FIMS Ambassador Tour to Eastern Europe, 2004 Belgrade, Serbia Montenegro Acute Knee Injuries - Controversies and Challenges Professor KM Chan OBE, JP President of FIMS Belgrade ACL Athletic Career ACL Rupture - Warning Features Intensive pain Immediate swelling Locking Feel a Pop Dead leg Cannot continue to play 1
Acute Symptoms Acute Signs pain swelling on-set Effusion moderate moderate hours - days Haemarthrosis intense high tension a few hours Haemarthrosis MRI 75% of ACL Injuries X-Ray Clinical Examination Lachman Test Clinical Examination Anterior Drawer Test 2
Arthroscopic Assessment ACL Injury Delay in treatment Watch-dog ligament Symptomatic Instability Stability Pivoting Cutting Operative Treatment Mechanical Stability + Functional Stability + Meniscal Injuries + Osteoarthritis? Main Goals Restore ROM Muscle function Knee joint stability - No giving way Pre injury activity level Decrease risk for late sequelae 3
Graft Strength Tunnel Placement Site Stability Fixation Device Associated Pathologies Meniscus Articular Cartilage Minimal Invasive Surgery ACL Meniscus Tear Patellar Tendon Hamstring Tendon Quadriceps Tendon ACL Rehabilitation Early rehabilitation Full range of motion At least 90% normal strength and endurance Return to ADL Return to sports ACL Rehabilitation Accelerated Programme 4
Closed Chain CLOSED CHAIN HAMSTRING ( CO-CONTRACTION CONTRACTION ) Isokinetic Technology ACL Proprioceptive Training Return to Sports Meniscus tear 6-12 months after surgery No swelling and giving way No pain ROM 0-140 degrees of flexion Quadriceps strength > 85% Hamstrings strength > 90% 5
Meniscus tear History Twisting and/or flexion injury; possible associated ligament rupture Swelling may be sudden or occur over 24 hours Clinical Examination Exam Focal joint line tenderness Pain with compression/ rotation test Full range of motion, able to meet demands of sports McMurray test Bucket-Handle Tear of Lateral Meniscus MRI Arthroscopy Preserve the Meniscus Partial Menisectomy Meniscus Repair FIMS Team Physician Development Course 6
Patellar dislocation Meniscal Transplant Patellar dislocation History Sudden giving way sensation of kneecap going out of place May reduce spontaneously or remain locked in dislocated position Rapid, marked swelling Patellar dislocation Exam Patella may still be dislocated, usually laterally Exquisite tenderness medial to patella (retinaculum( retinaculum) Tender anterior lateral femoral condyle may indicate articular fracture Possible associated ACL tear will give positive Lachman Diagnostic Arthroscoscopy Patellar dislocation Treatment Early mobilization Possible arthroscopic surgery for treatment of articular fracture and/or medial repair 7
Patellar dislocation Return to action Full range of motion Normal muscle strength, especially medial quadriceps When athlete can meet demands of sport Medial Collateral Ligament Injury History Valgus force Minimal to significant swelling depending on degree Medial Collateral Ligament Injury Exam Local tenderness Valgus stress test indicates severity Medial Collateral Ligament Injury Treatment For isolated rupture, protected mobilization, weight-bearing as tolerated Return to action Pain free, full range of motion, at least 90% normal strength and endurance Posterior Cruciate Ligament Rupture PCL Rupture History Blow to proximal anterior tibia, usually with hyper extended or flexed knee Extent of injury often not apparent 8
PCL Rupture Exam Positive posterior sag test, positive posterior drawer Check for associated ligament/meniscus injury Posterior sag test PCL Rupture Treatment Individualized as to operative/ non-operative operative Return to action Full range of motion Strength & endurance to meet demands of sport Posterior drawer test Posterolateral Complex Injury Clinical Importance Often associated with Cruciate ligament injuries Often missed and may be a cause for failure of cruciate ligament reconstruction operation Loss of knee stability with possible dislocation of the knee & Neurovascular injuries 12-29% 29% associated with Peroneal nerve injuries How to make the diagnosis? 35% +ve in normal patient Reverse pivot shift test Normal amount extremely variable!!! External rotation recurvatum test Are those specific tests useful? Dial Test Difficult to quantify Increase varus laxity (Cooper DE; JBJSA 1991) Posterolateral drawer test 9
Radiological Features Radiological Features Avulsion # PCL attachment Widened lat. Joint space Posterior position of tibia relative to femur Arcuate # fibular head Avulsion of Gerdy tubercle / ITB Goals of Treatment Aim to restore anatomy to reduce abnormally high contact pressures and the chances of early OA Restore stability In acute injuries, surgical repair in 3/52 Direct repair ( ideal) In chronic injury (Difficult) Tissue advancement Tenodesis Tissue augmentation with autograft or allograft ( Correct any varus malalignment by proximal valgus tibial osteotomy before PLC reconstruction or simultaneously ) Patellar Tendinosis Patellar Tendinosis Ultrasound Patellar Tendinosis MRI 10
Patellar Tendinosis Anterior knee pain, non-acute Anterior knee pain, non-acute History Gradual onset of pain Single specific location, multiple locations, or diffuse Effusion suggests more serious problem Pre-disposing factor: previous injuries to any portion of the limb Anterior knee pain, non-acute Exam Determine specific locations of tenderness Patellar mobility Muscle flexibility and strength Anterior knee pain, non-acute Athlete Dialogue Treatment Make specific diagnoses where possible Generally, stretching and strengthening to correct deficits NSAIDS, RICE Return to action Full range of motion, no effusion, and able to meet demands of sport 11
Surgeon Coach & ATHLETE Rehabilitation Doctor & FIMS 75th Anniversary Trainer Therapist Scientist THANK YOU 12