1. 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

2. 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

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

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

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

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

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

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

9. 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

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

11. Meniscal Tears

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

13. Meniscal tear

14. Arthroscopic Meniscal Repair

15. Lateral meniscal repair

16. Lateral meniscal repair

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

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

19. Trans-Tibial v Anatomic ACLR

20. 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 Mar;27(3):
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

21. Vertical v anatomic graft placement

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

23. ACL rupture

24. Notch clearance

25. Anatomic placement of femoral tunnel

26. Hamstring harvest and prep

27. Femoral tunnel reaming

28. Tibial tunnel placement

29. Graft passage

30. Tibial fixation

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

34. 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

35. MPFL Reconstruction

36. Osteochondral Lesions

37. 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

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

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

40. Microfracture

41. 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

42. 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

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

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

45. 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

47. Osteochochondral Transplant

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

50. Very large OCD

51. Double COR

52. 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

54. PFJR

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

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