Updated ACL and MCL Injuries for Postgraduate Orthopaedic Course in Newcastle March 2015
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Transcript of Updated ACL and MCL Injuries for Postgraduate Orthopaedic Course in Newcastle March 2015
POSTGRAD ORTH Deiary Kader
ACL InjuriesFRCS(Tr&Orth) Revision Course
Professor Deiary Fraidoon KaderConsultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
Postgraduate OrthopaedicsFRCS(Tr&Orth) Revision Course
Newcastle Upon Tyne 16-21 March 2015
•
Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Nuffield Hospital Newcastle
NGMV Charity
POSTGRAD ORTH Deiary Kader
Classification of Knee Stabilisers
Lateral Complex
ITB
LCL
Popliteus
Biceps Femoris
Central Complex
ACLPCL
Med Menx
Lat Menx
Medial Complex
MCL
Postromedial Capsule
Semi-Memb
Pes anserinus
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Anatomy
33 mm long, 11 mm in diameter
Two bundles
AM bundle – tighten in flexion
PL bundle – tighten in extension
Supplied by middle geniculate artery
90% type I and 10% type III collagen
Anatomy (Weber brothers 1836)
(PL) bundle fibres tighten rapidly during the early extension <30º.
POSTGRAD ORTH Deiary Kader
ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the anterolateral ligament is a stabiliser of internal rotation
in >35º of flexion .Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh
The Biomechanical Function of the Anterolateral Ligament of the KneeAm. J. Sports Med. Jan 2015
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POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
Immunohistochemical analysis revealed some free nerve endings ( ) and ovoid
Ruffini corpuscles ( * ) are present.Curtesy of French Arthroscopic SocietyDr Sonnery Cottet
Free nerve endings
Ruffini corpuscles
Proprioception:
“Call for help” from ACL under stress to the surrounding muscles. The Hamstrings
Type II receptors (Ruffini and Pacini bodies
Anatomy: ACL MechanoreceptorsPOSTGRAD ORTH Deiary Kader
AnatomyProprioception:
knee proprioception returned to normal within
6 months of ACL reconstruction,
Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, et al. Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee. 2011;18:76–82.
Curtesy of Mr Panos Thomas
POSTGRAD ORTH Deiary Kader
Mechanism of injury
Low velocity, deceleration and pivotal injury, usually non-contact
High-energy RTA
Audible or feeling of “popping”
Acute haemarthrosis in young 1–2 h, less dramatic in older patient
20% of ACL injury associated with MCL injury
80% incidence of lateral meniscal injury with combined ACL–MCL
Valgus + ER
POP
POSTGRAD ORTH Deiary Kader
Causes of InjuryMechanisms of Injury:
1) “plant-and-cut” manoeuvre
2) Knee Hyperextension (Fall backwards)
3) Landing on one leg following a jump
(Olsen et al 2004)
POSTGRAD ORTH Deiary Kader
Clinical presentationChronic ACL Deficiency:1) “Subjective Instability”2) ‘Pain’3) Recurrent joint
effusion4) Locking5) Quadriceps Atrophy
POSTGRAD ORTH Deiary Kader
McDaniel – Rule of Thirds
One-third is able to compensate, and can pursue
normal recreational sports
One-third is able to compensate but will have to
reduce their sporting activities
One-third does poorly and develop instability with
simple activities daily living
Clinical Examination
Stability Testing:The Lachman test is the most
Sensitive test in Dx ACL tear
History:
- Noulis test (Georges Noulis Thesis in Paris, 1875)
- Ritchley test (1960)
- Ritchley-Lachman test (Torg et al 1976)
POSTGRAD ORTH Deiary Kader
Curtesy of Mr Panos Thomas
POSTGRAD ORTH Deiary Kader
Clinical ExaminationPositive Lachman test with a FIRM ENDPOINT
1. Partial ACL tear
2. Displaced bucket-handle meniscus tear
3. Intra-articular loose bodies
4. OA changes
LFC
PCL
ACL
“Lambda healing” AM bundle heals over PCL
(no subjective instability) (Zantop et al 2007)
An Empty wall sign
POSTGRAD ORTH Deiary Kader Curtesy of Mr Panos Thomas
Clinical ExaminationPivot Shift Sign:
Intact Iliotibial tract is required
Lachman tests anterior translation,
Pivot shift tests rotational stability
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POSTGRAD ORTH Deiary Kader
Paul F. Segond
a Paris surgeon
1879
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ACL Injury
Diagnosis
Physical Exam
Lachman
Pivot shift (confirmatory)
Plain Radiographs Segond Fracture (<5%)
Standing films for middle-aged athlete (Arthritis)
MRI
MRIAcute tear:1. Discontinuity ACL fibres (T1
weight)2. Signal irregularities in the
ACL course (T2 weight)3. Empty notch sign (coronal T1
weight)4. Changes of the ACL angle5. Partial ACL tear (T2 weight)Indirect signs:1. Buckling of PCL 2. Bone bruise (Lat femoral
condyle, lat tibial plateau)
POSTGRAD ORTH Deiary Kader
MRIChronic tear:1) Direct and indirect signs
of ACL tear2) Subchondral lesions3) Notch changes4) Evaluation of articular
cartilage lesions5) Loose bodies6) Evaluation of menisci7) Subchondral oedema8) Other soft tissue (PCL,
PLC)
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POSTGRAD ORTH Deiary Kader
ACL Evidence-Based Review
Factors affecting results:
Patient Selection
Tunnel placement
Strong graft choices
Solid fixation
Rational rehabilitation
Non-Operative Treatment Activity modification
(swimming, bicycling, jogging on flat ground)
Muscle Training (Hamstrings strength)
Proprioceptive Training
Bracing (reduce anterior drawer)
Surgical TreatmentIndications:1) Subjective instability (non-coper)2) ACL tear in children and
adolescents3) Multiligament injury4) Displaced meniscal tears5) Instability in OA (positive brace
test)?
