Treatment of knee DX

• Initial management

- Vascular inj - Open DX - Irreducible DX - Compartment syn

Vascular Injury• Palpable pulses alone do not rule out a significant

vascular inj • Screening for all knee DX (documented &

suspected ) recommended

• ABI > 0.9 means 100% negative predictive value for major Vascular inj

• ABI < 0.9 means more screening (CT angiogram)

Treatment

• Operative • Conservative

-superiority of Operative to conservative TX (ROM, functional outcome, stability, return to sport & work ) 32 studies after 2000 peskun et al;

Conservative treatment

• Indications

- Comorbidity (head inj-soft tissue problem )

- Old patient (osteoporosis- DJD )

- Skeletally immature patients

Conservative treatment

• Reduction

• Immobilization 3-6 wk in full Ext ( cast, splint or Ext Fix ; if can not maintain reduction)

• Rehabilitation

Operative treatment • Early (1-3 wk ) ( repair & augmentation ) -Avulsion FX -Stener lesion -Flipped or displased meniscal tear preventing ROM

• Delayed ( more than 3 wk ) ( reconstruction )

Operative treatment

• Stress x-ray under fluoroscopic imaging

- side to side diference ; Lat > 2.7 mm = isolated FCL > 4 mm = FCL, PLC

; Med > 4 mm =isolated MCL > 10 mm = MCL; PMC

• Arthroscopy for all patient ( meniscal,chondral, loose body )

• Tourniquet is applied but rarely inflated

Operative treatment (KD classification)

• KD 2 ( ACL - PCL without Med & Lat )

- delayed OP ( 6-8 wk after inj )

Operative treatment (KD classification)

• KD 3 M (distal tear ) ( stener lesion )

- early op ( MCL repair- ACL & PCL recons )

MCL repair (prox on Tib by anchor in full Ext & dist on Tib by screw –washer in 30 deg Flex )

Operative treatment (KD classification)

• KD 3 M ( MCL mid substance )

- repair is not effective

-delayed ( 6-8 wk ) ACL-PCL –MCL recons

Operative treatment (KD classification)

• KD 3 M ( prox )

- hinge knee brace ( 6-8 wk ) then ;

If – Med stable ; ACL- PCL recons

If – Med lax ; ACL-PCL –MCL recons

Operative treatment (KD classification)

• KD 3 M ( very extensive )

- stage 1 ( Med repair & augmentation with allograft )

- stage 2 (delayed (6-8 wk ) ACL- PCL recons )

Operative treatment (KD classification)

• KD 3 L (avulsion of fibular head )

-early fixation of avulsion & ACL- PCL recons - if quality of tissue or repair is not good go to augmentation

Operative treatment (KD classification)

• KD3 L ( mid substance & prox )

- delayed ACL-PCL –Lat recons

Operative treatment (KD classification)

• KD 4 ( global instability )

- if Med or Lat are reparable - stage 1 ; early repair of Med & Lat - stage 2 ; delyed ACL-PCL recons

-if Med or Lat are not reparable - delayed all Lig recons

FX-DX • As a general rule

-stage 1 ; FX fixation and after bone healing - stage 2 ; delayed Lig recons