- Anterior jerk off test This is considered the reverse of the classic pivot shift test as it starts from flexion to extension.
  97. 97. 1- Ducking test 1- Ducking test 2- Acceleration deceleration test (Gallop Test) 2- Acceleration deceleration test (Gallop Test) 3- Single leg jump test 3- Single leg jump test
  98. 98.  PCL and PLC : Step Off test Step Off test Posterior drawer test Posterior drawer test Postero lateral drawer test Postero lateral drawer test Dial test Dial test External rotation recurvatum test External rotation recurvatum test Reversed pivot shift test Reversed pivot shift test Quadriceps Active test Quadriceps Active test Whipple Ellis test Whipple Ellis test PLC PLC TEST TEST
  99. 99.  Step off test : - Knee flexed at 90° -The medial tibial plateau normally lies approximately 1 cm anterior to the medial femoral condyle. -This step-off, is usually reduced in the PCL-deficient knee - It can easily be felt by running the thumb down the medial femoral condyle toward the tibia.
  100. 100.  Posterior test : drawer The posterior drawer was the most sensitive test (90%) and highly specific (99%). -The patient supine, with the hip flexed to 45°, the knee flexed to 90°, and the foot in neutral position. - A posterior- directed force is applied to the tibia, assessing the position of the medial tibial plateau relative to the medial femoral condyle.
  101. 101.  Posterior drawer test : The posterior translation is graded according to the amount of posterior subluxation of the tibia (Noyes grading): 1-Grade I : Tibial translation between 1 and 5mm. 2-Grade II : Posterior tibial translation is between 5 and 10 mm, and the tibia is flush with the femoral condyles. 3-Grade III : This is seen when the tibia translates greater than 10 mm posterior to the femoral condyles.
  102. 102. Because it is important to accurately measure the posterior translation of the tibia to select a proper treatment, instrumental devices such as the KT-1000 (MedMetric) has been developed as adjuvant tool.
  103. 103.  External Rotation Recurvatum Test : - Patient supine position. - Suspending the lower extremity in the extension while grasping the great toe. The sensitivity of this test, as reported in the literature, ranges from 33% to 94%.
  104. 104.  Dial Test : - The patient positioned prone or supine. - An external rotation force is applied to both feet with the knee positioned at 30° and then 90° of flexion. -When compared with the uninjured side, an increase of 10° or more of external rotation at 30° of knee flexion, is suggestive of an isolated PLC injury. - Increased external rotation at both 30° and 90° of knee flexion suggests a combined PCL and PLC injury .
  105. 105.  Quadriceps active Test : - The patient supine and the knee flexed to 90°. - The examiner stabilizes the foot, and the patient is asked to slide the foot down the table. -Contraction of the quadriceps muscle results in an anterior shift to the tibia in the PCL-deficient knee. A shift greater than 2 mm is considered positive for PCL insufficiency.
  106. 106.  Whipple and Ellis Test : -The patient prone and the knee flexed at approximately 70°. - Grasping the lower leg with one hand and posteriorly displacing the tibia by the other. - This test avoids quadriceps contraction, Moreover, if there is an associate damage of posterior capsular structures, the foot moves during this test medially or laterally
  107. 107.  Reverse Pivot Shift Test : - The patient is supine and the knee is held, initially, in 90° of flexion. - The examiner externally rotates and extends the knee. - When positive, an anterior shift of the tibia will occur at approximately 20° to 30° of flexion. It usually signifies injury to the PLC mainly in addition to PCL injury.
  108. 108. Meniscal tests :: Meniscal tests 1- Mcmurray test 2- Appley compression test 3-Jerk test 4-Steinmen test. MOST IMPORTANT TENDER JOINT LINE
  109. 109.  Mcmurray test:
  110. 110.  Appley compression distraction test:
  111. 111. I- Anteroposterior and Lateral views : To evaluate for fractures and/or dislocation.
