L12 LE Surgeries Flashcards
Proximal Hamstring Tears
-30% of new LE injuries in atheltes
-common in soccer, track, field, football
-eccentric contraction of hamstring when muscles are at max elongation
Avulsion hamstring injury
sudden hip flexion/kne extension
Sudden takeout phase of running causes
intramuscular or musculotendinous injuries
Conjoint tendon
semitendinosus and long head biceps
Presentation of Proximal Hamstring Tears
-pop followed by sudden pain in post thigh and buttock
-painful to sit
-palpable painful mass, palpable defect
-everyone will be weak initially, regardless of grade
-sciatic irritation not common in acute
bruising indicates higher grade injury
Exam/imaging for proximal hamstring tears
-x ray always, looking for bony avulsion in younger patients
-MRI to determine if surgical in appropriate patient
Treatment for proximal hamstring tears
nonoperative in most situations
Rest, NSAIDs, PWB for 4 weeks, PT
usually 3 month recovery
Who has non-operative proximal hamstring tears?
single tendon tears
2 tendon tears <2 cm retraction
myotendinous jxn injury
low demand/poor surgical candidates
Surgical Treatment for Proximal Hamstring Tears
acute within 4 weeks
repair with 2-4 anchors in ischial tub
open or endoscopic
+/- sciatic neurolysis
chronic requires reconstruction w/bridge graft
Outcomes for proximal hamstring tear surgeries
84% return to pre-injury strength
8% sciatic n injury
12% re-rupture rate
Grade 0 Ligament Laxity
<2 mm translation
tight, firm endpoint, same as contralateral side
Grade 1 Ligament Laxity
3-5 mm translation
normal increase compared to contralateral side
Grade 2 Ligament Laxity
6-9 mm translation
slight increase in laxity, soft endpoint
Grade 3 Ligament Laxity
> 10 mm, significant laxity and no endpoint
ACL Injury
knee valgus collapse and hip adduction
poor landing mechanics, neuromuscular activation
usually non-contact, with tibia translating anterior with knee flexed in valgus
contact injury = direct blow to lateral knee
History/Exam of ACL Injury
-felt a pop, pain, swelling, unable to WB
-rapid effusion, limited mobility
-exam often confounded by guarding/swelling
-pivot shift in acute isn’t helpful
-should still consider ACL even if exam isn’t clear, but history is
Imaging ACL Injury
X ray = can show segond fracture
MRI = confirms tears, looks for other pathology like L. meniscus, chondral damage, collaterals
Treatment of ACL
consider patient, activity level, expectations. is it a functional instability or sports instability
Nonoperative treatment for ACL
use PT and functional bracing
low demand patients
recreational activities not in level 1 or 2
arthritis
Sports Activity Rating
1 = jumping, cutting, pivot
2 = lateral movements, less pivot
3 = straight ahead actions
4 = sedentary
Repair for ACL
Partial tears, proximal tears, avulsion
internal brace is really helpful
reconstruction is the gold standard
Bridge Enhanced ACL Repair
new in last 2-3 years
comparable to ACLR
acl repaired with collagen based implant soaked in PRP, helps bridge the gap and heal the ACL
ACL reconstruction
gold standard
prehab is critical, need full ROM and no swelling
3 months post injury is the best time
Post-op rehab is key in patients looking to return to sport
post rehab should be at least 6 mo
For active high level athlete
bio ACL with quads tendon autograft
lateral extra-articular tenodesis, helps to reduce reoccurrence
Low demand/functional instability patients
soft tissue allograft
Moved away from bone/patella
quad outcomes equal
less morbidity
MCL Injury
most common ligamentous injury
valgus stress w/knee in flex and ER
proximal tears more common
often associated with ACL tear
Distal MCL Tear…
has poor healing capacity
Superficial MCL
primary valgus restraint at all angles, greatest in 30° flexionD
Deep MCL
secondary stabilizer, greatest in full extension
Presentation of MCL injury
valgus stress, medial pain, maybe swelling
instability with WB
laxity w/valgus stress, increased laxity in full ext
