Knee patho (ligaments and meniscus)- Dr Davies Flashcards
MCL (MOI)
Traumatic valgus force
Twisting injury associated with an ACL injury
MCL (Symptoms)
Pt describes the MOI Pts may describe a "tearing" sensation Pain Pain with palpation over MCL *subjective*
MCL (Signs)
*attaches to the meniscus so can injury the meniscus
Localized swelling (extra-articular)
If also affects ACL or meniscus, then will have effusion (intra-articular)
Increases c/o pain with valgus stress test
Laxity testing (depending on severity whether there is instability)
objective
Sprain vs Strain
Sprain- involves the non-contractile tissue (ligament or capsule)
Strain- involves the contractile tissue (muscle tendon unit)
Knee laxity testing biomechanics
Medial restraints at 0- MCL is only 57%
Medial restraints is 30- MCL increase to 78%
Lateral restraints at 0- LCL is 55%
Lateral restraints at 30- LCL increases to 69%
when you go to 30% you are able to target more of the LCL/MCL because the other tissues are more slackened than the LCL/MCL
Knee Instability Testing (Grades)
classification of the knee instability testing:
Grade 1: mild sprain
Grade 2: moderate sprain (partial tear of the MCL)
Grade 3: severe sprain (full tear)
Grade 2 1+
1-5 mm more laxity than the uninvolved side
- *make sure you know that 1+ and 2+ are both under grade 2
- *the amount of laxity is compared to the contralateral side
Grade 2 2+
6-10 mm more laxity than the uninvolved side
Grade 3 3+
> 10 mm more laxity than the uninvolved side
total rupture
Grade 1
pain, may be some swelling, NO LAXITY, some microtearing
interstitial injury to the MCL
If you have 3 mm of laxity on the uninvolved side and 7 mm on the involved side, what is the grade of the laxity?
Grade 2, 1+ because there is only 4mm different between involved and uninvolved
Valgus stress test in young people (what might go wrong)
when testing a young person (under the age of 16), you may think it is the MCL you are testing; you have to make sure you are on the joint line
there can be a lot of valgus movement at the physes (because the ligament is stronger than the physes)
*Problem can be at the physes instead of the MCL
what may go along with a MCL injury?
think about a PF subluxation also as a potential additional injury and a co-morbidity
palpate the adductor tubercle to see if there was a subluxation
Grade 1 MCL sprain (treatment)
Treat the symptoms MCL double upright brace Dynamic stability exercises Neuromuscular reactive training exercises Functional (specificity) exercises
Grade 1 MCL sprain (how long until return)
Should be back to sports approximately 1-3 weeks (average of 2 weeks) with the MCL double upright brace
Average of 10 days
**tell them the higher end of the time; they will think you know what you are doing (don’t what to get them back too early or have to not let them back)
lie on the side of caution
Grade 2 MCL sprain (treatment)
Treatment symptoms MCL double upright brace Avoid valgus stresses in rehabilitation Dynamic stability exercises Neuromuscular reactive training exercises Functional (specificity) exercises
Grade 2 MCL sprain (how long until return)
Should be back to sports in approximately 3-5 weeks (average of 4 weeks) with the MCL double upright brace
Grade2 1+ (3 weeks)
Grade2 2+ (4-5 weeks)
Grade 3 MCL sprain (treatment)
Treat symptoms Avoid valgus stresses in rehabilitation Drop-lock brace immediate post injury MCL double upright brace Dynamic stability exercises Neuromuscular reactive training exercises Functional (specificity) exercise
why do doctors have different protocols for the MCL drop lock brace?
limit the extension because it stresses the ligament (screw home mechanism will stress it even more
*but if you limit extension you may lose extension ROM
limit the amount of flexion will stress the ligament
*if you limit too much flexion, you many lose the amount of flexion ROM
Grade 3 MCL (amount of time to return to sports)
should be back to sports in 8-12 weeks with a MCL double upright brace
Surgery vs not surgery for MCL
Similar outcome
few MCL have surgery if good rehab
for surgery: isolated- high performance pt, functional instability, performed within the first several days (scarring will occur after that), associated injuries (multiple-plane injuries
will use suture anchors to reattach
On an MRI, how can you tell if there is a meniscus tear?