  112. 112. I- Anteroposterior and Lateral views : Mediolateral displacement Segond`s Fracture
  113. 113. I- Anteroposterior and Lateral views : Avulsion of tibial spine indicating ACL avulsion
  114. 114. II- Axial radiography : - Knee flexed 70 and X ray beam angled superiorly. -The location of the tibia in relation to the femur as compared with the contralateral normal side. -An axial press 18kg may be used to produce maximum posterior translation.
  115. 115. III- Stress Radiography : -Divided according to the type of the force applied to : A) Manual Force Technique : - Produced by examiner or weight loading 200-300 N (25-30 Kg). - Another method based on hamstring contraction.
  116. 116. B) Instrumented Technique : Due to lack of standardized applied force, errors in knee flexion angle and tibial rotation, an instrumental applied stress force is produced. One of the most commonly used is Telos device.
  117. 117. IV- The kneeling view (Barlet view ): - The patient in the kneeling position applies a direct force which subluxes the tibia posteriorly. be calculated.
  118. 118. Normal ACL , PCL and Menisci on MRI presents T1 MRI was found to be 99% accurate and sensitive diagnosing the presence of ACL and PCL injury. T2
  119. 119. Primary Signs: 1- Change of signal 2- Change of contour Loss of continuity in three successive cuts
  120. 120. Secondary Signs: 1- Change of signal 2- Change of contour 3- Buckling of ACL and posterior PCL line does not intersect the posterior femoral line. 4- Posterior border of the lateral plateua in the most lateral cut is translated anterior to the LFC
  121. 121. MRI classification was first published by Gross et al. Grade I : Intraligamentous lesion : High signal intensity within the ligament.
  122. 122. Grade II : Partial lesion: High intensity signal on the dorsal edge of the ligament. (Anatomical site of the posteromedial fascicle) Grade III: Partial lesion : High signal intensity on the ventral edge of the ligament. (The anatomical site of the anterolateral fascicle.)
  123. 123. Grade IV: Complete lesion : No remaining fibres are detected. AL and PM fascicles at the site of injury show high signal intensity and are scarcely detectable.
  124. 124. Example of Example of GIII tear GIII tear Discoid Discoid Meniscus Meniscus Stallar Stallar Classification Classification
  125. 125. Bucket Handle Tear: Bucket Handle Tear: --Partof the meniscus Part of the meniscus in the intercondyler in the intercondyler notch notch --Verticalcut in the Vertical cut in the coronal section coronal section --DoublePCL sign in Double PCL sign in both Coronal and both Coronal and Sagital Sagital
  126. 126. Osteochondral Lesion + MCL Osteochondral Lesion + MCL
  127. 127.  The role of diagnostic arthroscopy is debatable as history taking, clinical examination and MRI are sufficient for diagnosis.  But other surgeons state that arthroscopy can provide further information which is useful.  Arthroscopy is done 2 to 3 weeks after injury.
  128. 128. ISOLATED ACL     ACL has no potentional for spontaneus healing If tibial avulsion ORIF If midsubstance tear we should do ACL reconstruction Preopertive physiotherapy phase I for three wks then ACL reconstruction ISOLATED PCL: The PCL has high potential for spontaneus healing  If avulsion ORIF  It depends on the grade: - GI and II conservative treatement - GIII usually accompanied with PLC so usually needs rsurgical interference for acut PLC repair then three weeks later PCL reconstruction 
  129. 129. ISOLATED MCL: 1. 2. MCL has a potentional healing as it is broad According to the grade: - GI and GII usually conservative using hinged knee brace and physiotherapy - GIII needs open repair if early or reconstruction if late. ISOLATED LCL :    LCL has no potential for healing as it is cord like. If grade I usually conservative Grade II and III treated usually be LCL reconstruction
  130. 130. ACL+ COLLATERAL(S) TORN 1. 2. 3. 4. Collateral ligament heal. Early ROM. Delayed ACL reconstruction. If PLC injuried this require early operative repair or reconstruction. PCL+ COLLATERAL(S) TORN  Treatment should be directed 1st to pcl
  131. 131.  ACL+PCL 1. rare 2. good outcome 3. Intact collateral make treatment simplified. 4. Early repair of PCL after ROM then delayed ACL reconstruction or bicurciate reconstruction simultaneously.
