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Acute Knee InjuriesAcute Knee Injuries-- Controversies and Controversies and

ChallengesChallenges

Professor KM Chan OBE, JP President of FIMS

FIMS Ambassador Tour to Eastern Europe, 2004Belgrade, Serbia Montenegro

Belgrade

ACL ACL Athletic Career

ACL Rupture ACL Rupture -- Warning FeaturesWarning Features

• Intensive pain

• Immediate swelling

• Locking

• Feel a “Pop”

• “Dead” leg

• Cannot continue to play

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Acute SymptomsAcute Symptoms

Acute SignsEffusion Haemarthrosis

painswellingon-set

moderatemoderatehours - days

intensehigh tensiona few hours

75% of ACL 75% of ACL InjuriesInjuries

Haemarthrosis

X-Ray

MRI

Lachman Test

Clinical ExaminationAnterior Drawer Test

Clinical Examination

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Arthroscopic AssessmentArthroscopic Assessment ACL Injury – Delay in treatment

Symptomatic Instability

Watch-dog ligament

Stability

Pivoting Cutting

Mechanical Stability +

Functional Stability +

Meniscal Injuries +

Osteoarthritis ?

Operative TreatmentOperative Treatment

• Restore ROM

• Muscle function

• Knee joint stability - No giving way

• Pre injury activity level

• Decrease risk for late sequelae

Main GoalsMain Goals

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Graft StrengthGraft StrengthTunnel PlacementTunnel Placement

SiteSiteStabilityStability

Fixation DeviceFixation DeviceAssociated PathologiesAssociated Pathologies

MeniscusMeniscusArticularArticular CartilageCartilage

Minimal Invasive Surgery

Patellar Tendon

Hamstring Tendon

Quadriceps Tendon

ACL Meniscus Tear

ACL RehabilitationEarly rehabilitationEarly rehabilitation•• Full range of motionFull range of motion•• At least 90% normal strength At least 90% normal strength

and enduranceand endurance•• Return to ADLReturn to ADL•• Return to sportsReturn to sports

ACL ACL RehabilitationRehabilitation

Accelerated ProgrammeAccelerated Programme

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Closed Chain

HAMSTRINGHAMSTRINGHAMSTRING

CLOSED CHAINCLOSED CHAIN

( ( COCO--CONTRACTION )CONTRACTION )

IsokineticTechnology

ACL ACL ProprioceptiveProprioceptiveTrainingTraining

6 6 -- 12 months after surgery12 months after surgeryNo swelling and giving wayNo swelling and giving wayNo painNo painROM 0 ROM 0 -- 140 degrees of 140 degrees of flexionflexionQuadriceps strength > 85% Quadriceps strength > 85% Hamstrings strength > 90%Hamstrings strength > 90%

Return to Sports Meniscus tearMeniscus tear

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Meniscus tearMeniscus tear• History

• Twisting and/or flexion injury; possible associated ligament rupture

• Swelling may be sudden or occur over 24 hours

• Exam• Focal joint line

tenderness• Pain with

compression/rotation test

• Full range of motion, able to meet demands of sports

Clinical Examination

McMurray test

Arthroscopy

Bucket-Handle Tear of Lateral Meniscus

MRI

• MeniscusRepair

Preserve the MeniscusPreserve the Meniscus

FIMS Team Physician Development Course

Partial Menisectomy

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Meniscal Transplant

Patellar dislocation

Patellar dislocationPatellar dislocation• History

• Sudden giving way sensation of kneecap going out of place

• May reduce spontaneously or remain locked in dislocated position

• Rapid, marked swelling

ExamExam•• Patella may still be dislocated, Patella may still be dislocated,

usually laterallyusually laterally•• Exquisite tenderness medial to Exquisite tenderness medial to

patella (patella (retinaculumretinaculum))•• Tender anterior lateral Tender anterior lateral

femoral femoral condylecondyle may may indicate indicate articulararticular fracturefracture

•• Possible associated ACL tear will Possible associated ACL tear will give positive give positive LachmanLachman

Patellar dislocationPatellar dislocation

Diagnostic Diagnostic ArthroscoscopyArthroscoscopy

TreatmentTreatment•• Early mobilizationEarly mobilization•• Possible arthroscopic surgery Possible arthroscopic surgery

for treatment of for treatment of articulararticularfracture and/or medial repairfracture and/or medial repair

Patellar dislocationPatellar dislocation

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Patellar dislocationPatellar dislocationReturn to actionReturn to action•• Full range of motionFull range of motion•• Normal muscle strength, Normal muscle strength,

especially medial quadricepsespecially medial quadriceps•• When athlete can meet demands When athlete can meet demands

of sportof sport

Medial Collateral Ligament Medial Collateral Ligament InjuryInjuryHistoryHistory•• ValgusValgus forceforce•• Minimal to significant swelling depending Minimal to significant swelling depending

on degreeon degree

•Exam• Local tenderness• Valgus stress test indicates severity

Medial Collateral Ligament Injury

TreatmentTreatment•• For isolated rupture, protected For isolated rupture, protected

mobilization, weightmobilization, weight--bearing as bearing as toleratedtolerated

