This patient is a 22 year old man who presented with an anterior knee dislocation after tripping. On examination, he has an obvious knee deformity, shortened limb, inability to dorsiflex or move toes, and decreased sensation on the dorsum of the foot. X-rays show an anterior knee dislocation without fracture. Immediate management includes analgesia, traction to reduce deformity, splinting, and checking vascular status. Further assessment is needed to evaluate for additional injuries. Surgical management may be required for open dislocations, irreducible dislocations, or vascular injuries. The goals of treatment are restoration of stability and range of motion through either conservative immobilization or surgical repair/reconstruction of ligaments.

1. Gashaye T.
5th round case discussion

2. Q13
A 35 years old male
patient sustained injury
to leg and fixed with
SIGN nail 1 year back .
Now he complains pain
from the injury site

3. Describe x-ray
 X ray not proper
 Partly AP an lateral x ray of
left tibia and femur
 Tibial IMN with single
locking screw both proximal
and distally
 VISIBLE FRACTURE GAP
NO SIGN OF CALLUS
FORMATION
 No periosteal rxn
 Segmental fibular fracture

4. B. Diagnosis
NON UNION
C. Risk factors
Fracture specific
Host factor
Treatment factor

5. Fracture-specific Factors
 Type of bone
 Fracture location
 Fracture pattern
Comminution
Bone loss
Initial displacement
Segmental patterns
 Degree of injury
o Bony
o Soft
tissue(iatrogenicvs
traumatic)
o Associated infection

6. Host Factors
 Smoking
 Diabetes
 Malnutrition
 Vascular disease; rheumatoid disease, and
malignancy,
 Medications: nsaids,steroids,iiradiation
 Osteoporosis increase risk of fracture than risk of
non union
 Advanced age
 Immunosuppression

7. Treatment factors
 Excessive motion at fracture
secondary to
1. Poor fixation
2. Failed fixation
3. Inadequate
immobilization
 Lack of physiologic mechanical
stimulation to fracture area
 Non-weight bearing
 Extremely rigid stabilization
 Rigid stabilization with
inadequate contact

8. D. Classifications
 Ddiffrent type of classification based on different
factor
 Presence or absence of infection
 Relative biologic activity of the fracture site
 Weber–cech system –most widely used
 Clinical mobility & radiology;illizarov
 clinical mobility & radiology; Paley
 AO classification scheme

9. • Presence or absence of infection
 Septic
 aseptic

10. E. Investigations
 Weber–cech system
–most widely used
 BASED ON
VIABLITY AND
VASCULARITY
 1. Vascular
/Hypertrophic
/viable non unions
1. Elephant foot
2. Horse hoof
3. Oligotrophic
2. Avascular /atrophic
/inert non unions
1. Torsion wedge
2. Comminuted
3. Defect
4. Atrophic

11. Ilizarov classification
 based on clinical mobility & radiology
 lax
 Atrophic end
 Movement at fracture end >7deg or shortening
>2cm
 Stiff
 Hypertreophic bone end
 No movement
 may OR no deformity

12. Paley and Herzenberg
 Two major types:
1. Type a – a bone defect of less than 1
cm
2. Type B – a bone defect of more than 1
cm
3. Type C –infected non unions
A1: lax (mobile)
A2: stiff (nonmobile)
A2-1: no deformity
A2-2: fixed deformity
B1: bone defect, no shortening
B2: shortening, no bone defect
B3: bone defect and shortening

13.  AO classification
scheme
1. Hypertrophic non-
union
2. Oligotrophic
3. Atrophic non-
union
4. Pseudarthrosis

14. F. Options of management
 Before management
 We need investigation
 Proper AP,lat x ray of leg including knee and ankle
 CBC,ESR,CRP
 Total protein and albumin levels

15. Cont..
 Based on status of infection
 Genral for all pt
 Smoking cessation
 Optimizing nutrition
 Correction of endocrine and metabolic disorders
 Elimination or reduction of certain medications