there will be a black line in the middle of the white meniscus (the black part is the tear)
3 meniscus surgeries
Arthroscopic partial meniscetomy (most common)
Arthroscopic meniscus repair
Meniscus allograft
Arthroscopic Partial Meniscetomy
the most common in the knee (and that most surgeons do)
the doctors will go in and remove part of the meniscus when it will not heal (white section of the meniscus can be smoothed out or debrided)
Arthroscopic Partial Meniscetomy (problem)
When you remove part of the meniscus, you will increase the weight bearing in the joint
Increase in weight bearing will lead to earlier OA changes; will have chondral DJD changes
the amount of DJD/ when the onset is will depend on how much meniscus was removed
Vascular Zones
IMPORTANT
Red-Red Red-White White-White genicular arterial supply *be able to draw and describe these* a dye is injected into circulation; this will show where there is good circulation/blood supply
Red-Red Zone
peripheral capsular detachment with blood supply on both sides so fully vascular with excellent healing potential
Red-White Zone
junction of vascular zone blood supply peripherally, not centrally. Border of vascular supply and has a generally good healing prognosis
*transition phase
White-White Zone
avascular zone and a poor prognosis for healing (no hope)
Red-Red Zone (info on it)
peripheral 10-30% (lateral 1/3)
vascular therefore repairable (within 3 mm of vascular periphery)
Red-White Zone (info on it)
tears to this zone (avascular midsubstance) repairable if vascularity stimulated through 3 techniques
3 techniques to help facilitate meniscus repair
1) fibrin clot injection
2) vascular access channel creation
3) synovial abrasion
Fibrin clot injection
a fibrin clot can be injected into the meniscal lesion to promote healing through hematoma chemotactic factors
the clot will be sown into there to help the avascular transition zone go through the healing process
vascular access channel creation
Vascular access channels (trephination) are tunnels created from vascular portions of the peripheral meniscus (red zone) to the more central avascular area (white zone)
Theoretically, trephination enables fibrovascular scar proliferation in the damaged meniscal section
*they make little channels in the vascular area to the non vascular area into to help with the healing
Synovial abrasion
Abrasion of the synovium with a surgical rasping device activates chemotactic factors that stimulate meniscal healing
*causes bleeding/ healing
Meniscal Repair Surgical Techniques
Open repair or arthroscopically assisted **Repairs are named by the origin of suture delivery Inside-Out Repair Outside-In Repair All-Inside Repair Meniscus arrows
Open repair (meniscal)
Rarely done anymore
Inside-Out Repair (meniscal)
the scope is inside and they pass the sutures outside
Outside-In Repair (meniscal)
the scope and the sutures start on the outside and pass inside the joint
All-Inside Repair (meniscal)
All is done inside
Meniscus Arrow
they have a gun and they literally shot a dart into the meniscus; not as effective
this is not a very good procedure
Meniscal Repair (rehab)
Rehabilitation is dependent on the strengthen of repair, fixation used, location of tear, and concomitant surgery
2 types of meniscal repair rehab
controversy exists among clinicians in the area or rehab principles after meniscal repair
traditional versus accelerated
traditional rehab for meniscal repair
Slow the pt down and do not do a lot of early weight bearing; wait a while before sending back to activities
Problem: too slow can decrease the ROM/ stiffness in the knee
accelerated rehab for meniscal repair
Let the pt do things at a faster pace
Problem: don’t want to have re-injury because the 2nd surgery will not be as good as the first
Meniscus Allograft
use a allograft tissue, size it, and attach it
have bone plugs at the posterior and anterior horns that will attached in the tibial plateau; will have to drill through the tibial to the contralateral side of the bone
(can also use a bone bridge and sow all the way around the new meniscus)
when would you do a meniscus allograft?
good for younger individuals (do not want to remove the meniscus in younger individuals since it can lead to DJD)
ACL MOI
Direct macrotrauma
pivot shift motion
the pt will have the “grab sign”
Types of ACL Grafts
Autogenous BTB (bone tendon bone) Autogenous Hamstring/ Gracilis Autogenous Quadriceps tendon Autogenous Contralateral BTB Allograft Any of these combinations + ALL Synthetic Grafts (didn't work) Tissue Engineering
Primary Repair
when you take the original tissue and sow it together
Reconstruction
when you remove the original tissue and replace it
want to try and leave the stumps of original (helps with the blood supply and proprioception)
what are the two things you can do with an ACL tear
surgery right away (NON-COPER)- even time they move, their knee gives out on them; you will not be able to return to a high level of function without surgery
OR
try and rehab it (COPER)- hop test, etc
Doing a contralateral harvest (positive and negative)
Positive- try and normalize the knees
Negative- why would you hurt a good knee; its also harder to rehab the harvest site knee
Allograft (why you have to worry)
it has to go through a process to try and kill any potient diseases: Radiate, Chemicals, Freeze
worry about diseases (1 in a million); also the body may reject the tissue
higher injury of rejection in allograft
Bundles of the ACL
Anteriomedial
Posteriorlateral
(sometimes say there is an intermediate)
Tests for AM and PL bundles
AM is tight doing a drawer test and the PL is loose; Laucmann’s will get both the AM and PL bundles
Surgeries for ACL
Single bundle
Double bundle
Portals for the surgeries (ACL)
will do a standard medial and lateral portal (goes straight through the fat pads)- want the patient to do constant massage to knee from getting knots in these portals
Accessory medial portal
Tibial incision
where to drill the trans tibial drilling for ACL?
