knee sports for postgrad orth course 2017
TRANSCRIPT
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POSTGRAD ORTH Deiary Kader
SPORTS INJURIES/ KNEE
FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader Knee Surgeon
South West London Elective Orthopaedic Centre Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University ICRC Specialist Surgeon (Geneva)
Research/Training War Trauma Elective
Postgraduate Orthopaedics
CHARITY
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POSTGRAD ORTH Deiary Kader
PLAN1. MENISCUS
2. ACL
3. MCL
4. PCL
5. PLC
6. MULTI LEGAMENT
7. PFJ
CLINICALS ?
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POSTGRAD ORTH Deiary Kader
Nerve Supply-KneeTibial Nerve Medial and Middle GB Common Peroneal N Lateral & Recurrent GB Obturator N - GB
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POSTGRAD ORTH Deiary Kader
BLOOD SUPPLY- KNEEFemoral Popiteal A
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POSTGRAD ORTH Deiary Kader
MENISCAL RESECTION & REPAIR
Fibro-cartilaginous Type I collagen
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POSTGRADORTH Deiary Kader
➢ Lateral Meniscus
–Circular
–Close insertions
–Posterior = Anterior width
–Loosely attached to capsule
➢ Medial Meniscus
– Semicircular
–Wider Posterior
–Firmly attached to capsule
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POSTGRADORTH Deiary Kader
Composed of 70% water - 30% organic matter (Collagen constitutes 75%)
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Radial Fibres, serving as “ties” that resist shearing or splitting.
Circumferential Fibres run parallel to resist hoop stress during weight bearing.
8
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POSTGRAD ORTH Deiary Kader
Compression to radial to be contained by the Menx
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Meniscus Vascular Supply
Red
Red-White White
At 10 years of age
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What is the function of the Meniscus?
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Meniscal FunctionLoad /transmission/ distribution
50% in extension
90% in flexion
Post.Horn in >90º flexion
Lateral > Medial
Joint stability
Congruity
Lubrication/ Nutrition
Proprioception
Increase contact area and reduce contact stresses
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POSTGRAD ORTH Deiary Kader
Meniscal Tear Management :-
Excision 60% of people over 65yrs have incidental tears
Repair
Transplant
Replacement
Traumatic tears & Degenerative tears
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POSTGRAD ORTH Deiary Kader
Arthroscopy Papers1- N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. Sihvonen R 2- CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. Khan M
3-BMC Musculoskelet Disord. 2013 Feb 25;14:71. doi: 10.1186/1471-2474-14-71. Arthroscopic partial meniscectomy in middle-aged patients with mild or no knee osteoarthritis: a protocol for a double-blind, randomized sham-controlled multi-centre trial. Hare KB
4-Am J Sports Med. 2013 Jul;41(7):1565-70. doi: 10.1177/0363546513488518. Epub 2013 May 23. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus.Yim JH
5-Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):358-64. doi: 10.1007/s00167-012-1960-3. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Herrlin SV
6- N Engl J Med 2002; 347:81-88July 11, 2002DOI: 10.1056/NEJMoa013259 A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. J. Bruce Moseley
7- Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms, BMJ 2015; 350 doi: JB Thorlund
Moseley 2002 & Thorlund 2015
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Repair
Excise
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POSTGRAD ORTH Deiary Kader
Horizontal cleavage tear
Pisani’s sign
The cyst size decrease
with knee flexion
knee flexed <45º
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
DD - Cyst • Ganglia: superficial, not as hard and unconnected to the joint
• Calcified deposits in the collateral ligament: show on radiographs
• Prolapsed torn meniscus (pseudocyst)
• Sebaceous cyst
• Bursitis
• Various tumours: sarcoma, lipoma, fibroma and histiocytoma
• PVNS
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POSTGRAD ORTH Deiary Kader
Snapping knee in deep
flexion
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POSTGRAD ORTH Deiary Kader
Snapping knee in deep flexion
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POSTGRADORTH Deiary Kader
Meniscal repairWhen would you repair a menx
Factors to consider
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POSTGRADORTH Deiary Kader
Meniscal repairFactors to consider:
1. Patient
2. Chronicity
3. Type
4. Location
5. Tissue quality
6. Stability of knee
7. Axial alignment
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POSTGRADORTH Deiary Kader
Meniscal repair Techniques
1. Inside-out vertical mattress suture (gold standard)
2. Outside-in
3. All-inside
4. Overall 75-90% success
5. New research
1. Better devices
2. Biologic healing/augmentation
3. Growth factors/Stem cell therapy
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POSTGRADORTH Deiary Kader
Partial Meniscal Substitutes Engineered constructs
Polyurethane polymeric implant (Actifit®)
Synthetic Scaffold
Collagen Meniscus Implant (CMI®)
Collagen(CMI®)
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POSTGRADORTH Deiary Kader
Collagen Menx implant
Rodkey et al
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POSTGRADORTH Deiary Kader
hydrogels knee
?
