Acute Knee Injuries Diagnosis and Management

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1 Acute Knee Injuries Diagnosis and Management Mandeep Lamba Consultant Orthopaedic Surgeon Whipps Cross Hospital Holly House Hospital

2 Acute Knee Injuries Meniscal Injuries Cruciate and other Ligamentous Injuries Osteochondral Injuries

3 Other Causes of Acute Knee Pain Patellar Dislocation Patellar Tendon Rupture Quadriceps Tendon Rupture Intra-articular Fractures

4 Initial Assessment: History Mechanism of injury Pain Swelling Clicking Locking Giving way Instability

5 Common Symptoms Meniscal Cruciate MCL/LCL Swelling delayed early ecchymosis Locking yes no no Clicking yes no no Giving way yes yes +/- Holly House GP seminar 09/04/2016

6 Initial Assessment Inspection Effusion Bruising Alignment Palpation Joint line tenderness Special Tests McMurray s Apley s Drawer Lachman s Pivot shift

7 Meniscal Injuries

8 Anatomy of the Meniscus

9 Zones of Meniscus According to its blood supply Red / Red Red / White White / White

10 Meniscal Function Shock absorption Joint stability Increase congruity between the femur and tibia

11 Etiology Of Meniscal Injuries Twisting injuries Associated OA Associated meniscal pathology e.g., meniscal cyst, discoid meniscus

12 Classification

13 Diagnosing Meniscal Injuries Effusion Direct palpation of joint line McMurrays test Apleys Compression Test MRI Arthroscopy

14 Palpation of Joint Line

15 McMurrays Test

16 Apleys Compression Test

17 MRI

18 Normal Arthroscopic view

19 Meniscal Tears

20 Management of Meniscal Tears Repair when possible if within vascular zone of the meniscus, simple tear pattern Partial menisectomy

21 Meniscal Repair For tears in Red / Red Zone or less preferably in Red / White Zone Importance of meniscal repair in youngsters as they have wide zone of blood supply Acute tear Repair only possible in certain tear configuration Longer recovery as compare to menisectomy Different techniques available

22 Meniscal Repair

23 Partial Menisectomy

24 Risk factors for long-term poorer outcome Greater size of meniscal resection Articular cartilage degeneration assessed at surgery Prior surgery on the index knee Body mass index >30 Degenerate tears had poorer outcomes Holly House GP seminar - 25/7/2015

25 Cruciate Ligament Injuries

26 Anatomy

27 ACL Injuries ACL injury commonest cause of prolonged absence from sport ACL often with MCL &/or meniscal pathology Holly House GP seminar 09/04/2016

28 How does a torn ACL occur? Twisting force when applied to the knee whilst the foot is firmly planted on the ground or upon landing Direct blow to the knee, usually the outside, as may occur during a football or rugby tackle Holly House GP seminar 09/04/2016

29 Symptoms of a torn ACL Audible pop or crack at the time of injury Swelling of the knee Restricted movement Inability to fully straighten the leg Difficulty in Weight Bearing

30 Clinical Examination Widespread Tenderness Haemarthrosis Drawer s test Lachman s test Pivot shift test Holly House GP seminar 09/04/2016

31 Anterior drawer test

32 Lachman Test

33 Pivot Shift Test

34 Investigations X Rays MRI Arthroscopy Holly House GP seminar 09/04/2016

35 Segond Fracture

36 ACL Tears on MRI

37 Arthroscopic View

38 Is surgery always necessary? NO Depends on the patient's level of activity job, age Extent of Functional knee instability Often training and strengthening exercises will be enough to prevent the need for complex surgery.

