PCL 11 - LCL Injury Fern & Myat

Mechanism of Injury

• Force directed on anteromedial aspect of tibia with foot planted and knee in various degrees of flexion
• An LCL injury should not be confused with other overuse lateral knee injuries (eg, iliotibial band syndrome, biceps femoris tendinitis)
• Other problems:
  Meniscal tear
  Osteochondral fracture
  Biceps femoris tendiniton

Examination

History

-Ask if there is any effusion within few hours of injury. One should not expect significant effusion unless there is cruciate ligament of meniscal tear.
-If the patient also felt or heard a pop it may suggest concomitant injury
Inquire about previous injuries, symptoms, surgeries to the knee

Physical

-Inspect – gross abnormalities, skin abrasions, swelling, redness, scars etc…
-Palpate – suprapatellar pouch for effusion, joint-line tenderness
-Move
With patient lying flat and leg extended, test for medial movement of the leg at the knee joint.
More than 5 to 10 degrees is abnormal
Varus stress occurs at 0 to 30 degrees of flexion

Investigations

-X – ray to rule out fractures, dislocations, acute traumatic injuries, degenerative joint disease
-MRI to confirm diagnosis
-Electromyogram (EMG) and nerve conduction velocity (NCV) tests may assess for peroneal nerve injury.
-Arteriogram – to check popliteal artery if multiple ligaments torn
-Grade the degree of the LCL injury according to the following:

Grade 1 – Interstitial injury without laxity is present, but there is pain with varus stress; only microscopic tearing has occurred.
Grade 2 – A 5-10 mm of joint-space opening with a distinct end point is noted; partial macroscopic tearing has occurred.
Grade 3 – Complete tearing (>10 mm joint-space opening) has occurred; complete macroscopic tearing is noted.




Treatment

Grade I and II:
-RICE
-Non-bearing restrictions with use of crutches
-NSAIDs

Grade III
-Surgical intervention
-Full weight-bearing gait should return in about 4 weeks
-Rehabilitation program
-Range of movement exercise e.g. cycling, quadriceps-strengthening exercises

Surgery
-Ligament Repair
Repair of a recently torn collateral ligament usually requires an incision through the skin over the area where the tear in the ligament has occurred. If the ligament has been pulled from its attachment on the bone, the ligament is reattached to the bone with either large sutures (strong stitches) or special staples called suture anchors. Tears of the middle areas of the ligament are usually repaired by sewing the ends together.

-Ligament Reconstruction
Chronic swelling or instability caused by a collateral ligament injury may require a surgical reconstruction. Reconstruction differs from repair of the ligaments, described earlier. A reconstruction operation usually works by either tightening up the loose ligament or replacing the loose ligament with a tendon graft.

-Ligament Tightening
In the tightening procedure, your surgeon will use the remaining ligament tissue and take up the slack (similar to taking in the waist on a pair of pants). This is usually done by detaching one end of the ligament from its place on the bone and moving it so that it becomes tighter. The ligament is then reattached to the bone in the new place and held with sutures or metal staples.

-Autograft Method
if a tendon graft is needed to replace the loose ligament, it is usually taken from somewhere else in the same knee. Taking tissue from your own body is called an autograft. A common autograft that is used is one of the hamstring tendons called the semitendinosus tendon. Studies have shown that this tendon can be removed without affecting the strength of the leg. This is because other bigger and stronger hamstring muscles can take over the function of the tendon that is removed. In this operation, your surgeon will use the tendon graft to replace the damaged collateral ligament. The ends of the tendon graft are attached to the bone using large sutures or metal staples.

-Allograft Method
Another way to replace a badly torn collateral ligament is with an allograft. For this procedure, the surgeon gets graft tissue from a tissue bank. This tissue is usually removed from an organ donor at the time of death and sent to a tissue bank. There the tissue is checked for infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn collateral ligament.