16. OPTION
 Debridement
 Exchange nail
 Ex fix
ilzarove
monoplanar ex fix
Bone graft

17. G. What are the possible
management pitfalls?
 Fixation fault
 distraction at fracture
site

19. Q 14
 This is a 60 year old female presented with
progressive bilateral knee pain for many years.

20. Questions?
 What are the x ray findings?
 Bilateral knee x ray AP and lateral
 Osteopenic bone
 Subchondral sclorosis with diffuse subchondral
cyst and significant osteophyte over medial and
lat femur condyle
 Joint space seems normal or no gross narrowing
 DX--Bilateral knee OA

21. Discuss the medical and surgical
management options?
 Treatment principle
 Education
 Physiotherapy
 Exercise program
 Pain relief modalities
 Aids and appliances
 Medical Treatment
 Surgical Treatment

23. Education
 Weight loss
 Avoid contact impact and ground level activity
 Strengthening of quadriceps and hamstring
 Reduce pain and disablity or improve function
 Explain nature of their condition, its prognosis,
investigations required.

24. Medical management
 NSAIDs---effective during identifiable periods of
inflammation and can be avoided at other times
 PCM 1st choice
 Other NSIADs and cox2 inhibitor
 Topical NSAIDs
 reduce the pain and night awakenings in some
studies.
 unwilling to take NSAIDs or are refractory to
NSAIDs.

25.  Symptomatic Slow Acting Drugs for OA (SYSADOA)
(glucosamine sulphate, chondroitin sulphate,
diacerein, and hyaluronic acid)
 Intraarticular injections of Sodium Hyaluronate
 Intraarticular injection of steroid is indicated for acute
exacerbation of knee pain especially if accompanied
by effusion. Result is usually short lasting.
 Intraarticular steroid is single most common cause of
postoperative infection.

26.  Surgical approaches to OA include
 arthroscopy
 joint lavage
 Osteotomy
 arthroplasty
 fusion

28. Arthroscopic debridement:
 mild to moderate OA
 Mechanical symptom
 For active with acute pain normal alignment
stable ligament
…….Greater and more persistent symptomatic
relief

29. What to be done?
 examination of the entire knee joint
 removal of all loose bodies,
 debridement of meniscal tears to a stable rim,
 excision and trimming of cartilage flaps,
 burring of motion blocking osteophytes,
 excision of the inflamed synovium
 Aggressive removal of cartilage and meniscus
should be avoided as this could aggravate the
condition and speed up the progression of
arthritis
 remove only the fibrillated and scaling fragments
of articular cartilage

30. Proximal/High Tibial
Osteotomy(HTO)
 to decrease pain and improve functional results in
 unicompartmental knee arthritis
 Associated Varus or valgus deformity
 For young <60,ligament stable and preop
ROM>90deg outcome is good

31.  Knee Arthroplasty
 Unicompartmental Knee Arthroplasty
 Total Knee Arthroplasty
 Knee arthrodesis

32. Q15
 This is a 22 year old man who tripped over a curb
and felt knee buckle with immediate pain
,deformity and inability to bear weight.
 He is a chain smoker and obese.
 He has obvious knee deformity,
 shortened limb,
 unable to dorsiflex foot or toes,
 decreased sensation on the dorsum of foot.
 Dorsalis pedis is not palpable and brisk capillary
refill.