  132. 132. PLC injuries acute Isolated (rare) repair chronic Combined with cruciate injury Isolated (rare) PLC repair +/augmentation PLC reconstruction + Cruciate reconstruction Combined with cruciate injury PLC reconstruction + Cruciate reconstruction + osteotomy if varus malignment
  133. 133. I- Graft Choice: The Graft of choice should be : - Strong. - Should provide secure fixation. - Should be easy to pass. - Should be readily available. - Should have low donor site morbidity.
  134. 134. Types of grafts: 1- Autograft: Quadriceps tendon autograft : - It is self available - Having a suitable size - Has approximately three times the cross-sectional area of the patellar tendon. - Long enough. - Leaves no anterior knee pain at the graft harvest site. That makes it an acceptable graft choice for PCL reconstruction specially double bundle technique and inlay method . Patellar tendon autografts Causes anterior knee pain. Hamstrings facilitate the arthroscopic method and can be split into two sets for the double-bundle technique.
  135. 135. 2- Allograft : Achilis tendon allograft graft is recommended : - The osseous portion of the graft - Has high tensile strength. - Size and length for easily splitting in -double bundle reconstruction. 3- Synthetic graft Synthetic graft augmentation 4- Allograft with Synthetic graft augmentation.
  136. 136. Equipments : 30°, 70°, 4.5 mm telescope  Pump  Shaver  Fluoroscopy for driling the tibial tunnel  Specific PCL tools 
  137. 137. II- Fixation Sites:  Aperture fixation: interf. screws & wedges.  Distal fixation: post, endobutton, fliptag.
  138. 138. Aperture fixation      Advantages: Provides rigid fixation. Improves stability & isometry. Decreases working length of the graft leading to less creep & relaxation. Avoids graft tunnel motion Early bone intergration and hence early walking . Disadvantages: Potential risk of graft laceration or fracture. Distal fixation      Provides less stiffness. Windshield wipering effect (A/P). Bungee cord effect (sup/inf). May cause delayed incorporation & tunnel dilatation leading to increased laxity. The strength & quality of fixation may be improved by filling the canal or by hybrid fixation.
  139. 139. III- Fixation devices: - Screw (biodegradable or Titanium - Endbutton or fliptag - Tranfix or RigidFix - Staples
  140. 140. ACL Transtibial Method (Arthroscopic)
  141. 141. ACL Reconstruction Steps: -Graft Harvesting - Graft Preparation -Notch Debridement - Tibial Tunnel -Femoral Tunnel
  142. 142. Notch Debridement
  143. 143. Tibial Footprint
  144. 144. Tibial Footprint In the center of ACL tibial insertion
  145. 145. Tibial Tunnel
  146. 146. Femoral Tunnel Femoral Footprint Femoral Footprint For decades, the conventional transtibial technique has been regarded as the gold standard for ACL reconstruction.
  147. 147. Femoral Footprint Femoral Footprint Transtibial tunnel always guide the Femoral Tunnel to vertical non anatomical OVER THE TOP position.
  148. 148. Femoral Footprint Femoral Footprint
  149. 149. Femoral Footprint Femoral Footprint A nonanatomically positioned femoral tunnel is one of the most common causes of clinical failure after ACL reconstruction, with 15% to 31% of athletes complaining of pain, persistent instability, or an inability to return to the previous level of competition
  150. 150. 1- PORTALS
  151. 151. 2- Femoral Footprint
  152. 152. 2- Femoral Footprint
  153. 153. 2- Femoral Footprint
  154. 154. 2- Femoral Footprint
  155. 155. Double Bundle ACL
  156. 156. Double Bundle Femoral Tunnels
  157. 157. Double Bundle Femoral Tunnels
  158. 158. Double Bundle Femoral Tunnels
  159. 159. Double Bundle Femoral Tunnels
  160. 160. Double Bundle Tibial Tunnels
  161. 161. Double Bundle Tibial Tunnels
  162. 162. Double Bundle Tibial Tunnels
  163. 163. Double Bundle Tibial Tunnels
  164. 164. Is there any benefit from Double Bundle ACL reconstruction ?