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POSTGRADORTH Deiary Kader
Total meniscal prosthesis
NUsurface
Synthetic implant
meniscus-like
Prof Zorzi from Verona
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POSTGRADORTH Deiary Kader
Menx Allograft IndicationsSymptomatic
Neutral alignment
Normal stability
No more than grade II-III Cartilage damage
Understand the risk of disease transmission
No knee abuser and
Not in BMI >35
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Prof Deiary Kader
Traumatic Chondral Damage
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POSTGRAD ORTH Deiary Kader
Outerbridge Arthroscopic Grading System
Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II
Partial thickness defect, fissures < 1.5cm diameter <50%
Grade III
Fissures down to subchondral bone, diameter > 1.5cm. >50%
Grade IV
Exposed subchondral bone
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POSTGRAD ORTH Deiary Kader
ICRS<1.5cm
>1.5cm
The modified International Cartilage Repair Society (ICRS)The Outerbridge classification
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Prof Deiary Kader
Traumatic Chondral Damage
Treated with Microfracture
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
MACI
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Microfracture
Effective in smaller lesions
Leads to fibrocartilage production,
ACI
Greater proportion of hyaline-like tissue
Effective in larger lesions.
MACI
Technically less challenging than ACI
For big lesions > 4 cm2
More effective than microfracture.
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J Bone Joint Surg Br. 2005 May;87(5):640-5.
Autologous chondrocyte implantation versus matrix-induced
autologous chondrocyte implantation for osteochondral
defects of the knee: a prospective, randomised study
.Bartlett W1, Skinner JA, Gooding CR, Carrington RW, Flanagan AM, Briggs TW, Bentley G.
We conclude that the clinical, arthroscopic and histological outcomes are
comparable for both ACI-C and MACI. While MACI is technically attractive,
further long-term studies are required before the technique is widely adopted
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
ACL InjuriesFRCS(Tr&Orth) Revision Course
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POSTGRAD ORTH Deiary Kader
Anatomy➢33 mm long, 11 mm in diameter
➢Two bundles
➢AM bundle – tighten in flexion (Translation)
➢PL bundle – tighten in extension (Rotation)
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
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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 .
THE ACL Prevents Internal Rotation of th
e Tibia
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POSTGRAD ORTH Deiary Kader
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Valgus + ER
POP
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Causes of Injury
Mechanisms of Injury:
1) “plant-and-cut” manoeuvre
2) Knee Hyperextension (Fall backwards)
3) Landing on one leg following a jump
(Olsen et al 2004)
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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
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POSTGRAD ORTH Deiary Kader
Surgical TreatmentIndications:
1) Subjective instability (non-coper)
2) ACL tear in children and adolescents
3) Multiligament injury
4) Displaced meniscal tears
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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
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POSTGRAD ORTH Deiary Kader
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
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Hamstring BTB
Grafts / Fixations
Quads
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POSTGRAD ORTH Deiary Kader
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●Biologically inactive
●Slower incorporation
●Less stability in 6 months
●Risk of disease transmission
●Role in revision surgery
●Weaker after having been irradiated
Allograft
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POSTGRAD ORTH Deiary Kader
➢ ◊
Paul F. Segonda Paris surgeon
1879
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Prof Deiary Kader
ANTEROLATERAL LIGAMENT
ALL
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POSTGRAD ORTH Deiary Kader
In 1972, D. L. MacIntosh In 1967,1975, M. Lemaire
Extra-articular reconstruction
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Prof Deiary Kader
OPEN ALL Recon
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POSTGRAD ORTH Deiary Kader
Anatomic Single bundle recon
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POSTGRAD ORTH Deiary Kader
5mm +
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What are the complications of ACL
reconstruction?
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POSTGRAD ORTH Deiary Kader
Complications
➢ Infection
➢ DVT and PE
➢ Osteoarthritis
➢ Cyclops lesion residual tissue anterior to
the ACL blocks extension
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POSTGRAD ORTH Deiary Kader
Complications
➢Failure of Fixation
➢Graft rupture from impingement
➢Flexion contracture and arthrofibrosis
➢Anterior placement of the femoral tunnel limits flexion
➢Anterior placement of the tibial tunnel limits extension
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POSTGRAD ORTH Deiary Kader
ACL Tunnels
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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.
