Knee Sports for PostGrad Orth Course 2017

1. 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

2. POSTGRAD ORTH Deiary Kader PLAN 1. MENISCUS 2. ACL 3. MCL 4. PCL 5. PLC 6. MULTI LEGAMENT 7. PFJ CLINICALS ?

3. POSTGRAD ORTH Deiary Kader Nerve Supply-Knee Tibial Nerve Medial and Middle GB Common Peroneal N Lateral & Recurrent GB Obturator N - GB

4. POSTGRAD ORTH Deiary Kader BLOOD SUPPLY- KNEE Femoral Popiteal A

5. POSTGRAD ORTH Deiary Kader MENISCAL RESECTION & REPAIR Fibro-cartilaginous Type I collagen

6. POSTGRADORTH Deiary Kader ➢ Lateral Meniscus –Circular –Close insertions –Posterior = Anterior width –Loosely attached to capsule ➢ Medial Meniscus – Semicircular – Wider Posterior – Firmly attached to capsule

7. POSTGRADORTH Deiary Kader Composed of 70% water - 30% organic matter (Collagen constitutes 75%)

8. Radial Fibres, serving as “ties” that resist shearing or splitting. Circumferential Fibres run parallel to resist hoop stress during weight bearing. 8

9. POSTGRAD ORTH Deiary Kader Compression to radial to be contained by the Menx

10. Meniscus Vascular Supply Red Red-White White At 10 years of age

11. What is the function of the Meniscus?

12. Meniscal Function Load /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

13. POSTGRAD ORTH Deiary Kader Meniscal Tear   Management :- Excision 60% of people over 65yrs have incidental tears Repair Transplant Replacement Traumatic tears & Degenerative tears

14. 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 Moseley 2002 & Thorlund 2015

15. Repair Excise

16. POSTGRAD ORTH Deiary Kader Horizontal cleavage tear Pisani’s sign The cyst size decrease with knee ﬂexion   knee ﬂexed <45º

17. POSTGRAD ORTH Deiary Kader

18. POSTGRAD ORTH Deiary Kader 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  

19. POSTGRAD ORTH Deiary Kader Snapping knee in deep flexion

20. POSTGRAD ORTH Deiary Kader Snapping knee in deep flexion

21. POSTGRADORTH Deiary Kader Meniscal repair When would you repair a menx Factors to consider

22. POSTGRADORTH Deiary Kader Meniscal repair Factors to consider: 1. Patient 2. Chronicity 3. Type 4. Location 5. Tissue quality 6. Stability of knee 7. Axial alignment

23. POSTGRADORTH Deiary Kader 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

24. POSTGRADORTH Deiary Kader Partial Meniscal Substitutes Engineered constructs Polyurethane polymeric implant (Actifit®) Synthetic Scaffold Collagen Meniscus Implant (CMI®) Collagen (CMI®)

25. POSTGRADORTH Deiary Kader Collagen Menx implant  Rodkey et al 

26. POSTGRADORTH Deiary Kader hydrogels knee ?

27. POSTGRADORTH Deiary Kader Total meniscal prosthesis NUsurface Synthetic implant meniscus-like Prof Zorzi from Verona

28. POSTGRADORTH Deiary Kader Menx Allograft Indications Symptomatic 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

29. Prof Deiary Kader Traumatic Chondral Damage

30. POSTGRAD ORTH Deiary Kader 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

31. POSTGRAD ORTH Deiary Kader ICRS <1.5cm >1.5cm The modified International Cartilage Repair Society (ICRS) The Outerbridge classification

32. Prof Deiary Kader Traumatic Chondral Damage Treated with Microfracture

34. POSTGRAD ORTH Deiary Kader MACI

35. 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.

36. 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

38. POSTGRAD ORTH Deiary Kader ACL Injuries  FRCS(Tr&Orth) Revision Course

39. POSTGRAD ORTH Deiary Kader Anatomy ➢33 mm long, 11 mm in diameter ➢Two bundles ➢AM bundle – tighten in flexion (Translation) ➢PL bundle – tighten in extension (Rotation)

42. POSTGRAD ORTH Deiary Kader 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 the Tibia

44. Valgus + ER POP

45. 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)

46. POSTGRAD ORTH Deiary Kader 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

47. POSTGRAD ORTH Deiary Kader Surgical Treatment Indications: 1) Subjective instability (non-coper) 2) ACL tear in children and adolescents 3) Multiligament injury 4) Displaced meniscal tears