  165. 165. ACL With Navigation System
  166. 166. Treatment of PCL
  167. 167. Indicatioins : 1- Partial rupture of the PCL 2- Less than 10mm of posterior tibial displacement (i.e. Grade I, II) 3- Elongation of the PCL  Physiotherapy is very essential for conservative treatment including three phases .
  168. 168.  Objects of applying physical therapy for patients with PCL : -Reduce swelling and knee pain - Strengthen the quadriceps muscle. -To stimulate the propioceptive sense. -Let the patient know their condition so that they can adapt daily life. -Sustain the elasticity of muscles around the knee.
  169. 169. The Following Physiotherapy Can be Applied For PCL and ACL but with difference of the mode either accelerated (3months) or normal rehabilitation (6 months)
  170. 170. -Knee braces applied to all patinets and locked between 0 to 60 degrees. -Weight bearing is allowed only partially up to 50% of body weight. Stretching program for thigh and leg muscles. - Propioceptive training is applied at the late 4th week of the injury.
  171. 171. - Quadriceps muscles to be strengthened with increasing loads. - Co-contraction of quadricpes and hamstrings muscles (Closed kinetic chain exercise). - Propiocetpive exercise continue. - Normal gait with full weight bearing to be allowed. - Knee brace is still used to support the knee during light activities in the early phase II.
  172. 172. - Jogging straight forward, side by side, and backward direction. - Performing advanced propioceptive training. - Return to sport activity.
  173. 173. Indications for operative treatment are : I- Avulsion PCL injuries either femoral of tibial avulsions II- Grade III PCL injuries with significant instabilily: Due to the probability of occult PLC injury. III- Combined injuries : PCL+ ACL, PCL+ PLC, PCL+MCL IV- Failure of conservative treatment.
  174. 174.  Reduction and fixation of the avulsed fragment via either : - Open technique - Arthroscopic technique  - The choice of the fixation device depends mainly on the size of the avulsed fragment: Large (more than 20mm) cannulated screw Meddium sized (10 to 20mm) K wires Small sized (less than 10mm) wire sutures
  175. 175. I- Posteromedial approach :
  176. 176. II- Direct posterior approach : Semimembronuses Biceps Tibial Femoris nerve Post. Joint Capsule Medial Head gastrocnemeus Common peroneal nerve Lateral head Gastrocnemeus Small Saphenous vein
  177. 177. Sandra et al. 2007 have described an arthroscopic method PCL avulsion repair: - Posterior triangulation for adequate visualisation for the avulsed PCL fragment. - Classic anteromedial and amterolateral ports for reduction of the fragment using tibial guide. - Stabilization of the fragment by temporarily guide wire through the tibial guide forming tunnel A. (The wire has 2 holes in its distal end) - Another two tunnels B and C are formed in the PCL crater 2cm medial and lateral to the tunnel A. - Steel sutures wires are passed through tunnel B, C ,then passed through the holes in the guidewire in tunnel A, then the guide wire is pulled.There is 4 ends for steel sutures wires free at the anterior tibial side to be tied firmly.
  178. 178. Portals : -The standard anteromedial and anterolateral portals. - In addition to posteromdial portal.
  179. 179. Debridement of PCL Remnants fibers : Meticulous debridement of the PCL insertion firbres by a shaver through the posteromedial portal.
  180. 180. Tibial tunnel: - Tibial C guide used - Entry point just distal and medial to tibial tubercle. - The guide passes medial to the ACL to the posterior tibia. - The vascular structures protected by the PCL Elevator.
  181. 181. Femoral tunnel: -It is helpful to leave the PCL femoral insertion fibers intact to outline the PCL foot print. - For the anterolateral bundle it present in the anterior half of the femoral PCL insertion 8 to 9 mm from the articular surface. - In double bundle technique the posteromedial bundle lies posterior and proximal to it.