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POSTGRAD ORTH Deiary Kader
Meyers and McKeever classification (1959)
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Treatment
• Casting in extension for type I
• Open reduction and internal fixation.
• Arthroscopic reduction and fixation
• Rarely ACL reconstruction is necessary
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66
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POSTGRAD ORTH Deiary Kader
Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course
MCL
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POSTGRAD ORTH Deiary Kader
Medial Collateral Ligament
In 25-30° of flexion, the MCL provides 80% of the support to
valgus stress
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POSTGRAD ORTH Deiary Kader
MCLTreatment Acute isolated MCL tear I RICE, physiotherapy. 2 Wks II ?Hinged brace for symptom improves, WBAA,
2wks III Hinged brace 30-90 or Surgical 3-4 wks
Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III
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POSTGRAD ORTH Deiary Kader
Chronic MCL Injury
Patient A MCL Reconstruction with AT + Revision ACLR
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
PCL and PLC
Postgraduate Orthopaedics FRCS(Tr&Orth) Revision Course
drive thru”
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POSTGRAD ORTH Deiary Kader
PCL Average length of 38 mm and diameter of 13 mm
AL Bundle: Long, thick, Large part
Tightens in flexion
PM Bundle: Tight in extension
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament
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POSTGRAD ORTH Deiary Kader
PMB tight in Extension
ALB
TIGHT IN FLEXION
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POSTGRAD ORTH Deiary Kader
a. Ant Meniscofemoral lig Humphrey
b. Post Meniscofemoral lig Wrisberg
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament
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POSTGRAD ORTH Deiary Kader
PCL Diagnosis in MRI ?MRI & PCL
➡ Clinical examination is more reliable than MRI scan ➡ The PCL may be dysfunctional despite normal MRI ➡ Kneeling stress x-ray ➡ Measure the degree of translation
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POSTGRAD ORTH Deiary Kader
Surgical reconstruction 1. Indications
2. Acute combined injuries
3. Acute bony avulsion
4. Symptomatic chronic PCL
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POSTGRAD ORTH Deiary Kader
PCL Reconstruction
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PTS BRACE POST OP-PCL
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POSTGRAD ORTH Deiary Kader
What are the structures in the Posterolateral Complex of the Knee?
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POSTGRAD ORTH Deiary Kader
Posterolateral Complex
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Posterolateral Complex Components:
– LCL, Popliteus, Popliteofibular ligament, arcuate ligament, ITB, Biceps
Function
– Resists External and Varus rotation
Mechanism of Injury
– Direct blow to anteromedial tibia
– Hyperextension/varus
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POSTGRAD ORTH Deiary Kader
What is the function of the Posterolateral
Complex of the Knee?
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POSTGRAD ORTH Deiary Kader
The Posterolateral Corner Summary
Primary stabilisers of external tibial rotation at all knee flexion angles
Secondary restraints to anterior and posterior translation
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The Posterolateral Corner Resist Ext Rotation of Tibia
The LCL is a cord like structure 5-7 cm in lengthS
Primary static restraint to varus opening of the knee
Secondary restraint to posterolateral rotation
The popliteus is a static and dynamic external rotation stabiliser.
The popletiofibular ligament acts as
a primary restraint to external rotation of
the tibia on the femur at 30º of flexion85
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The Posterolateral Corner (PLC)
Isolated PLC sectioning produce a maximal
Average increase of 13° of tibial ER at 30° of knee flexion
Average increase of 5.3° of tibial ER at 90°
Isolated PCL sectioning has no effect on external tibial
rotation
Combined injury to the PCL and PLC leads to ER of 20.9°
at 90° of knee flexion
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POSTGRAD ORTH Deiary Kader
DIAL TEST
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POSTGRAD ORTH Deiary Kader
Posterolateral Complex Injury
External rotation testDial Test
Increased External rotation (30º, 90º).
