ORTHOPAEDIC KNEE CONDITIONS AND INJURIES

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1 11. August 2014 ORTHOPAEDIC KNEE CONDITIONS AND INJURIES Presented by:

2 Dr Vera Kinzel Knee, Shoulder and Trauma Specialist Macquarie University Norwest Private Hospital + Norwest Clinic Drummoyne Specialist Center Sydney Adventist Liverpool Private Hospital + Liverpool Clinic

3 Dr Vera Kinzel Total Knee Arthroplasty Unicompartmental Knee Arthroplasty Patellofemoral Arthroplasty ACL reconstruction, Mutli-ligament Injuries Arthroscopic Knee Surgery Osteotomies Patella Realignment Trauma

4 Dr Vera Kinzel Rotator Cuff Surgery Impingement Total Shoulder Arthroplasty Reverse Total Shoulder Arthroplasty ACJ pathology Trauma

5 Definition Anatomy Specific knee injuries Anterior knee pain Fractures Meniscal injuries Ligament injuries

6 TERMINOLOGY Joint: where two ends of two bones meet Lined with cartilage Acts as a load-bearing and shock absorbing frictionless surface

7 TERMINOLOGY Tendon muscle to bone Ligament bone to bone Sprain ligament injury Strain muscle injury Laxity joint translation Subluxation pathologic laxity Dislocation no contact of joint surface

8 TERMINOLOGY Tendon connects muscle to bone Quadriceps Patella tendon Ligament connects bone to bone, limits abnormal motion ACL, PCL, MCL, LCL

9 TERMINOLOGY Strain: pull of muscle or tendon Pain in muscle/did not warm up Tenderness, swelling, defect hollow Possible to tear to the muscle Inability to contract muscle

10 TERMINOLOGY Sprain: Injury to ligament Ligaments stabilise a joint Severe sprain = tear Twisting injury Heard a pop Joint slipped out of space Deformity, discoloration, swelling Tenderness Decreased ROM

11 TERMINOLOGY Contusion = Bruise Direct blow or contact Discoloration or swelling Area of tenderness Difficulties on movement

12 TERMINOLOGY Dislocation: Bone/Joint is dislodged from normal articulation Joint no longer in proper position

13 TYPES OF INJURIES Acute: NEW Single, traumatic event: Fractures, ACL ruptures, sprains, strains Overuse: More common Subtle occur over time More difficult to diagnose and treat Anterior knee pain, chondromalacia

14 ANATOMY

15 HISTORY Onset Location Duration Quality/quantity Aggravating factors/relieving factors Associated symptoms Effect on function

16 COMMON KNEE INJURIES Anterior knee pain/patellar pain Meniscal tears ACL ligament injuries Fractures

17 ANTERIOR KNEE PAIN Common complaint Patellofemoral pain Chondromalacia patella Abnormalities Forces applied to the knee cap Anatomy of the knee cap

18 ANTERIOR KNEE PAIN SYMPTOMS: Pain in front of the knee/behind knee cap Pain going up/down stairs Difficulties sitting for prolonged periods Swelling, catching, locking Sense of knee cap instability Sense of giving away

19 ANTERIOR KNEE PAIN TREATMENT: Rehabilitation Surgery for patient with mal-alignment where non-operative treatment has failed

20 ANTERIOR KNEE PAIN RICE NSAIDS Activity modification Taping Brace Return to full work after 6 weeks

21 EXTENSOR MECHANISM INJURIES Maintain a standing position Function: When ambulating Rising from chair Ascending/descending stairs Overcome gravity

22 EXTENSOR MECHANISM INJURIES Fall from heights Direct blow to the anterior knee Rapid knee flexion with quadriceps resistance

23 EXTENSOR MECHANISM INJURIES Patella fracture Direct injury- comminuted fracture Knee hitting dashboard Fall onto knee Direct blow to knee Indirect injury transverse patella fracture Partial fall followed by collapse of knee Eccentric applied force to the patella tendon

24 EXTENSOR MECHANISM INJURIES Pain, contusion, abrasions, laceration Haemarthrosis Palpable defect Negative straight leg raise

25 EXTENSOR MECHANISM INJURIES Treatment: Modified tension band wire Cerclage wire Patellectomy Rehabilitation: 6 weeks in brace or cast Deskwork for 6 weeks PT x 3-4 months

26 EXTENSOR MECHANISM INJURIES Quadriceps tendon rupture: Eccentric injury to the knee Patient usually over 40 years Treatment direct repair to bone Cast or brace WB as tolerated Isometric exercise at 6 weeks 8-10 weeks full ROM

27 EXTENSOR MECHANISM INJURIES Patella tendon rupture: Eccentric contracture Usually < 40 years Treatment: tendon to bone repair TWB 3 weeks Flexion and passive extension at 2-3 weeks 6 weeks resistance exercise Competitive sport 4-6 months

28 EXTENSOR MECHANISM INJURIES Patella dislocation: years Female Valgus load, flexed knee,externally rotated Often associated with MPFL injury, chondral defects

29 EXTENSOR MECHANISM INJURIES Treatment non operative: 6 weeks in cast or early mobilisation Intensive physiotherapy Re-dislocation rate 4050% Treatment operative MPFL repair Lateral release Realignment surgery Rehabilitation 3-4 months

30 TIBIAL PLATEAU FRACTURES Age and mechanism important Younger patient : stiffer bone- split fractures Older patient: depression fractures Usually axial load

31 TIBIAL PLATEAU FRACTURES Associated injuries Femoral and tibial fractures Cruciate and collateral ligament injuries Meniscal injuries 50% Avulsion intercondylar emmince Treatment: Restore joint congruity Maintain limb alignment Allow early mobilisation

32 TIBIAL PLATEAU FRACTURES Rehabilitation ROM early NWB 6 weeks Strengthening 2-3 months

33 MENISCAL INJURIES Meniscus: Shock absorber Stability Lubrication & nutrition Protects underlying surface cartilage

34 MENISCAL INJURIES twisting/squatting swelling develop over night associated with ligament injuries 20-60% Mechanical symptoms: clicking catching locking

35 MENISCAL INJURIES Meniscal repair Meniscus has poor blood supply Tear must be in red zone Longer rehabilitation time 3 months

36 MENISCAL INJURIES Older patient: New injury vs degenerative tear Treatment- partial meniscectomy/debridement rehabilitation 6 weeks- 3 months

37 ACL INJURY Common injury Female > male 3>1 Genetic predispostion Difference in muscle firing patterns, landing

38 ACL INJURY ACL/PCL PCL prevents tibia from gliding posteriorly ACL prevents tibia from gliding anterior aids in anterior knee stability aids in pivoting motions instability leads to mensicus and cartilage damage

39 ACL INJURY Mechanism 70% noncontact Sudden stop combined with twist Symptons Pain Pop Rapid onset of swelling Knee feels unstable Does not trust knee

40 ACL INJURY ACL injuries do not heal Any active person should consider ACL reconstruction Pre-operation restore ROM, reduce swelling, strengthen muscles

41 ACL INJURY Treatment Patella tendon graft Hamstring graft Cadaver graft Synthetic graft

42 ACL INJURY Rehabilitation Brace 6 weeks vs non bracing 6-12 weeks no brace, ROM exercises strengthening exercises 3 months start running 6 months return to sport, manual work 6-12 months return to contact sport, full labour, knee feels normal

43 OSTEOARTHRITIS Common /Year TKR in Australia Genetic Postraumatic

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45 OSTEOARTHRITIS NSAIDS, Analgesia Physiotherapy Bracing Injections Osteotomies TKR

46 THANK YOU