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Professor Deiary F Kader
Department of Sport, Exercise, Northumbria University, Newcastle
www.oasir.co.uk
Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne
FRACTURES AROUND THE KNEE –
CLINICAL PATTERN RECOGNITION AND APPROPRIATE
ACTION PLANNING
Prof Deiary Kader
Plan
 Knee Osteonecrosis
 Fracture around the Knee
 Advances in ACL Surgery
 Advances in PFJ instability
 PCL & PLC
2
Prof Deiary Kader
Nuffield Hospital/Newcastle
ICRC 2015
QEH Gateshead 2005-2015
3
QEH
Gateshead Health
Prof Deiary Kader
Knee Osteonecrosis (ON)
Spontaneous ON (SONK)
Secondary ON
Post-arthroscopic ON
4
Prof Deiary Kader
Spontaneous Osteonecrosis of the Knee
(SONK)
 Osteonecrosis without an identified cause.
 Females
 Middle age or elderly.
 Epiphysis of medial FC
 Lateral FC, Tibial plateau
 Almost always unilateral.
 Associated with meniscal root tear
 May represent a subchondral insufficiency / stress
fracture
Prof Deiary Kader
Clinical Presentation:
 Sudden onset of severe knee pain (usually non-
specific).
 Can be focused over the medial femoral condyle
 Decreased range of motion with no mechanical block
 Effusion present in the acute stages
 Pain worse on activity
Prof Deiary Kader
Treatment : Non-operative:
 Activity modification
 Rest and non or partial weight bearing
 Analgesia including NSAIDs
 Targeted physiotherapy focusing in range of
motion and quadriceps strengthening
Prof Deiary Kader
Treatment
Operative
Only after conservative Rx -success is variable.
 Retrograde drilling
 a trial with an off-loader brace is
recommended pre-operatively
 High tibial osteotomy (if mal-alignment
present)
 Arthroplasty (in larger lesions and bone
collapse)
Prof Deiary Kader
Outcome of SONK
 Small, isolated lesions often regress and heal
 Medium-sized lesions may regress
 Very large lesions, subchondral collapse will
occur, regardless of treatment
Prof Deiary Kader
Insufficiency Fractures of the
MFC
 Predominance in elderly women
 Osteoporotic bone
 Varus knee
 Obesity
 Trivial trauma
 Mechanical pain
 Increased radionuclide uptake.
 Rest and analgesics consistently ensured a better
outcome within three to four weeks
Prof Deiary Kader
Secondary Osteonecrosis
Subchonrdal AVN
 Often involves both femoral condyles
 Multiple lesions epiphysis, metaphysis, diaphysis ne.
 Typically younger than 45 years
 It is bilateral more than 80%
 Direct risk factors
 Radiation
 Chemotherapy
 Corticosteroid
 Trauma.
 Sickle cell disease or other myeloproliferative
Prof Deiary Kader
Treatment of secondary ON
 Diagnosis at early stages
 Eliminate the causative factor if possible
 Nonsurgical treatment lead to poor outcome
 Drill the lesions, may halt the progression
 Supplement the drilling technique with
 Bone morphogenetic protein
 Growth factors
 MSC
Prof Deiary Kader 13
Prof Deiary Kader
General causes of osteonecrosis include:
• TRAUMA
• CAISSON DISEASE
• HAEMOGLOBINOPATHIES SICKLE CELL DISEASE
• RADIOTHERAPY
• CONNECTIVE TISSUE DISORDERS
• RENAL TRANSPLANTAION
• CORTICOSTEROID EXCESS
• PANCREATITIS
• GOUT
• GAUCHER DISEASE
• ALCOHOL
14
Prof Deiary Kader
Post-arthroscopic ON
 Heat damage to the bone
 Trauma during surgery
 Lesions are typically only found in the epiphysis.
 Patient age and sex is not a factor.
 Some of the associated risk factors include
meniscectomy, cartilage débridement, and ACL
reconstruction.
Prof Deiary Kader
Hoffa Fracture
Prof Deiary Kader
 Isolated femoral condylar fractures in the coronal
plane
 Direct anteroposterior force applied to a flexed
knee in a high-energy accident
 Hoffa described the injury in 1904 as generally
involving the lateral femoral condyle
Prof Deiary Kader
Prof Deiary Kader
Sleeve Fracture
Patella
Prof Deiary Kader
Sleeve fracture occurs between the cartilage "sleeve" and
main part of the ossific nucleus
Age 8-12
20
Prof Deiary Kader 21
Patella Tendon Rupture
Prof Deiary Kader 22
???????
Prof Deiary Kader 23
Prof Deiary Kader 24
POSTGRAD ORTH Deiary Kader
???????
Sigond Fracture
pathognomonic of ACL Rupture
???????
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
 Type IIIB (Zifko) includes the entire intercondylar eminence.
 Type IV (Zaricznyj 1977): comminution of the fracture fragment.
Treatment
 Casting in extension for type I
 Open reduction and internal fixation.
 Arthroscopic reduction and fixation
 Rarely ACL reconstruction is necessary
Prof Deiary Kader
TP
???????