Surgical Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972)
Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern
regarding its effectiveness in addressing anterior translation
Intra-articular reconstruction. Current best practice
Intra + Extra articular reconstruction
Intra-articular ACL Reconstruction
Techniques of femoral tunnel placement
A. Transtibial technique
B. Medial portal technique
Transtibial techniqueAdvantages:1) Simple technique2) No graft angulationDisadvantages:1) Little ability to adjust
femoral tunnel position2) Posterior placement of the
tibia tunnel3) Risk of tibia tunnel
enlargement4) Need for a notch plasty5) Irrigating fluid leak from the
tibia tunnel
Curtesy of Mr Panos Thomas
Medial portal techniqueAdvantages:1) Independent placement of the
femoral and tibia tunnels2) No fluid leakage from the tibia
tunnel3) Anatomic placement of the tibia
tunnel4) Ability to customise the tunnel
diameters5) Excellent for revision procedures
Disadvantages:1) Restricted vision in max flexion2) Learning curve
Curtesy of Mr Panos Thomas
Hamstring BTB
Grafts / Fixations
Quads
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Curtesy of Dr Sonnery Cottet
Hamstring tendonsAdvantages Disadvantages
1. Small incisions
2. Easy graft passage
3. High initial ultimate load (>4000 N, Woo et al, 1991)
4. Less risk of cyclops syndrome
5. Variable graft length
1. Exacerbation of medial instability
2. Prolonged osseointegration of the graft 8-12 weeks
3. Weakening of knee deepflexion (3-4 months)
4. Saphenous nerve injury
Bone-to-bone healing
Direct rigid fixation
Faster biological
integration in 6 weeks
PFJ Morbidity (Pinczewski)
Anterior knee pain 30%–50%
Patellar tendinosis 3%–5%
Fracture patella, rare
Patella baja
Development of late OA
Patellar tendon
Advantages Disadvantages
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Allograft
Biologically inactive
Slower incorporation
Less stability in 6 months
Risk of disease transmission
Role in revision surgery
Weaker after having been irradiated
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POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
In 1972, D. L. MacIntoshIn 1967,1975, M. Lemaire
Extra-articular reconstruction
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POSTGRAD ORTH Deiary Kader
ANTEROLATERAL LIGAMENT
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POSTGRAD ORTH Deiary Kader
Am J Sports Med. 2015 Jan 2.The Biomechanical Function of the
Anterolateral Ligament of the Knee.
Damage to the ALL of the knee could result in knee instability at high angles of flexion.
It is possible that a positive pivot-shift sign may be observed in some patients with an intact ACL but with damage to the
ALL.
This work may have implications for extra-articular reconstruction in patients with chronic anterolateral
instability.
POSTGRAD ORTH Deiary Kader
The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion. J Biomech 2011Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT, Garrett WE, DeFrate LE.
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POSTGRAD ORTH Deiary Kader POSTGRAD ORTH Deiary Kader
Anatomic Single bundle recon
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5mm +
Comparison of 2 femoral tunnel locations in anatomic single-bundle anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy 2012;
Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR
Centre AM Bundle vs centre of femoral foot print
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Single or Double bundle technique?
