Joel Gonzales, M. D. William Beach, M. D. The Injured Knee Joel Gonzales, M. D. William Beach, M. D. Tuckahoe Orthopaedic Associates Richmond, Virginia

Tuckahoe Orthopaedic Associates

Philosophy Treat like an athlete Prompt and correct diagnosis Formulate treatment plan Rapid, safe return to work Tuckahoe Orthopaedic Associates

Injured Knee Anatomy Assessment Specific Injuries Treatment History and Physical Xrays and MRI Specific Injuries Treatment Rehabilitation Tuckahoe Orthopaedic Associates

Anatomy Not a hinge joint 6 degrees of freedom Flexion/Extension Rotation Translation

Anatomy Three Compartments Proximal Tib/Fib Joint Has not fully adapted

Muscles Quadriceps Hamstrings IT Band/Tract Popliteus

Important Structures Medial and Lateral Meniscus Anterior Cruciate Ligament (ACL) Posterior Cruciate Ligament (PCL) Collateral Ligaments (MCL and LCL)

Menisci “Cartilage Tears”

Role of Menisci Biomechanics “Shock Absorbers” Load Transmission 50% in extension, 85% in 90 flexion Partial Meniscectomy (15-34%) increases contact pressure 350% !

Medial Meniscus Inner aspect Ring like More commonly torn - less mobile Attached at horns and periphery

Medial Meniscus

Lateral Meniscus Outer aspect More discoid More difficult to repair Worse prognosis

Lateral Meniscus

Meniscal Tears Mechanism Loaded Twist Squatting

Meniscal Tears Acute pain and locked knee Bucket Handle tear Pain and gradual swelling Feeling of “tightness” Catching

ACL Anterior Cruciate Ligament Prevents anterior translation ADD MRI

Normal PCL and ACL

ACL Mechanism Hyperextension Non Contact Immediate Swelling (95% ACL) Bloody Effusion

ACL “Trick Knee” Giving Way Associated Injuries Menisci and collaterals

ACL Diagnosis History and Physical Positive Lachman test MRI to evaluate menisci or if unsure after physical exam

PCL Posterior Cruciate Ligament Behind ACL Much Larger Less common injury

Normal PCL and ACL

PCL Hyperflexion Blow to anteromedial tibia (dashboard) Associated injuries

PCL Diagnosis Posterior Drawer MRI more important

Posterolateral Corner Popliteus Arcuate Complex LCL/fibular collateral Lateral Head of Gastrocnemius Restraint to ER at 30 degrees

Posterolateral Corner Usually Associated with ACL or PCL Commonly Missed Failed ACL or PCL reconstruction

Collaterals MCL 2 components Deep portion intimate with MM LCL Varus/Valgus at 30 degrees

Collateral Ligaments Medial Collateral Lateral Collateral Prevent side to side motion with knee at 30 degrees

Collaterals Varus or Valgus stress Little Swelling May mimic meniscal tear Pain along ligament MCL Injury fairly common

Thank You

Treatment Dr. Beach

Arthroscopy Systematic Standard Portals Pump

Meniscus Zones Tear Types Biomechanics Meniscectomy, Repair, Replacement

Bucket Handle Tear

Horizontal Tear

Radial Tear

Meniscus Repair Inside-out, Outside-in, All-inside Fibrin Clot Arrows, Darts, Screws Heal faster with ACL

Meniscus Rehab Meniscectomy: none Repair: WBAT in full extension 6 weeks

Meniscal Allograft Patients with early disease (Grade I-II) Technically challenging Expensive Patients must undergo change in lifestyle

ACL Why fix it? (meniscus and djd, lifestyle) Endoscopic one incision Allo or autograft Hamstrings, Achilles, BTB, Fascia Lata Return to sports 6 months

ACL Rehab Hinged Knee Brace WBAT in full extension Crutches

ACL Cycling Stairmaster Straight ahead Jogging Return to cutting sports 6-9 months (Jerry Rice 3 months = Patella Fracture)

PCL Dashboard Injury Blow to anteromedial tibia Hyperflexion Usually combined with PL corner

PCL Many techniques (2 bundle femur) Indications - symptoms of functional instability Does not always need to be fixed

PCL Rehab Much Longer 1 Year return to sports

Chondral Defects Chondroplasty Microfracture (Steadman) Osteochondral Transplant (Hair plugs) Carticel

Extensor Realignment Very Controversial Lateral Release Proximal Imbrication (Insall) Maquet Elmslie-Trillat Hauser Roux-Goldthwait Fulkerson

Fulkerson Anteromedialization Complications