Treatment for MCL injury
almost always non-operative
grade 1 = nsaids, rest, RTP 1-2 weeks
grade 2 = bracing, RTP 4-6 weeks
grade 3 = bracing 4 wks, RTP 8-12
MCL is operative…
chronic laxity (grade 3)
full distal tears or flipped proximal
multigamentous injuries
When to use repair for MCL
acute grade 3 w/multi ligament
displaced distal avulsion
entrapped in joint
When to use reconstruction with allograft
chronic injury
loss of good tissue
gold standard in most cases
PCL Injury
always traumatic
fall with knee in HE, foot PF
presents with posterior instability
often associated with PLC
Exam for PCL
posterior sag sign
posterior drawer (most accurate)
dial test (for PLC)
Non-operative treatment for PCL
isolated tears
bracing, protected WB, rehab
Operative PCL injury
isolated grade 3 in young athletes
multigamentout injuries
displaced avulsion fx
chronic instability
PCL Repairs
for acute and avulsion injuries
PCL Reconstruction
chronic, significant tissue loss
LCL injury
sudden varus force to knee
isolated is very rare, often with PLC
LCL is tight in extension, lax in flexion
LCL Injury Symptoms/Exam
instability near full ext
difficulty with stairs
lateral pain/swelling
tender over LCL
hyperextension/varus thrust
Nonoperative treatment for LCL
isolated grade 1 or 2
bracing, progressive ROM, functional rehab
RTP by 6-8 weeks
Operative LCL Treatment
Need to prove that you need it
treat all isolated with non-op
reconstruct who needs it
fix/repair displaced avulsion fx
reconstruct LCL/PLC injuries
rate of failure is very high
Meniscal Tears
traumatic or degenerative
most common indication for knee surgery
higher risk in ACL tears b/c they become stabilizers
medial more common that lateral except with ACL injuries
Tear Types for Meniscal Tears
vertical/longitudinal
bucket handle
oblique/flap/parrot
radial
horizontal
complex
root
Vertical/longitudinal
common with ACL tears
Bucket handle
progression of vertical tear
locked knee
Oblique/flap/parrot beak
often cause mechanical symptoms
Radial
full thickness tears
rapid arthritis
Horizontal
common in older population
associated with meniscal cysts
Complex
usually chronic, degernative
Root
functionally equivalent to total meniscectomy
Presentation of Meniscal Tears
-twisting, immediate focal pain
-delayed effusion
-pain S/S with pivoting, deep flexion, squat
-possible effusion
-joint line tenderness
-pain with high flexion
Non-operative for meniscal tears
first line for degenerative tears
outcomes equivocal to menisectomy
stable apearing tears in red zone
NSAIDs, PT
do NOT use PRP
Surgery for Meniscal Tears
unstable tears, mechanical S/S
acute tears in young pts
root tear
buckethandle tear
Meniscal Root Tears
middle aged, overweight
pop in posterior knee
severe pain, swelling, instability
aggressive surgical indications, conservative tx will not heal this
Meniscus allograft transplant
young, healthy patient with subtotal meniscectomy
no or minimal degenerative changes
address concomitant pathology like ACL, cartilage, malalignment
Articular Cartilage
made mostly of water and type 2 collagen, proteogylcans, chondrocytes
helps to decrease friction and distribute load
Fibrocartilage
located in menisci, and is made of fibrous cartilage, type 1 collagen, some proteoglycans, chondrocytes
healing response to injury of articular cartilage. Compressive strength
Osteochondritis Dessicans
pathologic lesoin affecting articular cartilage and subchondral bone
present in juvenile or adult, most common in the knee
can be heriditary, traumatic, vascular
Pathoanatomic cascade of OCD
- softening of overlying articular cartilage
- early articular cartilage separation
- partial detachment of lesion
- osteochondral separation with loose bodies
Symptoms of OCD
activity related pain, vague, poorly localized
mechanical symptoms–unstable lesion, advanced disease
recurrent knee effusions
use MRI to diagnose advanced disease
MRI characterizes these things for OCD
size
status of bone
stability of lesion