39 Operative Management Patients with Functional instability High demand jobs or sports Reconstruction Hamstrings Bone-Patellar Tendon-Bone Allografts

40 Hamstring / Patellar Graft

41 After ACL Reconstruction

42 Post-operative ACL Supervised physical therapy for 4 to 6 months Return to light activities at 6 weeks Return to sports ~ 6 months

43 PCL Injury Commonly associated with posterolateral corner injury A direct blow to the proximal anterior tibia in a flexed knee Hyperextension injuries

44 PCL Injury Clinical Examination MRI Main stay of treatment conservative with intensive rehabilitation Reconstructive Surgery gaining popularity

45 MCL Injury Abduction force Can be part of multiligamentous injury Pain over ligament Swelling / Bruising / Tenderness Grade I / II / III

46 MCL Injury Valgus Stress Test Non Operative management Cricket Pad Splint Cast Hinged Brace Physiotherapy

47 LCL Injury Usually part of Posterolateral Corner injury Pain / Swelling Varus Stress Test MRI Isolated injury Conservative management

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49 Shearing Rotational force is the most common cause In adults, the tidemark zone is the weak link between the overlying cartilage and subchondral bone and therefore shearing injuries most often produce a chondral injury rather than an osteochondral injury In most cases injury is in the weight bearing region, and usually in the medial compartment (4 times more common that lateral injuries)

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51 Chondral and Osteochondral Injuries Symptoms of intermittent locking, recurrent effusions, crepitus, and persistant pain may all be associated with chondral injuries

52 Chondral Injuries Difficult treatment options Need to individualize according to lesion size, location, patient motivation, and occupation Microfracture Autologous osteochondral transfer Autologous chondrocyte implantation Allograft osteochondral transfer

53 Chondral Lesion Treatment Options < 1 cm 2 - Debridement, microfracture 1-2 cm 2 - Debridement, microfracure, osteochondral grafting, autologous chondrocyte implantation >2 cm 2 - ACI, allograft Holly House GP seminar 09/04/2016

54 Microfracture

55 Osteochondral Autograft/ Allograft

56 Autologous Chondrocyte Implantation

57 Chondral Treatment Outcomes Variable Good short term results with all treatments Long term return to sports/ work better with ACI than microfracture

58 Recent Advances: Meniscus Allograft Transplant Meniscal allograft is a cadaveric meniscus used to replace a defective or absent meniscus Right size needed Cryopreserved (frozen) no immunogenicity No need for any suppressive medication as it is inert Some evidence that it may delay onset of OA in addition to symptomatic improvement Recovery usually 3-4 months

59 Recent Advances ACL Allograft Particularly for revision ACL reconstruction Also useful for multiple ligament injuries Commonly used Bone-tendon-Bone graft

60 Recent Advances: Osteochondral Allograft Suitable for articular cartilage defects >2 cm in size Allografts typically are fresh or cryopreserved, preferably within 24 hrs after death and implanted within 7 days Less immunogenic if cryopreserved but with less viability of chondral cells Good 10 yrs results with survival over 80%

61 Typical Scenario 1 Meniscal Tear Mechanism of Injury Twisted knee while weight bearing or squatting Physical Examination Joint line tenderness, + McMurray s and Apley s tests

62 Radiographs Normal Arthrocentesis Clear synovial fluid may be some blood occasionally

63 Diagnosis MRI Procedure Arthroscopy with partial menisectomy

64 Typical Scenario 2 ACL Rupture Mechanism of Injury Pivoting injury, audible POP, Instability Physical Examination Positive Lachman s and drawer tests, positive pivot shift

65 Typical Scenario 2 ACL Rupture Radiographs Segond / intercondylar eminence fracture X Ray may be normal Arthrocentesis Haemarthrosis drained Holly House GP seminar - 25/7/2015

66 Typical Scenario 2 ACL Rupture Diagnosis MRI Procedure Physio ACL Reconstruction

67 Typical Scenario 3 Osteochondral Fracture Mechanism of Injury Direct blow to knee, unable to bear weight Physical Examination Abrasion, ecchymosis, haemarthrosis

68 Radiographs Osteochondral fracture Arthrocentesis Blood drained with fat globules

69 Diagnosis X Rays / CT / MRI Procedure ORIF

70 Questions? Holly House GP seminar - 25/7/2015