Complications

-Chronic pain
-Weakness
-Instability
-Peroneal nerve injury

Prognosis

Non-surgical rehabilitation
-Minor tears should get better in 4 to 6 weeks
-Moderate tears should rehabilitate in 2 months
-Severe tears 3 months, if longer à surgery
-LCL leave knee most unstable, patients without surgery don’t usually do well

After surgery rehabilitation
-Depends on type of surgery performed
-Continuous Passive Movement:
Machine that helps the joint to move and alleviate joint stiffness
-Patients are strongly advised to follow recommendations of how much weight and -pressure they place on leg while standing or walking (usually up to 12 weeks, no weight)
-Formal exercise therapy with physical therapist

ACL Tear - Mechanism of Injury, Examination & Complications & Prognosis of Surgery

Anterior Cruciate Ligament

- Mechanism of injury: usually occurs through a twisting force being applied to the knee whilst the foot is firmly planted on the ground or upon landing. A torn ACL can also result from a direct blow to the knee, usually the outside, as may occur during a football or rugby tackle. This injury is sometimes seen in combination with a medial meniscus tear and MCL injury, which is termed O’Donohue’s triad.

- Examination:

a) Lachman test: with patient’s knee bent 20-30 degrees, grasp limb over distal femur and proximal tibia. Tibia alternately pulled forward and pushed backward. Movement of 5mm or more than that in normal limb indicates rupture of ACL

b) Anterior drawer test: With patient lying on the table, hip flexed 45 degrees, knee 90 degrees. Examiner sits on patient’s foot to stabilise it, places hands on each side of upper calf and firmly pulls tibia forward. Movement of 5mm or more is positive result. Result is compared with normal limb which is tested first.

Surgery (involves reconstruction or repair of the ACL)

- Prognosis: About 60% of patients return to the full level of pre-injury activity. But 80 – 90% have favourable results (reduced pain, good knee function and stability, and return to normal levels of activity). Surgery is usually successful for cases of ACL avulsion, where the ligament has torn away from the femur or tibia. Between 3% and 10% of people who have ACL surgery still have knee pain and instability and may need another surgery (revision ACL reconstruction). Revision ACL reconstruction is generally not as successful as the initial ACL reconstruction.

- Complications:

• Problems related to the surgery itself: Numbness in the surgical scar area, infection in the surgical incisions, damage to structures, nerves (common peroneal and tibial), or blood vessels around and in the knee, blood clots in the leg and anaesthesia risks.

• Problems with the graft tendon (loosening, stretching, reinjury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal.

• Limited range of motion, usually at the extremes, e.g. not being to completely bend or straighten the leg. This is uncommon, and sometimes manipulation under anesthesia can help.

• Crepitus, as the patella moves against the lower end of the thighbone (femur), which may develop in people who did not have it before surgery. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery.

• Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.

• Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery.

http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-surgery

Medial Meniscus - Sarah and Bryn

Task – Medial Meniscus

The medial meniscus is a fibrocartilage band that spans the medial knee, and lies on the head of the tibia.
Its anterior end is attached to the anterior intercondyloid fossa of the tibia, in front of the anterior cruciate ligament.
Its posterior end is fixed to the posterior intercondyloid fossa of the tibia, between the attachments of the lateral meniscus and the posterior cruciate ligament.
The medial meniscus separates the tibia and femur and serves as a shock absorber, to increase the contact area between the bones, reducing the peak contact force experienced. It also reduces friction between the two bones to allow smooth movement in the knee

Meniscus tear

There are three types of tear to the meniscus that can occur and these lead to another three types.

Longitudinal tear - Bucket handle tear
Radial tear - Parrot beak tear
Horizontal tear - Flap tear

The medial meniscus has a rich supply to its periphery, a tear there healing fast and usually quite well. However a deeper tear may not heal as well.

The neuroanatomy of the meniscus is not well described. But it is believe to be enervated in a similar manner to the arteries, more on the periphery less deeper, these nerve endings are believed to play a role in sensory feedback and proprioception.

