orthopaedic research of virginia cramer anatomy course 1999 williamsburg, virginia
TRANSCRIPT
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Orthopaedic Research of Virginia
Cramer Anatomy Course 1999
Williamsburg, Virginia
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Anatomy and Sports Injuries of the Knee
Joel Gonzales, M. D.
Tuckahoe Orthopaedic Associates
Richmond, Virginia
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I. AnatomyII. AssessmentIII. TreatmentIV. Case StudyV. Dissection
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Anatomy
• Not a hinge joint
• 6 degrees of freedom
• Flexion/Extension
• Rotation
• Translation
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Anatomy
• Three Compartments
• Proximal Tib/Fib Joint
• Has not fully adapted
• Patella a sesamoid?
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Muscles
• Quadriceps
• Hamstrings
• IT Band/Tract
• Popliteus
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Neurovascular Structures
• Posterior Tibial Artery
• Tibial Nerve
• Peroneal Nerve
• Saphenous Nerve
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Menisci Anatomy
• Zones
• Ultrastructure
• Intermeniscal ligament
• Coronary ligament
• Mensicofemoral ligaments
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Role of Menisci
• Biomechanics “Shock Absorbers”
• Load Transmission– 50% in extension, 85% in 90 flexion
• Partial Meniscectomy (15-34%) increases contact pressure 350% !
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Meniscal Functions
• Increase congruity = Stability
• Proprioception
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Medial Meniscus
• C-shaped
• Wider posteriorly
• More commonly torn
• Restraint to anterior translation
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Medial Compartment
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Lateral Meniscus
• More Discoid
• Popliteal Hiatus
• More difficult to repair
• Worse prognosis
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Lateral Compartment
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ACL
• Anteromedial Tibia to Posterolateral Notch
• Primary Restraint to Anterior Translation
• Bundles/Fiber Regions AM, PL
• Reciprocal tightening• Isometry, Physiometry
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PCL• Anterolateral Femur to posterior tibia
• Primary restraint to posterior translation
• Intimate with ACL• Better blood supply
and synovial sheath• Bundles AL, PM• Much broader origin
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Normal PCL and ACL
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Posterolateral Corner
• Popliteus
• Arcuate Complex
• LCL/fibular collateral
• Lateral Head of Gastrocnemius
• Restraint to ER at 30 degrees
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Collaterals
• MCL 2 components
• Deep portion intimate with MM
• LCL
• Varus/Valgus at 30 degrees
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Anatomy
• Patellofemoral joint
• Medial Patellofemoral Ligament
• Retinaculum
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Assessment
• History not MRI most important
• Mechanism
• Locking, Catching, Giving Way
• Swelling?
• Plain Films
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Assessment
• Inspection– Effusion– Ecchymosis– Attitude
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Assessment
• ROM
• NV Check
• Joint Line Tenderness
• Stability
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ACL
• Lachman “Gold Standard” watch medial tibia
• Anterior Drawer
• Pivot Shift (lateral tibia)
• Pivot Glide
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PCL
• Posterior Drawer (Knee at 90)
• Quads Active
• Godfrey Test (Sag Sign)
• Reverse Pivot Shift
• Pivot Jerk
• Grades
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Posterior Drawer
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Posterolateral Corner
• Posterolateral Drawer
• External Rotation Recurvatum
• External Rotation at 30 and 90
• Prone ER at 90 and 30
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Collaterals
• Test at 30
• Palpate LCL in figure 4
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Menisci
• Joint Line Tenderness
• MacMurray’s
• Duck Walk
• Squat
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Patellofemoral Joint
• Patellar Glide
• Patellar Inhibition
• Patellar Tracking
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Don’t Miss Obvious
• Extensor Rupture
• Fracture
• Knee Dislocation
• Physeal Fracture
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Arthroscopy
• Systematic
• Standard Portals
• Pump
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Meniscus
• Zones
• Tear Types
• Biomechanics
• Meniscectomy, Repair, Replacement
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Bucket Handle Tear
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Horizontal Tear
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Radial Tear
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Discoid Meniscus
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ACL
• Non contact
• Gives way
• Immediate swelling
• Bloody effusion
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ACL
• Why fix it? (meniscus and djd, lifestyle)
• Endoscopic one incision
• Tension at 30 or full extension
• Allo or autograft
• Hamstrings, Achilles, BTB, Fascia Lata
• Fixation
• Return to sports 6 months
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ACL Basic Science
• Native ACL 2700 newtons
• ACL graft completely replaced
• 30-50% strength of native ACL after incorporation
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ACL Complications
• Tunnel Placement
• Loss of fixation
• Loss of motion
• Patellofemoral pain
• Surgeon Dependent
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PCL
• Dashboard Injury
• Blow to anteromedial tibia
• Hyperflexion
• Usually combined with PL corner
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PCL
• Many techniques (2 bundle femur)
• Indications - symptoms of functional instability
• Tension at 90 degrees
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Posterolateral
• Primary Repair (early)
• Split Biceps (Clancy)
• Semitendinosus figure 8
• Hughston Imbrication
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Chondral Defects
• Chondroplasty
• Microfracture (Steadman)
• Osteochondral Transplant (Hair plugs)
• Carticel
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Meniscus Repair
• Inside-out, Outside-in, All-inside
• Fibrin Clot
• Arrows, Darts, Screws
• Heal faster with ACL
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Meniscal Allograft
• Patients with early disease (Grade I-II)
• Technically challenging
• Expensive
• Patients must undergo change in lifestyle
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Meniscus Rehab
• Meniscectomy: none
• Repair: WBAT in full extension 6 weeks
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ACL Rehab
• Hinged Knee Brace
• WBAT in full extension
• Crutches
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ACL Rehab
• Decrease swelling
• Full extension
• Quad Control
• Patellar Mobilization
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ACL Rehab
• Closed chain
• Co-Contraction
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ACL
• Cycling
• Stairmaster
• Straight ahead Jogging
• Return to cutting sports 6-9 months
• (Jerry Rice 3 months = Patella Fracture)
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Braces
• No evidence of increased proprioception
• Can’t protect ligament
• Patients expect them
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Braces
• Cti
• Donjoy Defiance
• Playmaker
• Townsend
• Richards
• Breg
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Extensor Realignment
• Very Controversial• Lateral Release• Proximal Imbrication (Insall)• Maquet• Elmslie-Trillat• Hauser• Roux-Goldthwait• Fulkerson
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Fulkerson
• Anteromedialization
• Complications
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Case Study
• 23 y.o. male playing basketball
• Varus injury
• Fibular head fracture
• Peroneal nerve palsy
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MCL PLC
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Normal PCL and ACL
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Thank You