48. POSTGRAD ORTH Deiary Kader ACL Evidence-Based Review Factors affecting results: Patient Selection Tunnel placement Strong graft choices Solid fixation Rational rehabilitation

49. POSTGRAD ORTH Deiary Kader 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

50. Hamstring BTB Grafts / Fixations Quads

52. ●Biologically inactive ●Slower incorporation ●Less stability in 6 months ●Risk of disease transmission ●Role in revision surgery ●Weaker after having been irradiated Allograft

53. POSTGRAD ORTH Deiary Kader ➢ ◊ Paul F. Segond  a Paris surgeon  1879

54. Prof Deiary Kader ANTEROLATERAL LIGAMENT ALL

55. POSTGRAD ORTH Deiary Kader In 1972, D. L. MacIntosh  In 1967,1975, M. Lemaire Extra-articular reconstruction

56. Prof Deiary Kader OPEN ALL Recon

57. POSTGRAD ORTH Deiary Kader Anatomic Single bundle recon

58. POSTGRAD ORTH Deiary Kader 5mm +

59. What are the complications of ACL reconstruction?

60. POSTGRAD ORTH Deiary Kader Complications  ➢ Infection ➢ DVT and PE ➢ Osteoarthritis ➢ Cyclops lesion residual tissue anterior to the ACL blocks extension

61. POSTGRAD ORTH Deiary Kader 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

62. POSTGRAD ORTH Deiary Kader ACL Tunnels

63. 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.

64. POSTGRAD ORTH Deiary Kader Meyers and McKeever classification (1959)

65. Treatment  • Casting in extension for type I • Open reduction and internal fixation. • Arthroscopic reduction and fixation • Rarely ACL reconstruction is necessary

66. 66

67. POSTGRAD ORTH Deiary Kader Postgraduate Orthopaedics   FRCS(Tr&Orth) Revision Course MCL  

68. POSTGRAD ORTH Deiary Kader Medial Collateral Ligament In 25-30° of flexion, the MCL provides 80% of the support to valgus stress

69. POSTGRAD ORTH Deiary Kader MCL Treatment 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

70. POSTGRAD ORTH Deiary Kader Chronic MCL Injury Patient A MCL Reconstruction with AT + Revision ACLR

72. POSTGRAD ORTH Deiary Kader   PCL and PLC         Postgraduate Orthopaedics   FRCS(Tr&Orth) Revision Course drive thru”

73. POSTGRAD ORTH Deiary Kader 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

74. POSTGRAD ORTH Deiary Kader PMB tight in Extension ALB TIGHT IN FLEXION

75. POSTGRAD ORTH Deiary Kader a. Ant Meniscofemoral lig Humphrey b. Post Meniscofemoral lig Wrisberg Meniscofemoral ligaments: mechanically very strong Anterior: Humphrey’s ligament Posterior: Wrisberg’s ligament

76. POSTGRAD ORTH Deiary Kader 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

77. POSTGRAD ORTH Deiary Kader Surgical reconstruction 1. Indications 2. Acute combined injuries 3. Acute bony avulsion 4. Symptomatic chronic PCL

78. POSTGRAD ORTH Deiary Kader PCL Reconstruction

79. PTS BRACE POST OP-PCL 79

80. POSTGRAD ORTH Deiary Kader What are the structures in the Posterolateral Complex of the Knee?

81. POSTGRAD ORTH Deiary Kader Posterolateral Complex

82. 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

83. POSTGRAD ORTH Deiary Kader What is the function of the Posterolateral Complex of the Knee?

84. POSTGRAD ORTH Deiary Kader The Posterolateral Corner Summary Primary stabilisers of external tibial rotation at all knee flexion angles Secondary restraints to anterior and posterior translation

85. 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 flexion 85

86. 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

87. POSTGRAD ORTH Deiary Kader DIAL TEST

88. POSTGRAD ORTH Deiary Kader Posterolateral Complex Injury External rotation test Dial Test Increased External rotation (30º, 90º). External rotation recurvatum

89. POSTGRAD ORTH Deiary Kader 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

90. POSTGRAD ORTH Deiary Kader 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).

92. POSTGRAD ORTH Deiary Kader Knee dislocation Any 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.

93. POSTGRAD ORTH Deiary Kader 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 intervention Warm ischaemia time >3-4 leads to irreversible damage Imaging 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