Mechanism of Injury
• The meniscus both medial and lateral are often torn by a twisting injury, common in sporting injuries, which involve twisting and bending of the knee.
• Can also be damaged in the elderly as it becomes weaker, and more likely to tear.

Investigation
• When taking a history these things should be noted:
o Tears sometime related to significant trauma, but not always.
o The injury often results from twisting or bending of a weight bearing knee in various degrees of flexion and extension.
o Pain is often intermittent and results from synovitis or abnormal motion of the unstable meniscus fragment.
o The pain is usually localised at the joint line.
o Patients can complain of: clicking, scratching, catching, locking, pinching or the sensation of giving way.
o Swelling usually occurs as a delayed symptom or may not occur at all. Immediate swelling indicates a tear in the peripheral vascular aspect.
o Degenerative tears often manifest with recurrent effusion due to synovitis.

Examination
• Associated findings such as a perimeniscal cyst or ligamentous laxity suggest a higher likelihood of a meniscus injury.
• Joint line tenderness – is an accurate clinical sign, found in 77 – 86% of cases of people with meniscus tears.
• The tenderness must be differentiated from a collateral ligament tear, this pain will extend above and below the joint line towards the ligament attachments.
• Effusion occurs in approx 50% of tears.
• Range of motion
o A mechanical block to motion or frank locking can occur with displaced tears.
o Restricted motion caused by pain or swelling is also common.
• Tests that can be performed are:
o The McMurray test: elicits pain: The medial meniscus is evaluated by extending the fully flexed knee with the foot/tibia internally rotated while a varus stress is applied.
o The Steinmann test: Tibial rotation is performed with the patient seated and the knee flexed 90º. Asymmetric pain is created with external rotation when testing the medial meniscus.
o The Apley test: This maneuver is performed with the patient prone and the knee flexed 90º. An axial load is applied through the heel as the lower leg is internally and externally rotated. This grinding maneuver is suggestive of meniscal pathology if pain is elicited at the medial or lateral joint.

Management
• Physical Therapy/medical management:
A home physical therapy program or simple rest with activity modification, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) is the non-operative management of possible meniscus tears. The physical therapy program goals are to minimize the effusion, normalize gait, normalize pain-free range of motion, prevent muscular atrophy, maintain proprioception, and maintain cardiovascular fitness. Choosing this course of treatment must include consideration of the patient's age, activity level, duration of symptoms, type of meniscus tear, and associated injuries such as ligamentous pathology. A trial of conservative treatment should be attempted in all but the most severe cases, such as a locked knee secondary to a displaced bucket-handle tear.’
• Surgical Intervention
If symptoms persist, if the patient cannot risk the delay of a potentially unsuccessful period of observation (eg, elite athletes), or in cases of a locked knee, surgical treatment is indicated.
The basic principle of meniscus surgery is to save the meniscus. Tears with a high probability of healing with surgical intervention are repaired. However, most tears are not repairable and resection must be restricted to only the dysfunctional portions, preserving as much normal meniscus as possible.
Surgical options include partial meniscectomy or meniscus repair (and in cases of previous total or subtotal meniscectomy, meniscus transplantation). Arthroscopy, a minimally invasive outpatient procedure with lower morbidity, improved visualization, faster rehabilitation, and better outcomes than open meniscal surgery, is now the standard of care.
Partial meniscectomy is the treatment of choice for tears in the avascular portion of the meniscus or complex tears that are not amenable to repair. Torn tissue is removed, and the remaining healthy meniscal tissue is contoured to a stable, balanced peripheral rim.
Meniscus repair is recommended for tears that occur in the vascular region (red zone or red-white zone), are longer than 1 cm, involve greater than 50% of the meniscal thickness, and are unstable to arthroscopic probing. A stable knee is important for successful meniscus repair and healing. Thus, associated ligamentous injuries must be addressed. The most commonly associated ligamentous disruption is complete tear of the ACL, which must be reconstructed to prevent recurrent meniscal tears. Fortunately, the increased blood and growth factors in the knee during meniscal repair combined with cruciate reconstruction significantly improves the outcome of the meniscal repair. In ACL-intact knees with isolated meniscal tears, healing rates are less than those in ACL-reconstructed knees, but they are higher than those in ACL-deficient knees.
The principles of repair include smoothing and abrading the torn edges and bordering synovium to promote bleeding and healing. Likewise, needle trephination of the meniscal body (poking holes to create vascular channels) can be performed.
Human allograft meniscal transplantation is a relatively new procedure but is being performed increasingly frequently. Specific indications and long-term results have not yet been clearly established. Meniscus transplantation requires further investigation to assess its efficacy in restoring normal meniscus function and preventing arthrosis.