  182. 182. Femoral Tunnel tunnel: - Femoral guide is used. -The femoral tunnels are marked with cautery. - Then probed. - Then 2 guide wires are passed through them and overdrilled.
  183. 183. Passage of the graft :
  184. 184. Fixation of the graft : -Anterolateral bundle is fixed to the femrol in 90 degree frlexion. -The posteromedial bundle is fixed in 20-30 degree flexion. Single Bundle Double Bundle
  185. 185. Position of the patitent: Incisions : -Posterior approach. -Postrerior.
  186. 186. Preparation of the inlay graft: A unitcoritical window is fashioned to fit the dimensions of the bone block.
  187. 187. Fixation of the graft and femoral passage: -The graft bone plug is fixed with 4.5 mm cannulated screws. -Then the femoral ends are passed through the femoral tunnels to be either Single bundle or Double bundle.
  188. 188. Harner, et al (2000) - Showed in their cadaveric study that the use of double bundle technique reduced the posterior laxity by 3.5mm. Bergfeld et al (2005) - No statistical differences between the single-bundle and double-bundle reconstructions were found at any angle of flexion
  189. 189. Disadvantges of the transtibial method includes : - Neurovascular injury.(The most seriuos) - Patients frequently retain grade I or II laxity (Residual laxity) - Graft failure due to killer turn. 
  190. 190.  Advantages of tibial inlay method: Imrpoved biomechanical stability by using larger graft. - Less risk to neurovascular structures. - - Avoid the “Killer turn” in transtibial method
  191. 191.  Disadvantages of the inlay method includes: Change the position of the patient intraoperatively. - Opening of the posterior capsule. - Longer time of operation. - Making additional skin incision at the popliteal fossa. -
  192. 192. Bergfeld, et al. (2001) -A study on 6 pairs of cadaveric knees, 6 inlay method and 6 transtibial method. -After cyclic loading, the transtibial technique grafts became compromised and failed, that is because" killer turn” that the graft makes at the mouth of the transtibial tunnel.   MacGilliravay, et al. (2006) -Transtibial tunnel technique with quadrupled hamstring autograft group on 21 knees was used and the tibial inlay technique with bone–patellar tendon–bone autograft on 22 knees. -The study identified no significant differences between the transtibial and tibial inlay techniques, and satisfactory clinical and stress radiologic results were obtained in both groups
  193. 193. A- Complications from trauma : -Associated ligamentous injury -Associated meniscal and chondral complications. -Associated bone injury -Fixed posterior subluxation (FPS): * It is a posterior displacement of the tibia more that or equal to 3mm on anterior stress radiograph. * Reduction of the FPS is essential before any surgical interference as it adds more stresses on the graft and leads to its failure.
  194. 194. - FPS can be treated by using a Posterior Tibial Support splint. - The splint is worn during the night for 6-8 weeks.
  195. 195. 1- Neurovascular iatrogenic injury : (The most serious) -In transtibial tunnel during reaming. -Methods to avoide: I- Use of oscillating drill. II- Use PCL elevator as a protector II- Use of tapered instead of square drill. III- Intraoperative image intensifier. IV- Formation of posteromedial safety incision. (best method)
  196. 196. 2- Residual laxity : (The Most common) Methods to avoid: -The use of strong graft -Correct tunnel placement -Correct graft tensioning -Secure graft fixation. 3- Loss of knee ROM 4- Medial femoral condyle osteonecrosis 5- Residual laxity : (The Most common)
  197. 197. 6- Graft failure: Technical considerations to avoid it: I- Smooth well chamfered tunnel edges. II-Anatomic positioning of PCL reconstruction tunnels to avoid acute angles. III-Secure fixation. IV- Treatment of FPS before surgery. V- Postoperative immobilization in full extension for 4-6 weeks.
  198. 198. 7- Residual laxity : (The Most common) -Persistent posterior sag. - Prominent hardware. -BTB patellar tendon graft. -Suprapatellar synovitis. 8- Intraoperative iatrogenic fracture.
