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Complex Ligament Injuries of The Knee H.Makhmalbaf MD Consultant Knee Surgeon Assistant Professor Orthopaedics Mashad University of Medical sciences.

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Presentation on theme: "Complex Ligament Injuries of The Knee H.Makhmalbaf MD Consultant Knee Surgeon Assistant Professor Orthopaedics Mashad University of Medical sciences."— Presentation transcript:

1 Complex Ligament Injuries of The Knee H.Makhmalbaf MD Consultant Knee Surgeon Assistant Professor Orthopaedics Mashad University of Medical sciences

2 Surgical Management of Knee dislocations JBJS supp Anikar Chhabra MD & Christopher Harner MD, University of Pittsburgh Medical Center Pittsburgh Pennsylvania

3 Evaluation & Management Characterize the pattern of injury Determine the surgical approach By ligament examination After, survival of the limb is assured And, the patient is stabilized

4 Investigations : Plain radiographs AP& LAT –Avulsion fx: –Fibular head, PCL, Segond’s sign –Depression CTscan, for fractures & avulsions MRI –Ligament injuries –Other soft tissue injuries –Bony injuries

5 Imaging

6 Postermedial repair

7 PM inj.& Subluxation

8 PCL MCL ACL injury

9 After repair

10 Final outcome: Stable,pain free, good ROM Stiff knee Unstable & pain free Unstable & painful

11 Type of instability One plain Rotational Posteromedial Posterolateral Convert multidirectional to: One plain instability

12

13 Anatomic classification of knee dislocation KDI,single cruciate torn+ one corner KDII,ACL/PCL torn,collaterals intact KDIIIM,ACL/PCL/MCL KDIIIL,ACL/PCL/LCL/PLC torn KDIV,ACL/PCL/MCL/LCL-PLC torn KDV knee fracture dislocation

14 Knee dislocation management Reduce Splint & observe then operate External fixation Transfix pins Vascular repair Soft tissue condition?

15 Planning Surgical & non surgical issues Timing of surgery Repair Graft selection for reconstruction Surgical techniques Risks & benefits Complications discussed with the patient

16 EUA & Positioning Position the patient EUA Determine ligaments injured Arthroscopic assessment Gravity inflow irrigation Avoid extravasation & compartment syn.

17 Graft selection for multiple ligament injuries Graft choice is based on the: Extent of the injury Timing of the surgery Experience of the surgeon Autograft –Better graft incorporation & –Remodeling Allograft

18 ACL& PCL reconstruction BPB allograft for ACL Achilles tendon allograft for PCL Or Hamstring tendon autograft Tunnel preparation Achilles tendon allograft or BPB for LCL Pass PCL graft first then ACL Fix in the femoral tunnel,tibial at the end

19 Lateral side injury Repair if fresh, or reconstruct After fixation of ACL & PCL reconstructs Lateral incision Expose proneal nerve LCL,Popliteofemoral lig.,popliteus tendon Joint capsule Avulsion of biceps femoris & ITB

20 KDIIIL

21 Lateral side reconstruction

22 KDIIIM

23 Critical concepts: The majority of the knees are treated surgically The goal of anatomic repair & reconst. Approach with in 1 st three weeks Emergency surgery in: open, irreducible Or with vascular injury or compartment syn

24 Order of fixation of ligaments in repair or Reconstruction 1 st FIX PCL in 90 flexion Then ACL in extention Then LCL in 30 FLEXION Finally MCL in 30 flexion

25 Critical concepts In open knee dislocations : Wound management Adequate soft tissue coverage Dictate : The timing of ligament reconstruction Never be performed acutely

26 Irreducible Dislocations Uncommon but needs prompt, Surgical reduction To avoid NV damage Delay definitive reconstruction Allow complete knee imaging Planning & stabilization of the patient Emergent vascular repair

27 Critical concepts Management & treatment of compartment syndrome Simple primary repair of injured soft tissue Avoid additional incisions Delay definitive ligament reconstructions In vascular repair give enough time

28 Contraindications: Advanced age or sedentary lifestyle An active infection Intra-articular or periarticular fractures Osteoarthritis Debilitating or posttraumatic comorbidities

29 Pitfalls: Well planned skin incisions MIS, use of Allograft & arthroscopy Open technique for medial & lateral Low intra-articular fluid pressure To avoid compartment syndrome Re check to make sure the compartments are soft

30 Causes of failure in PLC inj Frank R Noyes et al. Am J Sport Med PLC operative procedures Untreated varus malalignment (10) Failure to reconstruct all ruptured ligaments, including cruciates (27) Nonanatomical graft reconstruction (23 )

31 F. Noyes recommendations AJSM 2006 Anatomical graft reconstruction of one or more P Lateral ligaments Restoration of all cruciate ligaments & correction of varus malalignment

32 Chronic inj.of the PLC of the knee ( Chronic inj.of the PLC of the knee (Covey DC.JBJS 2001) More complex problem than acute Scarring, secondary changes to other st. Possible limb malalignment The goals of operative treatment are: Restoration of knee stability & kinematics Return to preinjury activity level Reduce chance OA,

33 THANK YOU Tehran 2007


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