Complications of Surgury:

Can be intraoperative or postoperative

Intraoperative
-anesthetic problems
-articular cartilage damage
-vessel or nerve injury
-instrument failure

Postoperative
-anesthetic concerns
-thrombophlebitis
-hemarthrosis
-infection
-stiffness
-persistent pain
-effusion
-synovitis

Prognosis
Healing of a medial meniscus tear is slow. If surgery is required and the meniscus is removed there is an increase risk of osteoarthritis in later life.

References
• http://www.emedicine.com/SPORTS/topic160.htm

PCL 11- ACL tear: anatomy, investigation and management

Anterior cruciate ligament

Anatomy

· Origin

o Anterior intercondylar area of tibia

· Attachment

o Posterior to the attachment of medial meniscus

· Function

o Weakest of the cruciate ligaments

o Limits posterior rolling of femoral condyles

o Prevents posterior displacement of femur on tibia

o At 90^o flexion, the knee cannot be pulled anterior because ACL prevents this

Investigation

· Physical examination (diagnosis is made with this and presenting complaint)

o Look and feel for swelling, inflammation

o The Anterior drawer sign

§ Flexing the knee at 45o, if the tibia can be pulled anteriorly it shows that ACL is ruptured

o Lachman’s test

§ Passively flex knee to 20-30^o, put one hand on calf while the other holds the leg above knee joint, thumb must be on tibial tuberosity

§ Pull tibia towards you, if the tibia move towards you, ACL torn is present

· X-rays

o To rule out possible bone fractures

· MRI

o Unsure about the extent of damage, the doctor might order MRI to check for partial or complete tears

· Arthroscope

o Check for damages

Grading

· grade I sprain: pain with minimal damage to the ligaments

· grade II sprain: more ligament damage and mild looseness of the joint

· grade III sprain: the ligament is completely torn and the joint is very loose or unstable.

Management

· Pain and first aid

o Immobilise, injured knee should be held in a splint

o Elevate joint, use NSAIDS or ice

· Surgery

o ACL Reconstruction surgery (for severe tears)

§ Done with autograft or allograft with and arthroscope

· Using hamstring tendon or patella tendon

§ New tendon is fixed into bone while it heals into the bone

§ Strong enough for sports in 6 months

o Surgeon Martha Murray at Children’s Hospital Boston reported that a collagen gel enriched with platelets can stimulate healing of partial ACL tears

§ 40% strength increase than 14% in ARS

· Rehabilitation

o Rest, ice, elevation, bandage

o Strengthening exercises

§ Bike riding, swimming…

o Is done before (to regain most range of motion, reduce swelling) and after surgery (recover strength)

Reference:

Moore and Dalley 5^th edition

http://www.mayoclinic.com/health/acl-injury/DS00898/DSECTION=treatments-and-drugs

http://www.mayoclinic.com/health/acl-injury/DS00898/DSECTION=treatments-and-drugs

http://www.melbourneorthopaedics.com.au/ligament.html#4

http://137.190.56.8/hthsci/casestudies/ACL/examination_of_theanterior_cruci.htm

http://www.med.umich.edu/1libr/sma/sma_ancrulig_sma.htm

Articular Cartilage Injury

GENERAL

What is Hyaline cartilage?
• Covers bony articular surfaces
• Provides model for early foetal skeleton
• Glassy appearance → due to parallel collagen fibres
• Almost frictionless
• Avascular and aneural → receives nutrition from synovial fluid in joint cavity

