Advances in cartilage and soft tissue injuries of the knee

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1 Advances in cartilage and soft tissue injuries of the knee Dr Tim McMeniman BSc(Med)/MBBS (UNSW), FRACS (Orth) Senior Lecturer, University of Queensland

2 Declarations Mater Health Services Visiting Medical Officer University of Queensland Senior Lecturer Private Orthopaedic Practice - BOSMC No royalties or consultancies

3 Outline Posterior horn menisal avulsion and repair ACL Reconstruction Rationale and current issues PCL and collateral ligament injuries Patella instability PRP injections Explanation and applications Chondral replacement

4 Posterior root avulsion Increasingly recognised - MRI 2 groups of patients Acute traumatic younger Sudden onset pain in older patients with early degeneration Consequences Accelerated chondral degeneration Osteonecrosis

5 Selected Literature Contact pressure increases to that of total meniscectomy Harner et al, JBJS(A) 2008 and 2009 Repair restores function, but not completely Kim et al, KSSTA 2013 Suture fixation in the meniscus is the critical factor La Prade et al, AJSM 2014

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10 Typical history 2 groups Those associated with ACL disruption Usual features of an ACL rupture, more severe pattern of injury Isolated avulsion

11 Isolated avulsion Often older patient (50+) Knee with minimal preceding symptoms Minor or no recollection of a significant antecedent injury

12 Isolated avulsion Significant pain usually medial and posterior, NSAIDs often of little benefit Night pain Associated significant swelling Mechanical features not prominent Often resort to walking aides

13 Technique 2 Portal arthroscopy Menisco-tibial portion of the MCL frequently needs to be released Drilling under direct vision from anteromedially to the posterior root of the meniscus Sutures are placed in the horn Sutures retrieved down the bone tunnel by use of a lead suture

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21 Case example 43 yo tradesman ACL rupture? 3 years prev - untreated Minor instability episodes Playing AFL - major instability episode

22 Arthroscopy

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34 Postoperative Rehab Much as for a normal meniscal repair Protected weight bearing (NWBing to PWBing) out to 6/52 Avoidance of loaded flexion >90 deg out to 3 months. All patients followed to 3 months routinely (2/6/12 week appts)

35 BOSMC series P Myers/T McMeniman/B Collins 51 Patients Follow-up 3 months to 12 years Age range 12 to 71 years (Average 49.7) One bilateral case - 12 months between presentations

36 Outcomes Patients followed to 3 months all report decrease in pain aside from 1 in our series Established AVN at time of surgery Often patients notice immediate decrease in pain? Deep MCL release? LA? Non weight bearing? Effect of Meniscal repair

37 Complications Reoperation 1 DVT 2 Below knee 1 Above knee

38 Meniscal dettachment If recognised should be dealt with Safe and reproducible technique Chondral damage (Age) not necessarily a contraindication If not repaired - the remnant posterior horn should not be extensively resected. Anticoagulation post op advisable

39 ACL reconstruction What is it?

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41 ACL normal and ruptured

42 ACL reconstruction What does it do? Stabilises the knee in rotation and prevents the tibia moving forward on the femur. What are the consequenses of injury? Instability Further damage to meniscii and cartilage surfaces

43 ACL reconstruction How does it get injured Sidestep gone wrong Netball Touch Football Contact injury Hyperextension Snow skiing and to a lesser extent snowboarding

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45 Symptoms Pain Swelling almost immediately Blood Stiffness pain and swelling slowly subside over 2 to 4 weeks Instability the reason to reconstruct

46 Pivot Shift Test

47 Treatment options Live life in a straight line Rehabilitation Reconstruction

48 ACL Indications Symptomatic instability despite appropriate rehabilitation 1 strike, your out (PM Philosophy) Anticipated high demand pivoting activity Controversial Recent studies Roe et al (North Syd) Spontaneous healing of ACL in 3% KANON study (Lund University, Sweden) No difference in randomised controlled trial of surgical versus non surgical Choi et al AJSM 2012 hamstring tendon regeneration

49 Graft Choice Autograft Hamstrings Bone Patella Tendon Bone (BPTB) Quads tendon Allograft As above plus tib post, tendo achilles Synthetic Numerous tried over the years Unfortunately high failure rate LARS ligament may do better

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51 ACL Reconstruction - Fixation

52 Results Excellent for stability 95% success Rerupture rate 2 to 5 % No evidence as yet that it prevents osteoarthritis Highly controversial I strongly believe a stable knee is less likely to develop arthritis.

