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Young Adult Knee Injuries
Mr Hersh Deo MB BS, MRCS, MSc., FRCS(Tr&Orth) Consultant Orthopaedic Surgeon James Paget University Hospital NHS Foundation Trust & The Spire Norwich Hospital
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The knee is the most commonly injured joint in the high risk sports of football and rugby.1
Acute knee injury is the commonest cause of permanent disability after a sports injury.2 1.Bollen S. Injuries of the sporting knee. Br J Sports Med2000;34:227–8. 2.Kujala UM, Taimela S, Antti-poika I, et al. Acute injuries in soccer, ice hockey, volleyball, basket ball, judo and karate: an analysis of national registry data. BMJ1995;311:1465–73
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Range of injuries Traumatic synovitis Meniscal tears ACL rupture
Patella dislocation OCD Collaterals PCL PLC Combined injuries
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History Contact - Valgus force (rugby tackle from the side) – terrible triad…
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History Non contact - Twisting with foot planted, cutting, jumping, sudden deceleration
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History Exact mechanism of injury Rip / tear?
Immediate / delayed swelling Since the injury Swelling Pain Giving way (instability – when?) Locking
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Examination Effusion Look Patellar stability
Joint line tenderness / crouch Feel ROM Move Collaterals ACL Pivot shift Special tests Lachman’s Anterior drawer
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Investigations Plain radiographs – 3 views CT – exclude #
MRI – soft tissues
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Common knee injuries Meniscal tears – excise or repair
OCD – Chondroplasty, microfracture, chondral transplant ACL rupture – conservative or reconstruct (arthroscopic anatomic 4 strand hamstring) Patella dislocation – conservative / surgery if recurrent
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Acute Management Analgesia Brace Crutches TWB + RICE
Refer to knee clinic
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Meniscal Tears
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Meniscal Tears Localised pain, effusion, giving way, locking(BHT)
Tender joint line, unable to squat MRI Arthroscopic debridement or repair
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Meniscal tear
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Arthroscopic Meniscal Repair
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Lateral meniscal repair
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Lateral meniscal repair
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Meniscal Repair 85% successful repair Age of patient
Tear <6 weeks old Prevents OA (lateral > medial)
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ACL Tear Twisting on planted foot, “pop or rip”, rotational instability Effusion, +ve Lachman, ADT & PST +ve MRI Physio or Reconstruction
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Trans-Tibial v Anatomic ACLR
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Trans-Tibial v Anatomic ACLR
Trans-tibial versus antero-medial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Bedi A et al. Arthroscopy Mar;27(3): The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in improvement in control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction
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Vertical v anatomic graft placement
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ACL Reconstruction 4 strand hamstring v BPTB autograft
Anatomic tunnel placement Arthroscopic Back to sport 9-12 months
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ACL rupture
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Notch clearance
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Anatomic placement of femoral tunnel
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Hamstring harvest and prep
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Femoral tunnel reaming
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Tibial tunnel placement
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Graft passage
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Tibial fixation
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Recurrent Patella Instability
Recurrently subluxing or dislocating patella which affects quality of life Positive apprehension test Skyline view and MRI Physio (VMO) MPFL reconstruction
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MPFL Reconstruction 91% good to excellent results at 5 years
Steiner TM, AJSM 2006;34:1254 Drez D, Arthroscopy 2001;17:298 95% return to previous level of sporting activity
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MPFL Reconstruction
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Osteochondral Lesions
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What’s the problem? 60% of knees we scope have an articular cartilage lesion Microfracture is very commonly performed Success depends on many factors Patient selection Post op rehab
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Microfracture – patient selection
Focal, full-thickness chondral defects with surrounding rim of cartilage Size of lesion Age Femoral condyle
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How does micro# work? – “stem cell therapy”
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Microfracture
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Microfracture “Microfracture success depends not only on the operation but rehabilitation as well…we felt that the rehabilitation program was equally as important as the surgical procedure,” J. Richard Steadman, MD
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Microfracture - rehab 8 weeks partial weight bearing
If a CPM machine is not used, the patient begins passive flexion/extension (straightening and bending) of the knee with 500 repetitions three times a day. Patients must not resume sports that involve pivoting, cutting, and jumping for 4 to 6 months after a microfracture procedure. Steadman
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Prognosis Micro-fracture is only about 70% successful long-term
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What’s the answer for the remaining 30%?
Cartilage regeneration procedures
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Cartilage Regeneration
ACI / MACI – too expensive, only used in large centres RNOH Artificial (bovine collagen) scaffolds – no evidence Mosaicplasty (small plugs) – again only 60-70% success
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Osteochochondral Transplant
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Osteochondral Transplant
Useful after failed microfracture Excellent mid to long-term results Rehab as for micro-fracture
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Very large OCD
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Double COR
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Partial Knee Replacement
Used in isolated knee OA Medial , lateral or PFJ Excellent for maintaining patients function and proprioception Back to sport 3-6 months
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PFJR
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Summary Recent advances
Meniscal repair Anatomic ACLR MPFL reconstruction Osteochondral transplant Partial knee replacement (Medial / lateral UKR, PFJR)
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Any questions? www.yarmouthkneeandhipsurgeon.co.uk
Thank you Any questions?
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