Used to do at 11 or 1 o’clock which puts the graft very vertical, which makes thing rotate around it
Within a couple of years, moved the drill hole to 3 or 9 o’clock, which decreases the transverse plane motion
Double bundle (Positive and Negative)
Negative: the drill hole is only a couple of mm apart. there has been collapses. No long term outcomes (only been done a few years in the US); increases the time to do the surgery
Positive: decrease the mirco transverse plane motion and stronger biomechanically
Single vs Double (anterior translation and combined rotatory)
Anterior Translation- SB (89%) DB (97%)
Combined Rotatory SB (66%) DB (91%)
single helps with the sagittal plane motion
double will help more with the transverse plane motion as well as the sagittal plane motion (helps more with decreasing OA changes)
Native ACL compared to grafts (%)
Native ACL= 100% BTB graft= 120% (as the native ACL) semitendinosus= 70% gracilis= 50% Semit+G= 120% 4 strand Semit and Gr= 240%
Cyclops Lesion in the ACL
scarring that occurs in the center in the notch of the knee
this develops because of all the scarring that has developed due to all the surgery, etc
the scar tissue build will cause you to not be able to regain full extension
Rehab for the ACL (most important)
most important to work on regaining physiological extension in the knee compared to the contralateral side TERT formula (heat and weight on the knee) range of motion limiting brace
ALL
anterior lateral ligament
next to your LCL
connects between your gerdy’s tubercle and the fibula head
helps with your anterior rotatory stability
Safety study for the ACL
taking the primary tear repair of the ACL and scaffold sponge filled with the patients blood and wrapping it around the ACL to help facilitate the healing
will sow the original tissue together and then the blood will help to enhance the healing
taking 10 people for this study
Suprapatella pouch
the pouch goes far out the leg; need to go 10cm up the leg the pouch
*why you start the milking test so high
the anthropometric measurements in the lower extremities
20 cm above jt line- the bulk of the quads and hamstrings
10 cm above jt line- about in the VMO and supra pouch
at jt line
15 cm below jt line- bulk of gastro
figure 8- fluid will go distally so need to measure distally as well
Intra-articular swelling
effusion
- the severity of the injury does not correlate with the severity of the swelling
- if you have a 3rd degree rupture- it will move out of the capsule (which is why you always need to do you distal and proximal measurements)
*the rapidity of the swelling does correlate to the severity of the swelling; if you tear something, you will get a hemarthrosis- rapid swelling in the joint; however, if you do not have much blood flow in the area, then you will not have rapid swelling
Extra-articular swelling
1) edema: fluid in the interstitial spaces
2) bursitis
3) contusion: injury to the muscles, which can lead to a 4)hematoma
3 different variations on Intra-articular
Synovitis
Hemarthrosis
Hemathrosis with fatty modules
*when the doctor aspirates the knee, you will be able to tell which of these are causing the pts swelling
Hemarthrosis
blood in the joint, can cause degeneration in the joint
Two schools of thought on whether or not to aspirate the joint
it is an invasive procedure but there are reasons to aspirate it:
1) its appearance will give you diagnosis information
2) its easier to exam the joint (it hurts with all that swelling and gets rid of all the biomechanical crap)
aspirating of the knee
this is done with a 18 gauge needle through the superior lateral capsule
provides diagnosis information; looks at the color and consistence
Colors of aspiration of the knee (Synovitis)
yellow (NO RED)
will be different consistency
Viscous- (in the white part) meniscus tear
watery- chondral injury, sterile inflammatory condition
Cruddy looking- inflammatory infection
Colors of aspiration of the knee (Hemarthosis)
red
Bright Red: ACL rupture (85%) of the time, peripheral meniscus tear
Dark Red: dislocated patella (tears the arterial and venous)
