Management of Ligament and Meniscal Injuries in Tibia Plateau Fractures Sohrab Keyhani (Ass. Prof. SBUMS , Knee surgeon) Presentation: Mehran Soleymanha (Ass. Prof. GUMS , Knee surgery fellowship, SBUMS, Akhtar Hospital) P.O.T.A Conference 2016. April. 15

Things to consider in plateau tibial fracture Articular depression Plateau widening Articular anatomic fixation Articular support and void Metaphyseal fixation Soft tissue injury Garner MJ. 2013

Incidence of soft tissue injuries Direct vision Ligament injury ……………… 27 % Meniscal injury ………………. 35 % Arthroscopy ACL injury ………… 25 % PCL injury …………. 5% MCL injury ………… 3% LCL injury …………. 3 % Delamarter R. 2005 Abdel-Hamid MZ. Arthroscopy. 2006

Incidence of soft tissue injuries MRI ligaments injury …………….…..… 77 % lateral meniscus tears ………..……. 91 % medial meniscus tears .…………….. 44 % Garner MJ. Journal of Orthopaedic Trauma. 2005 ACL injury …………….……....… 57 % PCL ……………….………..……. 28 % Complete LCL tears .…………….. 9 % Complete MCL tears .…………….. 12 % Mustonen AO. AJR AM J Roentgenol. 2008

Meniscus When you should think about in meniscus injury ? Joint line depression > 5 mm Joint widening > 6 mm Schatzker fracture I , II , III , IV posterior meniscus observation is often difficult by open arthrotomy and arthroscopy is necessary for better vision

Meniscal Injury meniscus injury incidence has been reported in the MRI analysis ……. 45-90 % Serious injury required to repair ……………………………………..... 35-40 %

Meniscal Injury lateral meniscus > medial meniscus post > ant Peripheral > central longitudinal > radial > root avulsion (ant & post)

Meniscal Injury It seams : untreated associated meniscus injury causes inferior outcome in long-term follow-up Repair of meniscal lesions during the primary surgery Repair peripheral longitudinal tear partial meniscectomy of complex irreparable tears radial tear and root avulsion should be fixed (if untreated is equal to total meniscotomy) King , et al. knee surgery sports traumatology arthroscopy. 2015

Ligament Injury avulsion fracture Ligament injury Delamarter R. Clinical Orthopeadic & Related Research. 1990

Ligament Injury Incidence : LCL , MCL < PCL < ACL Arthroscopy 3 % 5 % <25 % MRI 10 % 28 % 57 % When to consider ? High energy ( Schatzker V , VI ) complex fracture Coincidence with anterolateral avulsion Coincidence with anteromedial avulsion

Approach to avulsion fracture ACL avulsion PCL avulsion Stahl D. J Orthop Trauma. 2015

Approach to avulsion fracture MCL avulsion Stener’s like lesion LCL avulsion

Approach to avulsion fracture Anterolateral ligament avulsion Mechanism of injury : Varus flexion internal rotation It causes anterolateral instability

Ligament avulsion tibial tubercle avulsion gerdy's tubercle avulsion

midsubstance ligament injury Diagnosis MRI Arthroscopy Post fixation exam After adequate fixation in sagittal and coronal plane you should check stability and alignment ACL lachman test PCL posterior drawer test MCL & LCL varus and valgus stress test in 20 ̊flexion Be careful Joint depression Malreduction and translation displacement { can cause instability }

Treatment MCL ……………………… conservative treatment with Hinged knee brace LCL & PLC …………….. consider limb alignment ACL …………………..…... reconstruction (if needed) PCL ……………………..... reconstruction (consider fixed post subluxation)* Soft tissue treatment is based on : Age Fracture pattern Patient demand instability Strobel. American Journal of Sport Medicine. 2002

Take home massage Think about soft tissue injury Avulsion fracture fixation Arthroscopic evaluation Meniscus preservation Post- fixation physical exam and stress view Delayed reconstruction ( if needed )

Thank you