53 PCL Multiligamentous injury MCL/PCL likely an exception if managed well non surgically Grade 3 laxity with symptomatic instability Implies posterior capsule injury (PLC/POL) Lars ligament Evidence as yet a little light Not to prevent OA

54 MCL Rarely requires surgical intervention Most often proximal tears which heal well Always residual laxity test with co-contraction Proximal avulsion with ongoing symptoms, especially in external rotation Williams et al JBJS(B) Distal avulsion Stenner lesion of the knee Chronic laxity and instability (+/- ACL recon)

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56 LCL and Posterolateral corner Repair if 3 weeks old or less Reconstruct if beyond acute phase? Role of extent of laxity Dial test 90 and 30

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60 Anterolateral ligament of the knee

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62 Multiligamentous knee dislocation Uncommon injury in sport Heterogenous group of injuries NV status 1 st priority Good evidence for early surgical repair or reconstruction of these injuries

63 Meniscal tears To repair or not In conjunction with ligamentous injury Ideal patent, normal meniscal tissue, in conjunction with ACL recon, vascular zone. Controversial Isolated meniscal tears Radial tears Meniscal root avulsions Technique: Inside-out or fast fix Inside out remains the gold standard

64 Patella instability 3 factors in stability of the PFJ (or any joint) Bony Static soft tissue Dynamic soft tissue 1 st time dislocators rehab Only indication is a chondral or ostochondral loose body.

65 Patellar instabaility Patella alta Trochlea dysplasia Increase Q angle Ligamentous laxity Ruth Wynne-Davies MPFL injury Role of rotation

66 Patella Alta Lower over higher Insall-Salvati /-0.13 Blackburne- Peele 0.95 normal

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70 Q angle < 15 deg in men <20 deg in women Race dependant High intraobserver variablity Value of TTTG

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72 MPFL

73 Patella tendinopathy Management rarely surgical Role of injections PRP Dextrose Open excision for large areas of chronic tendinosis Arthroscopic debridement of proximal tendon and distal pole of patella

74 Platelet Rich Plasma (PRP) Derived from patients own blood Centrifuged 4 x platelet count Multiple growth factors Injected with or without activator

75 PRP: What is it used for? Non surgical Tennis and golfer s elbow Patella tendinitis Plantar fasciitis Knee osteoarthritis

76 PRP: What is it used for Surgical in combination with Achilles tendon repair Rotator cuff repair ACL reconstruction Chondral injury

77 PRP: Does it work? Many small studies showing a benefit when compared traditional results or with placebo Problems: Most of these conditions self limiting There is an expense associated with the techniques use

78 Surgery for cartilage defects Difficult surgical problem No clear solution Many options but no magic bullet

79 Options Debridement Microfracture Autologous chondrocyte implantation ACI, MACI, allograft chondrocyte etc Mosaicplasty

80 Debridement Pro Quick and easy No significant rehab Minimal pain in short term Cheap Cons Long term degeneration almost guaranteed Ongoing pain likely

81 Microfracture Pros Relatively easy Cheap, A/S Good long term follow up with reasonable results Cons Significant rehab period Not good for large lesions Late failure rate now recognised

82 Chondrocyte implantation Pros: Better cartilage on testing?slightly better long term results than microfracture ep in big defects Cons Very expensive 2 operations Usually open Just been removed from MBS

83 Mosaciplasty Pros: One operation Normal cartilage Reasonable results Cons: Donor site morbidity Results inferior in series to other methods Open operation

84 Thanks for your attention Questions?