Mechanism
• Occurs during twisting movement of the knee
• Usually happens with tear of ACL → prevents rotation of knee
• Due to contact between surfaces of femur and tibia
• Can lead to fractures of bone directly beneath areas where cartilage is lost

Symptoms/Examination
• Recurrent pain and swelling in the knee joint.
• Locking of the knee
• Crepitus with movement

Investigations
• X-ray
• Arthroscopy

Management
• NSAIDS
• RICE straight after injury

Lavage
• Joint Lavage removes loose intra-articular tissue debris and inflammatory mediators known to be generated by the synovial lining
• Lavage may relieve the symptoms and increase the resiliency and stiffness of articular cartilage is through changing the ionic environment within the synovial fluid.
Lavage provides only short-term symptomatic relief without correction of underlying pathology. The outcome of this simple procedure is generally insufficient for the active population, and benefits are short-lived

Microfracture

• This technique utilises primitive stem cells, which are capable of differentiating into bone and cartilage
• Stimulates the formation of a fibrin clot containing pluripotential stem cells.
• This clot differentiates and remodels, resulting in a fibrocartilaginous repair tissue.
• This tissue lacks several key structural components to perform the mechanical functions
• The fibrocartilage repair tissue does not produce a proper compressive stiffness against applied mechanical load and thus is subjected to an excessive deformation under physiological loading.
• Eventually leads to a recurrence of degeneration of the repaired cartilage.


Osteochondral Autologous Transplantation (OATS)
• Only surgical technique that can restore the height and the shape of articulating surface in focal osteochondral defects
• Contains all necessary ingredients: hyaline articular cartilage, intact tidemark and a firm bone carrier.
• The main problem with this reconstructive technique is the limited availability of autografts
• Deep and large, crater-like osteochondral defects are not suitable for osteochondral autograft transplantation, mainly because of the limited availability of autologous osteochondral grafts.


EXAMPLES

Osteochondritis dessicans (OCS)

Definition: This is when a small piece of bone or cartilage softens or breaks off from the end of a bone, which causes long-term knee pain.
Presentation: pain along joint line, swelling, inability to extend leg and other decreased range of movement, stiffness/catching/popping/locking with movement
Investigations: MRI or arthroscopy
X-ray may rule out other causes of knee pain
Treatment: resting the knee
wearing a cast for a few months
surgery: the cartilage will not heal well unless the injury penetrates to the bone (since it does not have a good blood supply), so arthroscopic surgery can remove damaged cartilage and increase blood flow from the underlying bone. Cartilage transplant from other joints in the body is also possible.


Chondromalacia

Definition: Cartilage in the knee joint softens due to injury/overuse/muscle weakness. The patella and femur may rub together.
Presentation: Pain and aching, especially when walking up stairs or hills
Treatment: surgery



References
http://www.sportsmed.org/secure/reveal/admin/uploads/documents/ST%20Articular%20Cartilage%2008.pdf

PCL 11 - PCL (Posterior Cruciate Ligament tear)

Mechanism of injury
Most common mechanism of injury of the PCL is the "dashboard injury." This occurs when the knee is bent, and an object forcefully strikes the shin backwards. It is called a 'dashboard injury' because this can be seen in car collisions when the shin forcefully strikes the dashboard. The other common mechanism of injury is a sports injury when an athlete falls on the front of their knee. In this injury, the knee is hyperflexed (bent all the way back), with the foot held pointing downwards. These types of injuries stress the PCL, and if the force is high enough, a PCL tear will result.

