Young Adult Knee Injuries Mr Hersh Deo MB BS, MRCS, MSc., FRCS(Tr&Orth) Consultant Orthopaedic Surgeon James Paget University Hospital NHS Foundation Trust & The Spire Norwich Hospital

The knee is the most commonly injured joint in the high risk sports of football and rugby.1 Acute knee injury is the commonest cause of permanent disability after a sports injury.2 1.Bollen S. Injuries of the sporting knee. Br J Sports Med2000;34:227–8. 2.Kujala UM, Taimela S, Antti-poika I, et al. Acute injuries in soccer, ice hockey, volleyball, basket ball, judo and karate: an analysis of national registry data. BMJ1995;311:1465–73

Range of injuries Traumatic synovitis Meniscal tears ACL rupture Patella dislocation OCD Collaterals PCL PLC Combined injuries

History Contact - Valgus force (rugby tackle from the side) – terrible triad…

History Non contact - Twisting with foot planted, cutting, jumping, sudden deceleration

History Exact mechanism of injury Rip / tear? Immediate / delayed swelling Since the injury Swelling Pain Giving way (instability – when?) Locking

Examination Effusion Look Patellar stability Joint line tenderness / crouch Feel ROM Move Collaterals ACL Pivot shift Special tests Lachman’s Anterior drawer

Investigations Plain radiographs – 3 views CT – exclude # MRI – soft tissues

Common knee injuries Meniscal tears – excise or repair OCD – Chondroplasty, microfracture, chondral transplant ACL rupture – conservative or reconstruct (arthroscopic anatomic 4 strand hamstring) Patella dislocation – conservative / surgery if recurrent

Acute Management Analgesia Brace Crutches TWB + RICE Refer to knee clinic

Meniscal Tears

Meniscal Tears Localised pain, effusion, giving way, locking(BHT) Tender joint line, unable to squat MRI Arthroscopic debridement or repair

Meniscal tear

Arthroscopic Meniscal Repair

Lateral meniscal repair

Lateral meniscal repair

Meniscal Repair 85% successful repair Age of patient Tear <6 weeks old Prevents OA (lateral > medial)

ACL Tear Twisting on planted foot, “pop or rip”, rotational instability Effusion, +ve Lachman, ADT & PST +ve MRI Physio or Reconstruction

Trans-Tibial v Anatomic ACLR

Trans-Tibial v Anatomic ACLR Trans-tibial versus antero-medial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Bedi A et al. Arthroscopy. 2011 Mar;27(3):380-90. The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in improvement in control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction

Vertical v anatomic graft placement

ACL Reconstruction 4 strand hamstring v BPTB autograft Anatomic tunnel placement Arthroscopic Back to sport 9-12 months

ACL rupture

Notch clearance

Anatomic placement of femoral tunnel

Hamstring harvest and prep

Femoral tunnel reaming

Tibial tunnel placement

Graft passage

Tibial fixation

Recurrent Patella Instability Recurrently subluxing or dislocating patella which affects quality of life Positive apprehension test Skyline view and MRI Physio (VMO) MPFL reconstruction

MPFL Reconstruction 91% good to excellent results at 5 years Steiner TM, AJSM 2006;34:1254 Drez D, Arthroscopy 2001;17:298 95% return to previous level of sporting activity

MPFL Reconstruction

Osteochondral Lesions

What’s the problem? 60% of knees we scope have an articular cartilage lesion Microfracture is very commonly performed Success depends on many factors Patient selection Post op rehab

Microfracture – patient selection Focal, full-thickness chondral defects with surrounding rim of cartilage Size of lesion Age Femoral condyle

How does micro# work? – “stem cell therapy”

Microfracture

Microfracture “Microfracture success depends not only on the operation but rehabilitation as well…we felt that the rehabilitation program was equally as important as the surgical procedure,” J. Richard Steadman, MD

Microfracture - rehab 8 weeks partial weight bearing If a CPM machine is not used, the patient begins passive flexion/extension (straightening and bending) of the knee with 500 repetitions three times a day. Patients must not resume sports that involve pivoting, cutting, and jumping for 4 to 6 months after a microfracture procedure. Steadman

Prognosis Micro-fracture is only about 70% successful long-term

What’s the answer for the remaining 30%? Cartilage regeneration procedures

Cartilage Regeneration ACI / MACI – too expensive, only used in large centres RNOH Artificial (bovine collagen) scaffolds – no evidence Mosaicplasty (small plugs) – again only 60-70% success

Osteochochondral Transplant

Osteochondral Transplant Useful after failed microfracture Excellent mid to long-term results Rehab as for micro-fracture

Very large OCD

Double COR

Partial Knee Replacement Used in isolated knee OA Medial , lateral or PFJ Excellent for maintaining patients function and proprioception Back to sport 3-6 months

PFJR

Summary Recent advances Meniscal repair Anatomic ACLR MPFL reconstruction Osteochondral transplant Partial knee replacement (Medial / lateral UKR, PFJR)

Any questions? www.yarmouthkneeandhipsurgeon.co.uk Thank you Any questions? www.yarmouthkneeandhipsurgeon.co.uk