External rotation recurvatum
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POSTGRAD ORTH Deiary Kader
Posterolateral Complex Injury--Treatment
Partial
– Grade I & II Instability with a good end point
– Nonsurgical Treatment
– 1-3 week immobilisation in extension
Complete Acute
– Primary repair best
– Augment with allo/auto graft
Complete Chronic
– Reconstruct Popliteus and LCL
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POSTGRAD ORTH Deiary Kader
PLC Reconstruction The reconstruction can be:-
1. Fibula based such as modified Larson’s technique or
2. Combined tibia and fibula based such as LaPrade’s (anatomical reconstruction).
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
Knee dislocationAny triple-ligament knee injury constitutes a frank dislocation. This is relatively rare but a severe and potentially limb-threatening injury.
High-energy injury such as RTA Sporting accident
May be missed on initial assessment.
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POSTGRAD ORTH Deiary Kader
Vascular injury associated with fractures or dislocations – BOAST 6
ABCs, manage catastrophic haemorrhage
Re-align the pulseless, deformed limb
A de-vasularised limb requires surgical interventionWarm ischaemia time >3-4 leads to irreversible damageImaging options include duplex, angiography, CT angio, on-table angio
Sequence – temporary shunt, skeletal stabilisation then definitive reconstruction with autologous vein grafts
Note:- Reperfusion may lead to compartment syndrome and myoglobinuria
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Vascular Injuries Previously it was thought there was a
50% incidence of vascular compromise
Now 3.3-18%
20%–30% incidence of nerve injury.
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Classification of Knee Dislocation Based on tibial displacement
➢Closed or open
➢High or low energy
➢Dislocation or subluxation
➢Neurovascular involvement
➢Anterior (common, associated with intimal tears)
➢Posterior; also medial, lateral (highest rate of peroneal
nerve injury) and rotatory (usually irreducible) or combined
➢ Hyperextension leads to anterior dislocation
➢ Dashboard injury leads to posterior dislocation95
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POSTGRAD ORTH Deiary Kader
Classification Classified on the basis on tibial displacement in respect to the femur
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ExaminationValgus and varus laxity
Anteroposterior translation
Recurvatum
>10º hyperextension suggests ACL injury
>30º hyperextension indicates PCL injury
Rotation indicates MCL and LCL injury
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ManagementSurgical emergency
Deal with life-threatening injuries first
Circulation check in A&E
Serial examination for 48 hours.
Ankle brachial Index (ABI) <0.9 is suggestive of significant
arterial injury
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POSTGRAD ORTH Deiary Kader
Management Emergency
Deal with life-threatening injuries first
Serial examination for 48 hours.
Ankle brachial Index (ABI)
ABI <0.9 is suggestive of significant arterial injury
Involve the vascular surgeon
Radiography before manipulation
(assess direction and associated fracture)
Reduction as soon as possible in theatre
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POSTGRAD ORTH Deiary Kader
ManagementSurgery as soon as the vascular surgeon allows Most ACL/PCL/MCL can be treated with bracing the MCL followed by combined ACL/PCL reconstruction once range of movement is restarted, usually after 6 weeks.
ACL/PCL/posterolateral corner can be treated by repairing the posterolateral corner acutely (within three weeks) and delayed ACL/PCL reconstruction 8 weeks later. Or all in One
Open dislocation, fracture dislocation and vascular compromise require staged procedures.
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POSTGRAD ORTH Deiary Kader
Patellar DislocationRe-dislocation rate is very high
After First Time 17-20% (to 49%)
After Second Time 44%-71%
High dissatisfaction following conservative Rx
Can be confused with ACL rupture
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POSTGRAD ORTH Deiary Kader
MPFL
VMO
VMO
MPFL
VMO
Patella Quads TendonPatella
Tendon
Medial Knee
M.E
Add.Tub
Femur
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POSTGRAD ORTH Deiary Kader
Med Epicondyle
Add Tubercle
Patella
MPFL
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POSTGRAD ORTH Deiary Kader
Why the patella is unstableLower limb Malalignment?? Femur, tibia or foot pronation Osseous abnormalities?? Patella alta Increased Q angle Trochlea dysplasia Soft Tissue?? HMS MPFL Insufficiency Muscle or ITB
Gait ??
