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Knee Ligament Injuries. Overview Ligament Anatomy Biomechanics Ligament Specific  Epidemiology  Classification  Clinical exam  Imaging  Tx.

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Presentation on theme: "Knee Ligament Injuries. Overview Ligament Anatomy Biomechanics Ligament Specific  Epidemiology  Classification  Clinical exam  Imaging  Tx."— Presentation transcript:

1 Knee Ligament Injuries

2 Overview Ligament Anatomy Biomechanics Ligament Specific  Epidemiology  Classification  Clinical exam  Imaging  Tx

3 Ligament Anatomy Type 1 collagen (70%) Elastin Extracellular matrix Hierarchical structure Fibrils > fibres >subfascicular unit >fasciculus Longitudinal fasciculi (MCL, LCL) Helical fasciculi (ACL, PCL)

4 Anatomic Features Bonding Crimping Random collagen alignment Complex blood supply Diffusion from synovium Proprioception and nociception

5 Biomechanics Laxity Stiffness Strength Viscoelastic behavior (creep, stress relaxation, hysteresis) Dynamic properties

6

7 Ligament healing Immobilization  Loading dramatically affects recovery of normal mechanical properties  Decrease strength  Insertion site vs. midsubstance Exercise  Favourable effect

8 Epidemiology Increasing incidence Combined injuries common Females > males Conditioned vs. unconditioned

9 Conditioned

10 Unconditioned

11 ACL Anatomy Intracapsular Extrasynovial Varied blood supply FAMPLE Origin / Insertion

12 ACL Function Limit anterior displacement 2 0 restraint rotation 2 0 restraint varus / valgus in extension

13 Mechanism / Hx Usually noncontact Change direction Stop / jump Audible “pop” Instability Swelling

14 General Ligament Exam Difficult acutely Early exam beneficial Pt. relaxed Displacement Endpoint quality Compare

15 ACL Exam Lachman – best Pivot Shift – diagnostic Anterior drawer – chronic tear Associated injuries

16 ACL Imaging XRAY  R/O #  ACL avulsion  Segond # Arthrography - poor Arthroscopy - gold standard

17 ACL MRI 95% accurate Low signal intensity Saggital view Acute injury high signal intensity on T 2 image Bone bruising

18 ACL Tx Pt selection Operative vs. Non-operative  Demand level  Modify lifestyle  ACL dependent  Other lesions

19 Non-operative Acutely – splint & crutches Early active ROM Closed chain WB to strengthen Avoid high risk Functional bracing controversial

20 Operative Pt selection  High demand  Young  Good ROM Open vs. endosopic Learning curve

21

22 Graft Auto vs. allo Collagen lattice Resorption – revascularization – restructuring Bone-patellar tendon-bone Semitendinosus/gracilis tensioning

23 Rehab Closed kinetic chain strengthening Acutely fixation weak Graft weakest 6-12 wks Outcome  >90% stable 3-5 yrs

24 MCL Anatomy Origin – femoral condyle Insertion – 4cm below joint line + posterior obl. Lig. + middle capsular ligament Parallel collagen

25 MCL Most common isolated ligament injury Valgus force Post. Obl. Lig. damage with rotn. injury Associated ACL common

26 MCL exam Valgus force Flex – isolated Extension  Assoc. POL,ACL,PCL 5-8 mm difference significant Swelling  Hemarthrosis vs. soft tissue

27 MCL Tx Non-surgical RICE Bracing Strengthening Functional brace

28 MCL Classification / Tx Grade 1 : 1-5 mm  Symptomatic Tx Grade 2 : 6–10 mm  Hinge brace 2-3 wks Grade 3 : mm  Hinge brace 3-4 wks Physio

29 PCL Injury 1.5 x ACL strength 5% all knee lig. inj. 1 0 restraint post. translation tibia Forced flexion Dashboard Associated injuries

30 PCL Pain Usually stable Posterior subluxation Medial & patellofemoral OA

31 PCL exam Posterior drawer test –best  Grade I - III Quadriceps active test Post sag sign

32 Non-operative Aggressive rehab Focus quadriceps No support for bracing closed kinetic chain Open kinetic chain extension avoided 90% quads strength prior to normal athletics

33 PCL Tx Repair :  Associated posterolateral corner  Associated ACL / MCL  Grade 3 Drawer test  Bony avulsion  20% athletes with isolated injury require repair

34 Operative Repair Require good ROM pre-op Graft > 40mm No good rehab protocol

35 Posterolateral Complex Combination of Structures  ITB  biceps femoris  fibular collateral  Popliteus complex  Capsule  etc

36 Posterolateral corner Usually assoc with:  PCL  Knee dislocation  Rarely ACL Instability esp descending inclines Peroneal N. inj. 10% pain

37 Biomechanical Increased:  External tibial rotation  Varus rotation  Posterior tibial translation

38 Exam Swelling / bruising Gait : Varus thrust AP translation > 30 0 than 90 0 Best tests:  Varus stress opening > 30 0 than 0 0  Prone external rotation test Other tests

39 Operative 1 0 Repair  Acute injury  Bony avulsion Reconstruction  Biceps tenodesis / arcuate lig advancement : mixed results  Graft - results pending Varus malalignment - HTO

40 Conclusion Common injuries Easily missed Large area Ongoing research


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