Prof Deiary Kader
TP
Prof Deiary Kader 34
Tibial Plateau Fractures
Prof Deiary Kader
Tibial Plateau Fractures
Prof Deiary Kader
???????
Prof Deiary Kader
Metastatic cancer
Prof Deiary Kader
Only bone cyst
Prof Deiary Kader

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Fractures around the knee for connect Physio Newcastle

  • 1. Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle www.oasir.co.uk Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne FRACTURES AROUND THE KNEE – CLINICAL PATTERN RECOGNITION AND APPROPRIATE ACTION PLANNING
  • 2. Prof Deiary Kader Plan  Knee Osteonecrosis  Fracture around the Knee  Advances in ACL Surgery  Advances in PFJ instability  PCL & PLC 2
  • 3. Prof Deiary Kader Nuffield Hospital/Newcastle ICRC 2015 QEH Gateshead 2005-2015 3 QEH Gateshead Health
  • 4. Prof Deiary Kader Knee Osteonecrosis (ON) Spontaneous ON (SONK) Secondary ON Post-arthroscopic ON 4
  • 5. Prof Deiary Kader Spontaneous Osteonecrosis of the Knee (SONK)  Osteonecrosis without an identified cause.  Females  Middle age or elderly.  Epiphysis of medial FC  Lateral FC, Tibial plateau  Almost always unilateral.  Associated with meniscal root tear  May represent a subchondral insufficiency / stress fracture
  • 6. Prof Deiary Kader Clinical Presentation:  Sudden onset of severe knee pain (usually non- specific).  Can be focused over the medial femoral condyle  Decreased range of motion with no mechanical block  Effusion present in the acute stages  Pain worse on activity
  • 7. Prof Deiary Kader Treatment : Non-operative:  Activity modification  Rest and non or partial weight bearing  Analgesia including NSAIDs  Targeted physiotherapy focusing in range of motion and quadriceps strengthening
  • 8. Prof Deiary Kader Treatment Operative Only after conservative Rx -success is variable.  Retrograde drilling  a trial with an off-loader brace is recommended pre-operatively  High tibial osteotomy (if mal-alignment present)  Arthroplasty (in larger lesions and bone collapse)
  • 9. Prof Deiary Kader Outcome of SONK  Small, isolated lesions often regress and heal  Medium-sized lesions may regress  Very large lesions, subchondral collapse will occur, regardless of treatment
  • 10. Prof Deiary Kader Insufficiency Fractures of the MFC  Predominance in elderly women  Osteoporotic bone  Varus knee  Obesity  Trivial trauma  Mechanical pain  Increased radionuclide uptake.  Rest and analgesics consistently ensured a better outcome within three to four weeks
  • 11. Prof Deiary Kader Secondary Osteonecrosis Subchonrdal AVN  Often involves both femoral condyles  Multiple lesions epiphysis, metaphysis, diaphysis ne.  Typically younger than 45 years  It is bilateral more than 80%  Direct risk factors  Radiation  Chemotherapy  Corticosteroid  Trauma.  Sickle cell disease or other myeloproliferative
  • 12. Prof Deiary Kader Treatment of secondary ON  Diagnosis at early stages  Eliminate the causative factor if possible  Nonsurgical treatment lead to poor outcome  Drill the lesions, may halt the progression  Supplement the drilling technique with  Bone morphogenetic protein  Growth factors  MSC
  • 14. Prof Deiary Kader General causes of osteonecrosis include: • TRAUMA • CAISSON DISEASE • HAEMOGLOBINOPATHIES SICKLE CELL DISEASE • RADIOTHERAPY • CONNECTIVE TISSUE DISORDERS • RENAL TRANSPLANTAION • CORTICOSTEROID EXCESS • PANCREATITIS • GOUT • GAUCHER DISEASE • ALCOHOL 14
  • 15. Prof Deiary Kader Post-arthroscopic ON  Heat damage to the bone  Trauma during surgery  Lesions are typically only found in the epiphysis.  Patient age and sex is not a factor.  Some of the associated risk factors include meniscectomy, cartilage débridement, and ACL reconstruction.
  • 17. Prof Deiary Kader  Isolated femoral condylar fractures in the coronal plane  Direct anteroposterior force applied to a flexed knee in a high-energy accident  Hoffa described the injury in 1904 as generally involving the lateral femoral condyle
  • 19. Prof Deiary Kader Sleeve Fracture Patella
  • 20. Prof Deiary Kader Sleeve fracture occurs between the cartilage "sleeve" and main part of the ossific nucleus Age 8-12 20
  • 21. Prof Deiary Kader 21 Patella Tendon Rupture
  • 22. Prof Deiary Kader 22 ???????
  • 25. POSTGRAD ORTH Deiary Kader ???????
  • 27.
  • 29. 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  Type IIIB (Zifko) includes the entire intercondylar eminence.  Type IV (Zaricznyj 1977): comminution of the fracture fragment.
  • 30.
  • 31. Treatment  Casting in extension for type I  Open reduction and internal fixation.  Arthroscopic reduction and fixation  Rarely ACL reconstruction is necessary
  • 34. Prof Deiary Kader 34 Tibial Plateau Fractures
  • 35. Prof Deiary Kader Tibial Plateau Fractures