Complications
1. Neurapraxia (localized loss of conduction that causes short-term paralysis. Usually, there is no degeneration of the axon and complete recovery often occurs) --> is the most common complication of posterior cruciate ligament (PCL) reconstruction
2. Infection
3. Blood clot formation
4. Swelling, bleeding or damage to blood vessels or nerves
5. Rare instrument breakage during procedures
6. Hemarthrosis (Bleeding into the joint)
7. Anaesthetic complications

Time of Recovery
The use of the scope in surgical procedures results in less trauma to the body when compared to “open” procedures. This has allowed athletes to return to participation faster. Recovery time after arthroscopic surgery varies. - “Simple” procedures such as cartilage resection (removal of a torn cartilage) can have a recovery time of as little as two weeks. - Complex procedures such as an ACL reconstruction can take 4 to 6 months. Actual recovery time can vary from person to person. The surgeon’s repair of the damaged tissue is only half of the recovery. The athlete must rehabilitate the surgical limb to regain normal strength, balance, and sport specific techniques. If the athlete approaches the rehabilitation with a poor attitude the outcome will be poor.

Swelling
Leg should be kept elevated as much as possible for the first few days after surgery. Apply ice as recommended by the orthopaedic surgeon to relieve swelling and pain.

Dressing Care
Avoid directing water at the incisions. Do not soak in a tub. Keep the incisions clean and dry.

Bearing Weight
After most arthroscopic surgeries, patient can walk unassisted. The patient may be advised to use crutches, a cane, or a walker for a period of time after surgery. Weight can be put on the leg when discomfort subsides and strength is regained in your knee.

Exercises to Strengthen Your Knee
Regular exercise is useful to strengthen the leg and knee muscles.

Medications
Antibiotics can help to prevent an infection and pain medication to help relieve discomfort following the surgery.

Anatomy of PCL
Stronger than Anterior Cruciate ligament

Course of ligament: Origin – Posterior intercondylar areas of tibia
Insertion – Anterior part of lateral surface of medial condyle of the femur

Function:

• Limits anterior rolling of femur on the tibial plateau during extension, converting it into a spin.
• Prevents anterior displacement of the femur on the tibia / prevents posterior displacement of tibia on femur.
• Prevent hyperflexion of knee joint

Examination
Medical history:

• WWQQAAAB (story of injury)
• History of knee injuries

Physical examination:

• Inspection and palpation for signs of trauma, inflammation and oedema.
• Movement - reduced
• Compare legs
• Posterior drawer test - with the knee flexed and resting on a surfac, the tibia is pushed backward gently. If it moves too far back, it is an indication of a torn PCL.
• Lachman's test - knee flexed 20-30 degrees, externally rotated, stabilise femur with one hand, other hand applying pressure on anterior tibia, torn pcl will cause pain and a laxity described as a 'soft end point' ie. no PCL restraint.

Investigation

• Xray may show possible fractured bones and/or cartilage but will not show a PCL injury.
• MRI will clearly show a damaged PCL and determine if other ligaments of the knee are also injured.
• Arthroscopy - optic tube inserted into knee joint via small incision. Used to determine extent of knee injury.
• Grade of severity of PCL tears (amount of backward tibial displacement observed when the knee is bent at 90 degrees):

Grade I: Partial tears of the PCL.
Grade II: Isolated, complete tear to the PCL.
Grade III: Tear of the PCL with other associated ligament injury.

Management

• RICE (Rest Ice Compression Elevation)
• For Grade I and II tears, nonoperative treatment is recommended such as: specific rehabilitative exercise programs, electrotherapy, ice and heat treatment or manual therapy treatment.
• Surgical PCL reconstruction difficult due to location of PCL in the knee, so it is reserved for patients with several major knee ligaments injured, or those who can't do their usual activities because of persistent knee instability.
• New PCL graft tends to stretch and become less functional.

Moore and Dalley 5th edition http://www.athleticadvisor.com/FAQs/scope/arthroscopy.htm www.medicinenet.com/arthroscopy/article.htm www.surgeryencyclopedia.com/Fi-La/Knee-Arthroscopic-Surgery.html www.medicinenet.com/arthroscopy/article.htm www.answers.com/topic/knee-arthroscopic-surgery www.emedicine.com/orthoped/topic545.htm