34. Questions?
 What x ray findings do you see?
 AP and lateral knee x ray
 Anterior knee dislocation
 No fracture seen

35. What would you do for this patient on
arrival to EOPD?
 Approach with ATLS approach
 Analegsic
 Traction try to align and correct the deformity
 Splint it
 Check for vascular status both dorsalis pedis and
posterior tibial artery
 Examine the distal nerve
 Check for compartment syndrome
 Check for other site injury esp hip and
ankle,thoraco lumbar region

37. How do you further assess this
patient?
 Assess for associated injury 57%, of multiple
fractures at 41%, and of open fractures at 27%
 viability of the limb for vascular injury..50%
 Check frequently pulse dorsalis pedis and post tibial
a.
 Capillary refill
 Color of the limb
 ABI
 Nerve injury-traction or blunt
 peroneal nerve… 25%

38. How do you manage the vascular
injury in this patient?
 The ideal technique to screen for vascular injury is still
under debate and many questions remain.
 Can one rely on physical examination alone?
 Is angiography required in all cases? And, what about
other screening modalities such as ankle brachial
indices (ABI), ultrasound, and CT or MR angiography?
 Ideally arteriography is investigation modality but
invasive and time taking followed by CT angiography
Sen=95% and sp 93%
 Bed side measurement ABI is the easiest way if no
actual sign of hard sign
 ABI>0.9 had negative predictive value of arterial injury
popliteal A. 100%.
 Doppler also easy and fast but technician variability
 Sen =90% Sp.=68%

40. How do you manage the possible
soft tissue injuries ?
 Once acute injury managed we need to take the
pt to the OR
 If not reduced in emergency try closed reduction
 Check for stability=EUA
 Open reduction
 open dislocations
 irreducible dislocations
 vascular injury, compartment syndrome

41.  The goal of definitive management is to provide a pain-free
and functional knee through restoration of ligamentous
stability and range of motion.
 Conservative
 Patients with substantial comorbidities
 polytrauma
 significant open wounds
 Immobilization
 concentrically reduced ----a long leg cylindrical cast (or
splint) for at least 3 weeks
 extended as long as 6 weeks, depending on the extent
of the original injury
 range-of-motion exercises are introduced and
progressed until these goals are met.

42.  External Fixator
 highly unstable joint
 Open
 Vascular injury
 Compartment syndrome
 Extensor mechanism disruption, a fixator will allow
a period of “splinting”
 Need MRI after stabilization to dx specific ligaments
injury

43. Operative Treatment
 Emergent and
 Nonemergent
 early (1 to 3 weeks)
 delayed (greater than 3 weeks).
 Emergent Intervention
 arterial injury requiring repair,
 knee dislocation with associated compartment
syndrome
 open knee dislocation,
 irreducible knee dislocation

44. Multiligament injury
 Surgical versus nonsurgical management
 Surgery improve outcome and postoperative
rehabilitation unless there is contraindication
 Repair vs Reconstruction
 REPAIR -higher rates of flexion deficit >6°, higher
rates of posterior instability and lower rates of return
to Preinjury activity levels.
 Repair of the collaterals is usually reserved
for bony avulsion injuries.

45.  Timing –controversial
 Acute with in 3 weeks
 Delayed more than 3 weeks
 Current recommendation
Immediate reduction
Early repair or reconstruction
Aggressive rehabilitation

47. Immidate vs delayed reconstruction
Immediate repair or
reconstruction delayed reconstruction
 ACL ,PCL and postero
lateral corner injuries
 PCL &postero lateral
corner tears
 ACL ,PCL & MCL
(grade III injuries, distal
tears)
 PCL & MCL (grade III
injuries, distal tears)
 displaced meniscal tear
preventing range of
motion.
 poor skin condition or swelling
 vascular repair
 associated injuries tibial plateau
fractures or femoral fractures
requiring internal fixation
 combined ACL, PCL, and MCL
disruptions
 ACL &PCL injuries with intact
collateral ligaments
 ACL ,PCL & medial collateral
ligament injuries (grade I or II)
with an intact posterior oblique
ligament

49. What are the potential
complications?
 Acute
 Vascular injury
 Nerve injury
 Compartment syndrome
 Infection
 DVT
 chronic
 Hetrotropic ossification
 Residual joint laxity
 Recurrent joint subluxation/dislocation
 Stiffness
 arthritis

50.  Thank you!