loose bodies
OCD Staging
1 = small area, compression on subchondral bone
2 = partially detached fragment
3 = fully detached, still in crater
4 = complete detachment/loose body
Nonoperative Tx for OCD
stable lesions, open physes
asymptomatic lesions in adults
restricted WB with bracing up to 3 mo
50-75% will heal
Operative Tx for OCD
unstable lesions, impending physeal closure, expanding lesions on XR, failed non-op
options include subchondral drilling, fixation of lesion >2 cm, chondral resurfacing, arthroplasty
Prognosis for OCD
correlates with age, location, appearance
open physes is best predictor of successful nonoperative tx
medial femoral condyle is better
adult OCD, sclerosis on x rays and fluid behind lesion on MRI is worse
Osteochondral Grafting–OATS
patient <50 yo, BMI <35, with lesions up to 15 mm
transfer of healthy cartilage from NWB area to the lesion
Osteochondral Grafting–OCA Transfer
for large lesions too large for autograft
fresh sterilized cadaver that is pt match
not useful in OA, bipolar lesion, inflammatory arthropathy, >50 years, smoking/alcohol abuse
Chondromalacia
sick cartilage, most often seen on patella and causes ant knee pain
most common in adolescents, young adults, women
Etiology of chondromalacia
roughening/damage to patellar cartilage
mult-factorial: muscle weakness, anatomy, patellar maltracking. Basically elevated PF contract pressures
miserable malalignment syndrome
Miserable malalignmnet syndrome
femoral anteversion, genu valgum, external tibial torsion, increased Q angle
Presentation of chondromalacia
retropatellar pain, often radiates post
insidious, chronic, vague
pain w/stairs, prolonged sitting, squat
quad atrophy, positive J sign, lateral patellar sublux, crepitus, pain with patellar compression with ROM
Chrondomalacia Imaging
X-ray = shallow sulcus, patellar tilt
MRI = assess cartilage, trochlear dysplasia, patellar tracking, rotation
Nonoperative Tx for Chondromalacia
almost always first line tx
min 6 mo before considering surgical intervention
avoid steroids
rehab focusing on core, posterior chain, hip ER, closed chain quad, flexibility
Operative Treatment for Chondromalacia
cartilage = chondroplasty, microfx
alignment = lateral elngthening, patellar realignment
trochlear deepening
MACI
for full thickness chondral defects up to 8 cm
patient harvested chondrocytes cultured and grown on film
implanted back into defect
excellent outcomes in appropriate patients
Realignment for chondromalacia
tibial tubercle osteotomy for patellar instability
increasingly more popular for chondromalacia
idea is to offload diseased area, improve tracking
Knee Arthritis
degenerative process causing progressive loss of articular cartilage
pain at rest, activity induced swelling, stiffness, instability, mechanical
Anyone above a grade ____ needs knee replacement
3
Grades for arthritis
Grade 0 = no OA
Grade 1 = minute osteophyste
Grade 2 = definite osteophyte, normal joint space
Grade 3 = some joint space reduction
Grade 4 = joint space greatly reduced
Nonoperative Treatment for OA
rehab, education, wellness
NSAIDs
weight loss program
bracing
Controversial treatments for OA
viscosupplementation (works with 60%)
corticosteroid injections (doesn’t work with activity based pain)
orthobiologics like PRP
Operative treatment for OA
High tibial osteotomy
Unincomportmental arthroplasty
Total knee arthroplasty
High Tibial Osteotomy
young, active, healthy patients
isolated OA with varus malalignment
many contraindications
Unicompartmental arthroplasty
older, low demand, health pts
unicompartmental disease
many contraindications
has faster rehab, less morbid, preservation of normal kinematics. Has high loosening rate and stress fx
not many patients meet the criteria
Total Knee arthroplasty
most people do great
15-20% of people have pain with no physiologic explanation
survival rates of at least 80% at 20 years
arthroscopic debridement is not recommended. Could make it worse and 50/50 chance success
