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

2. Tuckahoe Orthopaedic Associates

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

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

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

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

8. Muscles
Quadriceps
Hamstrings
IT Band/Tract
Popliteus

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

11. Menisci
“Cartilage Tears”

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

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

14. Medial Meniscus

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

16. Lateral Meniscus

17. Meniscal Tears
Mechanism
Loaded Twist
Squatting

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

22. ACL
Anterior Cruciate Ligament
Prevents anterior translation
ADD MRI

23. Normal PCL and ACL

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

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

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

28. PCL Posterior Cruciate Ligament Behind ACL Much Larger
Less common injury

30. Normal PCL and ACL

31. PCL Hyperflexion Blow to anteromedial tibia (dashboard)
Associated injuries

32. PCL
Diagnosis
Posterior Drawer
MRI more important

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

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

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

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

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

41. Thank You

42. Treatment
Dr. Beach

43. Arthroscopy
Systematic
Standard Portals
Pump

44. Meniscus Zones Tear Types Biomechanics
Meniscectomy, Repair, Replacement

45. Bucket Handle Tear

46. Horizontal Tear

47. Radial Tear

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

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

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

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

52. ACL Rehab
Hinged Knee Brace
WBAT in full extension
Crutches

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

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

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

56. PCL Rehab
Much Longer
1 Year return to sports

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

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

59. Fulkerson
Anteromedialization
Complications