  199. 199.  1- Acute Repair 1- Acute Repair (Direct Repair) (Direct Repair) Acute repair techniques of posterolateral corner (PLC) injuries. A, Injuries to the critical structures of the PLC. B, A sequential acute repair of the deep structures (popliteus complex, lateral collateral ligament, and capsule) and superficial structures (biceps and iliotibial band).
  200. 200. A- Non anatomic repair :: A- Non anatomic repair 2- Chronic PLC 2- Chronic PLC
  201. 201. A- Non anatomic repair :: A- Non anatomic repair Primarily sling procedures Biceps Tenodesis (nonanatomic)
  202. 202. A- Non anatomic repair :: A- Non anatomic repair Deficiency of LCL reconstruction with B-PT-B Deficiency of LCL figure of eight ST
  203. 203. B- Anatomic repair :: B- Anatomic repair  Two tailed reconstruction of FCL / PFL and popliteus tendon  Biomechanically restores function of native ligaments
  204. 204.   Femoral tunnels (8 mm) Tibial tunnel (10 mm)  Proximal 1/5 popliteus  AP from distomedial sulcus Gerdy’s (PLT) to popliteus  Proximoposterior to musculotendinous lateral epicondyle (FCL) junctioninterference  7 mm  Fix with bioscrew/staple screws (60°, IR)
  205. 205. Warren method : Is older method and resembles the previous anatomic mentioned technique
  206. 206. -Knee braces applied to all patinets and locked between 0 to 60 degrees. -Weight bearing is allowed only partially up to 50% of body weight. Stretching program for thigh and leg muscles. - Propioceptive training is applied at the late 4th week of the injury.
  207. 207. - Quadriceps muscles to be strengthened with increasing loads. - Co-contraction of quadricpes and hamstrings muscles (Closed kinetic chain exercise). - Propiocetpive exercise continue. - Normal gait with full weight bearing to be allowed. - Knee brace is still used to support the knee during light activities in the early phase II.
  208. 208. - Jogging straight forward, side by side, and backward direction. - Performing advanced propioceptive training. - Return to sport activity.
  209. 209. Zones of the meniscus
  210. 210. Length Long tears (more than 2.5 cm) heal poorly. • Tears that are known to cause locking or that can be locked during surgery are known to have higher healing failure rates. Pattern of tear •Vertical tears have better healing potential. •Oblique & horizontal tears are less likely to heal. •Stable tears heal readily ( tears less than 1 cm, tears that can not be displaced more than 3 mm, and partial thickness tears.
  211. 211. •Non operative treatment : Indications : •No history of locking, a block to extension, •No associated ACL injury •Partial-thickness tears •Incomplete radial tears Stable vertical longitudinal tears displacement less than 3mm and the length less than 10 mm in length do not need resection
  212. 212. •A- PARTIAL MENISCECTOMY Partial meniscectomy is indicated for: -Radial tears tears are treated periphery. •Most meniscal not extending to the by arthroscopic partial -Oblique tears meniscectomy. (flap or parrot beak) -Horizontal cleavage tears •The goal of partial meniscectomy is to remove only the -Degenerative tears unstable or pathologic portion, leaving as much healthy -Irreparable vertical longitudinal tears that are an abrupt meniscal tissue as possible while avoiding more than 5 mm from absolute periphery. (i.e. in WW zone) transition to the remaining meniscus.
  213. 213. B- MENISCAL REPAIR : Indications for Repair : Location : We repair all tears in the red zone and most in the gray zone Nonmacerated , nondeformed fragments in the gray zone only. Tear pattern : Repair is indicated for vertical longitudinal tears not Longer than 1 cm and for radial tears that extend into the red zone. Tissue quality : We do not repair macerated and degenerative menisci. AGE : We routinely perform meniscal repair in patients up to the age of 45 years.
  214. 214. Accepted techniques include : • Open repair. • Inside-out arthroscopic repair • Outside-in arthroscopic repair • All-inside repair.
  215. 215. Arrows
  216. 216. Fast Fix