Anatomical Single-Bundle Technique Double-Bundle Technique
Advantages:
1) Simplicity
2) Broad spectrum of grafts
3) Simpler graft passage
4) Lower cost
Disadvantages:
1) Inadequate rotational stability
Advantages:
1) ?Better rotational stability
2) Allowance for individual variables
Disadvantages:
1) Anatomic or not? (Numerous double bundle techniques)
2) Technically demanding
3) Longer operating time
4) Limited graft selection
Cochrane Database Rev. 2012 Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults
There is insufficient evidence to determine the relative effectiveness of double-bundle and single-bundle reconstruction for anterior cruciate ligament rupture in adults, although there is limited evidence that double-bundle ACL reconstruction has some superior results in objective measurements of knee stability and protection against repeat ACL rupture or a new meniscal injury.
Curtesy of Dr Sonnery Cottet
45°, Curve, QuickPass Lassos
POSTGRAD ORTH Deiary Kader
Curtesy of Dr Sonnery Cottet
HIDDEN LESION and Ramp tear
POSTGRAD ORTH Deiary Kader
Curtesy of Dr Sonnery Cottet
ACLR Clinical Questions?? Evidence
What is the risk of infection after ACLR 0.8% (LOE1)
Menx Repair Not on tech 94% success
What are the risk of ACLR graft failure at
2 years
3% (LOE1)
What are the risk of ACL tear in the
normal contra lateral knee at 2 years
3-6%
What is the risk of future OA
(radiographic) after ACL tear/ACLR?
Isolated ACL tear:0-13%
ACL+Menx tear: 21-48%
(LOE2)
POSTGRAD ORTH Deiary Kader
ACLR Clinical Questions Evidence
What is the best graft autograft or
allograft
No difference from meta-analysis but does
not address the young active or elite
athlete (LOE3)
Bioabsorbable or metal Screws No difference
Only knee effusion is higher in Bio!
(LOE1)
What is the best Autograft choice HG or
PTB
No difference (LOE1)
Should I use a brace after ACLR? No Evidence in isolated ACLR (LOE1)
POSTGRAD ORTH Deiary Kader
What are the complications after ACL
reconstruction?
POSTGRAD ORTH Deiary Kader
Complications
Infection
DVT and PE
Osteoarthritis
Cyclops lesion residual tissue anterior to the ACL
blocks extension
POSTGRAD ORTH Deiary Kader
Complications
Failure of Fixation
Anterior placement of the femoral tunnel limits
flexion
Anterior placement of the tibial tunnel limits
extension
Flexion contracture and arthrofibrosis
Graft rupture from impingement
Tibial Eminence Fracture
Meyers and McKeever classification (1959)
Type I: non displaced
Type II: partially displaced or hinged
Type III: completely displaced (Type III)
Type IIIA (Zifko) involves the ACL insertion only
Type IIIB (Zifko) includes the entire intercondylar eminence.
Type IV (Zaricznyj 1977): comminution of the fracture fragment.
Treatment
Casting in extension for type I
Open reduction and internal fixation.
Arthroscopic reduction and fixation
Rarely ACL reconstruction is necessary
Postgraduate OrthopaedicsFRCS(Tr&Orth) Revision Course
Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
MCL
Medial Collateral Ligament Injury
Incidence >> LCL Injury
Mechanism of injury
Direct blow laterally, valgus stress, forced external rotation
POSTGRAD ORTH Deiary Kader
Medial Collateral Ligament Exam
Opening @ 30o only Isolated MCL Injury
Opening @ 0o
Injury to Posteromedial Capsule
Usually with ACL +/or PCL injury
25-30° of flexion, the MCL
provides 80% of the support
to valgus stress
POSTGRAD ORTH Deiary Kader
Classification
I Localised tenderness, no instability, or laxity on testing
II localised swelling, possibly mild laxity, no instability
III definite clinical laxity ..Instability symptom . (80% MLI)
< 5 mm, 5-10 mm, > 10 mm
MCL
MCL
MCL4 mm proximal
4 mm posterior to the medial epicondyle
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
MCL tear arising from the tibial insertion May lead to
STENER type lesion
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TreatmentAcute isolated MCL tear
I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks
II Hinged brace for symptom improves, WBAA, 1-2weeks
III Hinged brace 30-90/ Surgical 3-4 wks
Operative treatment depend on site and patient
Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch
therefore needs Augmentation with semitendinosis
Combined injury ACL and MCL→Reconstruction ACL and non-operative
treatment MCL I-II but surgical for III
MCL
MCL Reconstruction with AT
+
Revision ACLR
Chronic MCL Injury
POSTGRAD ORTH Deiary Kader
THANK YOU