94. Vascular Injuries   Previously it was thought there was a 50% incidence of vascular compromise Now 3.3-18% 20%–30% incidence of nerve injury. 94

95. 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 dislocation 95

96. POSTGRAD ORTH Deiary Kader Classification Classified on the basis on tibial displacement in respect to the femur

97. Examination  Valgus and varus laxity Anteroposterior translation Recurvatum >10º hyperextension suggests ACL injury >30º hyperextension indicates PCL injury Rotation indicates MCL and LCL injury 97

98. Management  Surgical 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

99. POSTGRAD ORTH Deiary Kader 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

100. POSTGRAD ORTH Deiary Kader 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.

101. POSTGRAD ORTH Deiary Kader Patellar Dislocation Re-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

102. POSTGRAD ORTH Deiary Kader MPFL VMO VMO MPFL VMO Patella Quads TendonPatella Tendon Medial Knee M.E Add.Tub Femur

103. POSTGRAD ORTH Deiary Kader Med Epicondyle Add Tubercle Patella MPFL

104. POSTGRAD ORTH Deiary Kader 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 ??

105. POSTGRAD ORTH Deiary Kader 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)

106. POSTGRAD ORTH Deiary Kader 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

107. POSTGRAD ORTH Deiary Kader 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

108. POSTGRAD ORTH Deiary Kader Beighton Score 0---9

109. POSTGRAD ORTH Deiary Kader Imaging of the patellofemoral joint ✦ AP and Lateral Knee x-ray ✦ Merchant’s view ✦ MRI Axial view ✦ CT Rotational Profile Merchant’s

110. POSTGRAD ORTH Deiary Kader Trochlea dysplasia Blumensaat's line Normal Trochlea Depth NORMAL

111. POSTGRAD ORTH Deiary Kader Measuring patella Height Caton – Deschamps index =1.2 Blackburne-peel index = 1.12

112. POSTGRAD ORTH Deiary Kader MPFL injury Patella pain Articular Damage

113. POSTGRAD ORTH Deiary Kader 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)

114. POSTGRAD ORTH Deiary Kader analysis Normal measure is 5° to 15° Femoral anteversion

115. POSTGRAD ORTH Deiary Kader LATERAL PATELLAR TILT

116. POSTGRAD ORTH Deiary Kader lateral trochlear tilt The pathologic measure is <14°

117. POSTGRAD ORTH Deiary Kader Clinique de la analysis lateral tibia twisting slices n°3 and n°4 Normal Ext rotation is 25° to 30°

118. POSTGRAD ORTH Deiary Kader True Q angle, Measurement of the Tibial Tuberosity-Trochlear Groove (TT/TG) distance  Normally TT/TG = 2-9 mm pathologic measure is > 19 mm

119. POSTGRAD ORTH Deiary Kader Trochlear Dysplasia Dejour classification of trochlear dysplasia CT

120. POSTGRAD ORTH Deiary Kader Dejour classification of trochlear dysplasia on CT scans Shallow flat dome-shaped medial ‘‘cliff-face.’’ Dejour classification

121. POSTGRAD ORTH Deiary Kader Non-Surgical treatment of Patella Instability Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait

122. POSTGRAD ORTH Deiary Kader Tibial Tubercle Transfer Patellofemoral Instability with Malalignment

123. POSTGRAD ORTH Deiary Kader Fulkerson's Technique of Anteromedialization A steeper osteotomy plane will produce more anteriorization along with medialization

124. POSTGRAD ORTH Deiary Kader PATELLA ALTA Distal transfer (Distalization)

125. POSTGRAD ORTH Deiary Kader 14 mm Patella alta  

126. POSTGRAD ORTH Deiary Kader Med Epicondyle Add Tubercle Patella MPFL

129. POSTGRAD ORTH Deiary Kader Our Dissection

132. POSTGRAD ORTH Deiary Kader What are the complications of MPFL reconstruction?

133. POSTGRAD ORTH Deiary Kader Trochlea dysplasia TROCHLOPLASTY

137. POSTGRAD ORTH Deiary Kader 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

138. POSTGRAD ORTH Deiary Kader 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

139. POSTGRAD ORTH Deiary Kader LONDON COURSE 2-7 OCTOBER 2017 UCLH

Knee Sports for PostGrad Orth Course 2017

Knee Sports for PostGrad Orth Course 2017

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