15 Planning Surgical & non surgical issues Timing of surgery Repair Graft selection for reconstructionSurgical techniquesRisks & benefitsComplications discussed with the patient
16 EUA & Positioning Position the patient EUA Determine ligaments injured Arthroscopic assessmentGravity inflow irrigationAvoid extravasation & compartment syn.
17 Graft selection for multiple ligament injuries Graft choice is based on the:Extent of the injuryTiming of the surgeryExperience of the surgeonAutograftBetter graft incorporation &RemodelingAllograft
18 ACL& PCL reconstruction BPB allograft for ACLAchilles tendon allograft for PCLOr Hamstring tendon autograftTunnel preparationAchilles tendon allograft or BPB for LCLPass PCL graft first then ACLFix in the femoral tunnel ,tibial at the end
19 Lateral side injury Repair if fresh, or reconstruct After fixation of ACL & PCL reconstructsLateral incisionExpose proneal nerveLCL,Popliteofemoral lig. ,popliteus tendonJoint capsuleAvulsion of biceps femoris & ITB
23 Critical concepts: The majority of the knees are treated surgically The goal of anatomic repair & reconst.Approach with in 1st three weeksEmergency surgery in: open, irreducibleOr with vascular injury or compartment syn
24 Order of fixation of ligaments in repair or Reconstruction 1st FIX PCL in 90 flexionThen ACL in extentionThen LCL in 30 FLEXIONFinally MCL in 30 flexion
25 Critical concepts In open knee dislocations : Wound management Adequate soft tissue coverageDictate :The timing of ligament reconstructionNever be performed acutely
26 Irreducible Dislocations Uncommon but needs prompt,Surgical reductionTo avoid NV damageDelay definitive reconstructionAllow complete knee imagingPlanning & stabilization of the patientEmergent vascular repair
27 Critical concepts Management & treatment of compartment syndrome Simple primary repair of injured soft tissueAvoid additional incisionsDelay definitive ligament reconstructionsIn vascular repair give enough time
28 Contraindications: Advanced age or sedentary lifestyle An active infectionIntra-articular or periarticular fracturesOsteoarthritisDebilitating or posttraumatic comorbidities
29 Pitfalls: Well planned skin incisions MIS, use of Allograft & arthroscopyOpen technique for medial & lateralLow intra-articular fluid pressureTo avoid compartment syndromeRe 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 proceduresUntreated 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 ligamentsRestoration of all cruciate ligaments& correction of varus malalignment
32 Chronic inj.of the PLC of the knee (Covey DC.JBJS 2001) More complex problem than acuteScarring, secondary changes to other st.Possible limb malalignmentThe goals of operative treatment are:Restoration of knee stability & kinematicsReturn to preinjury activity levelReduce chance OA ,
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