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POSTGRAD ORTH Deiary Kader
PFJ BiomechanicsPatellofemoral joint reaction force
WALKING 0.5xBW
STRAIGHT LEG RAISE 0.5xBW 0 DEG
CYCLING: 1.2 × BW
RISING FROM A CHAIR w ARMS: <3 × BW
STAIRS (UP OR DOWN) 3.3xBW 60 DEG
JOGGING & SQUAT–RISE 6xBW at 140 deg
SQUAT–DESCENT 7.6x BW at 140 deg
JUMPING UP TO 12 × BW
Ff
Ft
Fj
Trigonometry Fjf=Ff cos(angle/2)
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POSTGRAD ORTH Deiary Kader
Knee assessmentLeg Alignment Varus/valgus
Femoral neck anteversion
Tibial rotation
Ligament assessment (ACL,PCL, MCL, LCL)
Meniscal assessment
Medial/ Lateral compartment OA
Hip , Spine, peripheral pulses
Apprehension test
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POSTGRAD ORTH Deiary Kader
Patella AssessmentBeighton Score 0---9 Patella Alignment (Q Angle) Dislocation in extn (J Sign) Quads Bulk/ ITB (Ober's test) Hamstring Tightness Patella height Alta/Baja Patella Mobility (N@300=<1/2) Parapatellar tenderness Patella Apprehension PFJ Crepitus PFJ Compression (Clarke test) Trochlea Depth Normal (1380)
Shallow ,Flat , Convex , Cliff
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POSTGRAD ORTH Deiary Kader
Beighton Score 0---9
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POSTGRAD ORTH Deiary Kader
Imaging of the patellofemoral joint
✦ AP and Lateral Knee x-ray
✦ Merchant’s view
✦ MRI Axial view
✦ CT Rotational Profile
Merchant’s
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POSTGRAD ORTH Deiary Kader
Trochlea dysplasia
Blumensaat's line
Normal Trochlea Depth
NORMAL
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POSTGRAD ORTH Deiary Kader
Measuring patella HeightCaton – Deschamps index =1.2
Blackburne-peel index = 1.12
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POSTGRAD ORTH Deiary Kader
MPFL injury
Patella pain
Articular Damage
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POSTGRAD ORTH Deiary Kader
Rotational Profile CT Evidence based intervention
Femoral Anteversion N=50 -150 Knee rotation N=30 External Tibial torsion 250-300 TT:TG offset (N= 10-19mm) Patella index Patella Tilt (N=average QD&QC <200) Trochlea Tilt (N>130) Trochlea Depth Normal (1380+/- 60)
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POSTGRAD ORTH Deiary Kader
analysis
Normal measure is 5° to 15°
Femoral anteversion
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POSTGRAD ORTH Deiary Kader
LATERAL PATELLAR TILT
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POSTGRAD ORTH Deiary Kader
lateral trochlear tilt
The pathologic measure is <14°
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POSTGRAD ORTH Deiary Kader Clinique de la Sauvegarde –
analysis
lateral tibia twisting
slices n°3 and n°4
Normal Ext rotation is 25° to 30°
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POSTGRAD ORTH Deiary Kader
True Q angle, Measurement of the Tibial Tuberosity-Trochlear Groove (TT/TG) distance
Normally TT/TG = 2-9 mm pathologic measure is > 19 mm
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POSTGRAD ORTH Deiary Kader
Trochlear Dysplasia
Dejour classification of trochlear dysplasia CT
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POSTGRAD ORTH Deiary Kader
Dejour classification of trochlear dysplasia on CT scansShallow flat
dome-shaped medial ‘‘cliff-face.’’
Dejour classification
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POSTGRAD ORTH Deiary Kader
Non-Surgical treatment of Patella Instability
Conservative first Quads strengthening Core stability McConnell Taping Insoles Gait
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POSTGRAD ORTH Deiary Kader
Tibial Tubercle Transfer Patellofemoral Instability with Malalignment
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POSTGRAD ORTH Deiary Kader
Fulkerson's Technique of Anteromedialization
A steeper osteotomy plane will produce more anteriorization along with
medialization
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POSTGRAD ORTH Deiary Kader
PATELLA ALTADistal transfer (Distalization)
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POSTGRAD ORTH Deiary Kader
14 mm
Patella alta
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POSTGRAD ORTH Deiary Kader
Med Epicondyle
Add Tubercle
Patella
MPFL
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
Our Dissection
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
What are the complications of MPFL reconstruction?
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POSTGRAD ORTH Deiary Kader
Trochlea dysplasia
TROCHLOPLASTY
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
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POSTGRAD ORTH Deiary Kader
24 years old female doctor had a permanents dislocation of the patella Treated with 1. Lateral release 2. Tib Tub Medialisation 3. Tib Tub Distalisation 4. Trochleaoplasty 5. MPFL Reconstruction
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POSTGRAD ORTH Deiary Kader
Surgical OptionsInstability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
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POSTGRAD ORTH Deiary Kader
LONDON COURSE 2-7 OCTOBER 2017
UCLH