Return to actionReturn to action•• Pain free, full range of motion, Pain free, full range of motion,

at least 90% normal strength at least 90% normal strength and enduranceand endurance

Medial Collateral Ligament Injury

Posterior Posterior CruciateCruciate Ligament Ligament RuptureRupture

HistoryHistory•• Blow to proximal Blow to proximal

anterior tibia, usually anterior tibia, usually with hyper extended with hyper extended or flexed kneeor flexed knee

•• Extent of injury often Extent of injury often not apparentnot apparent

PCL Rupture

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Posterior drawer test

Posterior sag test

• Exam• Positive posterior sag test, positive

posterior drawer• Check for associated ligament/meniscus

injury

PCL Rupture PCL RuptureTreatmentTreatment•• Individualized as to operative/Individualized as to operative/

nonnon--operativeoperativeReturn to actionReturn to action•• Full range of motionFull range of motion•• Strength & endurance Strength & endurance

to meet demands of to meet demands of sportsport

Posterolateral Complex Injury Clinical ImportanceClinical Importance

Often associated with Often associated with CruciateCruciateligament injuriesligament injuriesOften missedOften missed and may be a cause for and may be a cause for failure of failure of cruciatecruciate ligament ligament reconstruction operationreconstruction operationLoss of knee stability with possible Loss of knee stability with possible dislocation of the knee & dislocation of the knee & Neurovascular injuriesNeurovascular injuries1212--29% associated with29% associated with PeronealPeronealnerve injuriesnerve injuries

How to make the How to make the diagnosis ?diagnosis ?

Are those specific Are those specific tests useful ?tests useful ?

External rotation recurvatum test

Posterolateraldrawer test

Reverse pivot shift test

Increase varus laxity

Dial Test

35% +ve in normal patient

Normal amountextremely variable !!!

Difficult to quantify

(Cooper DE; JBJSA 1991)

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Radiological Features Radiological Features

Avulsion # PCL Avulsion # PCL attachmentattachmentWidened lat. Joint Widened lat. Joint spacespacePosterior position of Posterior position of tibia relative to femurtibia relative to femurArcuateArcuate # fibular head# fibular headAvulsion of Avulsion of GerdyGerdytubercle / ITBtubercle / ITB

Goals of TreatmentGoals of TreatmentAim to restore anatomy to reduce abnormally Aim to restore anatomy to reduce abnormally high contact pressures and the chances of high contact pressures and the chances of early OAearly OARestore stabilityRestore stabilityIn acute injuries, surgical repair in 3/52In acute injuries, surgical repair in 3/52•• Direct repair ( ideal)Direct repair ( ideal)

In chronic injury (Difficult)In chronic injury (Difficult)•• Tissue advancement Tissue advancement •• TenodesisTenodesis

Tissue augmentation with Tissue augmentation with autograftautograft or or allograftallograft

(( Correct any Correct any varusvarus malalignmentmalalignment by by proximal proximal valgusvalgus tibialtibial osteotomyosteotomy before PLC before PLC reconstruction or simultaneously )reconstruction or simultaneously )

Patellar Tendinosis

UltrasoundUltrasound

Patellar TendinosisMRIMRI

Patellar Tendinosis

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Patellar Tendinosis Anterior knee pain, non-acute

Anterior knee pain, nonAnterior knee pain, non--acuteacuteHistoryHistory•• Gradual onset of painGradual onset of pain•• Single specific location, Single specific location,

multiple locations, or multiple locations, or diffusediffuse

•• Effusion suggests more Effusion suggests more serious problemserious problem

•• PrePre--disposing factor: disposing factor: previous injuries to any previous injuries to any portion of the limb portion of the limb

ExamExam•• Determine specific locations of Determine specific locations of

tendernesstenderness•• Patellar mobilityPatellar mobility•• Muscle flexibility and strengthMuscle flexibility and strength

Anterior knee pain, nonAnterior knee pain, non--acuteacute

TreatmentTreatment•• Make specific diagnoses where possibleMake specific diagnoses where possible•• Generally, stretching and strengthening Generally, stretching and strengthening

to correct deficitsto correct deficits•• NSAIDS, RICENSAIDS, RICEReturn to actionReturn to action•• Full range of motion, no effusion, and Full range of motion, no effusion, and

able to meet demands of sportable to meet demands of sport

Anterior knee pain, nonAnterior knee pain, non--acuteacute Athlete DialogueAthlete DialogueAthlete Dialogue

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ATHLETEATHLETEATHLETECoach

&

Trainer

Rehabilitation

Doctor &

Therapist

Scientist

Surgeon

FIMS 75th AnniversaryFIMS 75th Anniversary

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