knee soft tissue postgraduate orthopaedic 2016

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)


PLAN1. MENISCUS

2. ACL

3. MCL

4. PCL

5. PLC

6. MULTI LEGAMENT

7. PFJ

MENISCAL RESECTION & REPAIR

POSTGRADORTH Deiary Kader

Meniscal Anatomy

Radial Fibres, serving as “ties” that resist shearing or splitting.

Fibres run parallel or circumferentially to resist hoop stress during weight bearing.

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Composed of 70% water 30% organic matter

Collagen constitutes 75%

MeniscusVascular Supply

Peripheral Vascularity 25-30%

Medial and Lateral Geniculates

Zones

Red

Red-White

White

Red Red-White White

Meniscal Function

➢ Load distribution •50% in extension •90% in flexion –PH in >90o flexion

•Lateral > Medial ➢ Joint stability ➢ Congruity ➢ Lubrication ➢ Proprioception

Meniscal Tear Management :-

➢ Excision – 60% of people over 65yrs have incidental

tears

➢Repair

➢ Transplant

➢Replacement

Repair

Excise


Arthroscopy Papers1- 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

http://www.ncbi.nlm.nih.gov/pubmed/24369076

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sihvonen%20R%5BAuthor%5D&cauthor=true&cauthor_uid=24369076


http://www.ncbi.nlm.nih.gov/pubmed/?term=Khan%20M%5BAuthor%5D&cauthor=true&cauthor_uid=25157057


http://www.ncbi.nlm.nih.gov/pubmed/?term=Hare%20KB%5BAuthor%5D&cauthor=true&cauthor_uid=23442554



http://www.ncbi.nlm.nih.gov/pubmed/?term=Herrlin%20SV%5BAuthor%5D&cauthor=true&cauthor_uid=22437659

http://www.nejm.org/toc/nejm/347/2/

Snapping knee in deep flexion


Meniscal repair

Factors to consider

When would you repair a menx?


Meniscal repair

Factors to consider:

Patient Chronicity Type Location Tissue quality Stability of knee Axial alignment


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


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Meniscal Substitutes

➢Engineered constructs

– Collagen Meniscal Implant

– Synthetic Scaffold (Actifit)

– Hydrogels

Collagen


Menx Allograft Indications

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


ICRS<1cm

>1cm

The modified International Cartilage Repair Society (ICRS)The Outerbridge classification

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.


ACL InjuriesFRCS(Tr&Orth) Revision Course

Anatomy➢33 mm long, 11 mm in diameter

➢Two bundles

➢AM bundle – tighten in flexion

➢PL bundle – tighten in extension

➢

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. CavanaghThe Biomechanical Function of the Anterolateral Ligament of the Knee

Am. J. Sports Med. Jan 2015

Prevent Internal Rotation of th

e Tibia

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


Paul F. Segonda Paris surgeon

1879


ACL Evidence-Based Review

Factors affecting results:

➢ Patient Selection ➢ Tunnel placement ➢ Strong graft choices ➢ Solid fixation ➢ Rational rehabilitation

Surgical Treatment

Indications:

1) Subjective instability (non-coper)

2) ACL tear in children and adolescents

3) Multiligament injury

4) Displaced meniscal tears

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

Hamstring BTB

Grafts / Fixations

Quads

In 1972, D. L. MacIntosh In 1967,1975, M. Lemaire

Extra-articular reconstruction


ANTEROLATERAL LIGAMENT

Anatomic Single bundle recon

ACL Tunnels

Meyers and McKeever classification (1959)


MCL

Medial Collateral Ligament Exam

25-30° of flexion, the MCL provides 80% of the support to

valgus stress

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

MCL Reconstruction with AT

+ Revision ACLR

Chronic MCL Injury

PCL and PLC


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

a. Ant Meniscofemoral lig Humphrey

b. Post Meniscofemoral lig Wrisberg

Diagnosis ?

Surgical reconstruction

Indications

• Acute combined injuries

• Acute bony avulsion

• Symptomatic chronic PCL

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PCL Reconstruction

What are the structures in the Posterolateral Complex of the

Knee?

Function???

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Posterolateral Complex

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What is the function of the Posterolateral Complex of the

Knee?

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The Posterolateral Corner (PLC)

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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

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Posterolateral Complex Injury

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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

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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.

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Vascular Injuries

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Classification

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ExaminationRecurvatum

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Management Emergency

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ManagementSurgery 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.

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MPFL

VMO

VMO

MPFL

VMO

Patella Quads TendonPatella

Tendon

Medial Knee

M.E

Add.Tub

Femur

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

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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 ??

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

PATELLA ASSESSMENTBeighton 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

IMAGING OF THE PATELLOFEMORAL JOINT

✦ AP and Lateral Knee x-ray

✦ Merchant’s view

✦ MRI Axial view

✦ CT Rotational Profile

Merchant’s

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Trochlea dysplasia

Blumensaat's line

Normal Trochlea Depth

NORMAL

MEASURING PATELLA HEIGHT

Caton – Deschamps index =1.2

Blackburne-peel index = 1.12

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MPFL injury

Patella pain

Articular Damage

MRI SCAN

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)

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analysis

Normal measure is 5° to 15°

Femoral anteversion

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LATERAL PATELLAR TILT

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lateral trochlear tilt

The pathologic measure is <14°

83Clinique de la Sauvegarde –

analysis

lateral tibia twisting

slices n°3 and n°4

Normal Ext rotation is 25° to 30°

TRUE Q ANGLE, MEASUREMENT OF THE TIBIAL

TUBEROSITY-TROCHLEAR GROOVE (TT/TG) DISTANCENormally TT/TG = 2-9 mm pathologic measure is > 19 mm

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TROCHLEAR DYSPLASIADejour classification of trochlear dysplasia on

CT scans

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Shallow flat

dome-shaped medial ‘‘cliff-face.’’

Dejour classification

NON-SURGICAL TREATMENT OF PATELLA INSTABILITY

Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait

PFJ BIOMECHANICSPatellofemoral 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)

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

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TIBIAL TUBERCLE TRANSFER

Patellofemoral Instability with Malalignment

FULKERSON'S TECHNIQUE OF ANTEROMEDIALIZATION

A steeper osteotomy plane will produce more anteriorization along with medialization

PATELLA ALTA

–Distal transfer (Distalization)

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1.4 cm

Patella alta

Med Epicondyle

Add Tubercle

Patella

MPFL

Our Dissection

TROCHLEA DYSPLASIA

TROCHLOPLASTY

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

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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