6 Days Postgraduate Orthopaedic Course for FRCS Exams

1. POSTGRAD ORTH Deiary Kader
KNEE 2
Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Professor Deiary F Kader
Knee Surgeon
South West London Elective Orthopaedic Centre
Epsom & St Helier University Hospitals
Sport and Exercise Sciences, Northumbria University
ICRC Specialist Surgeon (Geneva)

2. POSTGRAD ORTH Deiary Kader
PLAN
1. MENISCUS
2. ACL
3. MCL
4. PCL
5. PLC
6. MULTI LEGAMENT
7. PFJ

3. MENISCAL RESECTION &
REPAIR

4. POSTGRADORTH Deiary Kader
Meniscal Anatomy

5. Radial Fibres, serving as “ties” that resist shearing
or splitting.
Fibres run parallel or circumferentially to resist
hoop stress during weight bearing.
5

7. POSTGRADORTH Deiary Kader
Composed of
70% water
30% organic matter
Collagen constitutes 75%

8. Meniscus
Vascular Supply
Peripheral Vascularity 25-30%
Medial and Lateral Geniculates
Zones
Red
Red-White
White
Red Red-White White

9. Meniscal Function
➢ Load distribution
•50% in extension
•90% in flexion
–PH in >90o flexion
•Lateral > Medial
➢ Joint stability
➢ Congruity
➢ Lubrication
➢ Proprioception

10. Meniscal Tear
Management :-
➢ Excision
– 60% of people over 65yrs have incidental
tears
➢ Repair
➢ Transplant
➢ Replacement

11. Repair
Excise

12. POSTGRAD ORTH Deiary Kader
Arthroscopy Papers
1- N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189.
Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. Sihvonen R
2- CMAJ. 2014 Oct 7;186(14):1057-64. doi: 10.1503/cmaj.140433. Epub 2014 Aug 25.
Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-
analysis. Khan M
3-BMC Musculoskelet Disord. 2013 Feb 25;14:71. doi: 10.1186/1471-2474-14-71.
Arthroscopic partial meniscectomy in middle-aged patients with mild or no knee osteoarthritis: a
protocol for a double-blind, randomized sham-controlled multi-centre trial. Hare KB
4-Am J Sports Med. 2013 Jul;41(7):1565-70. doi: 10.1177/0363546513488518. Epub 2013 May 23.
A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears
of the medial meniscus.Yim JH
5-Knee Surg Sports Traumatol Arthrosc. 2013 Feb;21(2):358-64. doi: 10.1007/s00167-012-1960-3.
Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A
five year follow-up.
Herrlin SV
6- N Engl J Med 2002; 347:81-88July 11, 2002DOI: 10.1056/NEJMoa013259
A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. J. Bruce Moseley
7- Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and
harms, BMJ 2015; 350 doi: JB Thorlund
Thorlund

14. Snapping knee in deep flexion

15. POSTGRADORTH Deiary Kader
Meniscal repair
Factors to consider
When would you repair a menx?

16. POSTGRADORTH Deiary Kader
Meniscal repair
Factors to consider:
Patient
Chronicity
Type
Location
Tissue quality
Stability of knee
Axial alignment

17. POSTGRADORTH Deiary Kader
Meniscal repair
Techniques
➢Inside-out vertical mattress suture (gold standard)
➢Outside-in
➢All-inside
➢Overall 75-90% success
➢New research
– Better devices
– Biologic healing/augmentation
– Growth factors/Stem cell therapy

18. POSTGRADORTH Deiary Kader
??????

19. POSTGRADORTH Deiary Kader
Meniscal Substitutes
➢Engineered constructs
– Collagen Meniscal Implant
– Synthetic Scaffold (Actifit)
– Hydrogels
Collagen

20. POSTGRADORTH Deiary Kader
Menx Allograft
Indications

21. Outerbridge Arthroscopic Grading System
Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II Partial thickness defect, fissures < 1.5cm
diameter
Grade
III
Fissures down to subchondral bone, diameter >
1.5cm
Grade
IV
Exposed subchondral bone

22. POSTGRAD ORTH Deiary Kader
ICRS
<1cm
>1cm
The modified International Cartilage
Repair Society (ICRS)
The Outerbridge classification

24. MACI

25. Microfracture
Effective in smaller lesions
Leads to fibrocartilage production,
ACI
Greater proportion of hyaline-like tissue
Effective in larger lesions.
MACI
Technically less challenging
For big lesions > 4 cm
More effective than microfracture.

26. POSTGRAD ORTH Deiary Kader
ACL Injuries
FRCS(Tr&Orth) Revision Course

27. Anatomy
➢33 mm long, 11 mm in diameter
➢Two bundles
➢AM bundle – tighten in flexion
➢PL bundle – tighten in extension
➢

28. ACL is a primary resister to internal rotation of the tibia at <35º of flexion
while the anterolateral ligament is a stabiliser of internal rotation
in >35º of flexion .
Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh
The Biomechanical Function of the Anterolateral Ligament of the Knee
Am. J. Sports Med. Jan 2015
Prevent Internal Rotation of the Tibia

29. POSTGRAD ORTH Deiary Kader

30. McDaniel – Rule of Thirds
●One-third is able to compensate, and can
pursue normal recreational sports
●One-third is able to compensate but will have
to reduce their sporting activities
●One-third does poorly and develop instability
with simple activities daily living

31. POSTGRAD ORTH Deiary Kader
Paul F. Segond
a Paris surgeon
1879

32. POSTGRAD ORTH Deiary Kader
ACL Evidence-Based Review
Factors affecting results:
➢ Patient Selection
➢ Tunnel placement
➢ Strong graft choices
➢ Solid fixation
➢ Rational rehabilitation

33. Surgical Treatment
Indications:
1) Subjective instability (non-coper)
2) ACL tear in children and adolescents
3) Multiligament injury
4) Displaced meniscal tears

34. Surgical
● Extra-articular reconstruction (Lemaire 1967 & MacIntosh
1972) Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there
is concern regarding its effectiveness in addressing anterior translation
● Intra-articular reconstruction. Current best practice
● Intra + Extra articular reconstruction

35. Hamstring BTB
Grafts / Fixations
Quads

36. In 1972, D. L. MacIntosh
In 1967,1975, M. Lemaire
Extra-articular
reconstruction

37. POSTGRAD ORTH Deiary Kader
ANTEROLATERAL LIGAMENT

38. Anatomic Single bundle recon

39. 5mm +

40. ACL Tunnels

41. Meyers and McKeever classification (1959)

42. Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
MCL

43. Medial Collateral Ligament Exam
25-30° of flexion, the MCL
provides 80% of the support to
valgus stress

44. Treatment
Acute isolated MCL tear
I RICE, physiotherapy. 2 Wks
II ?Hinged brace for symptom improves, WBAA,2wks
III Hinged brace 30-90/ Surgical 3-4 wks
Combined injury ACL and MCL→Reconstruction ACL and
non-operative treatment MCL I-II but surgical for III
MCL

45. MCL Reconstruction
with AT
+
Revision ACLR
Chronic MCL Injury

46.
PCL and PLC
Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course

48. PCL
Average length of 38 mm and
diameter of 13 mm
AL Bundle: Long, thick, Large part
Tightens in flexion
PM Bundle: Tight in extension
Meniscofemoral ligaments: mechanically very strong
➢Anterior: Humphrey’s ligament
➢Posterior: Wrisberg’s ligament

49. a. Ant Meniscofemoral lig
Humphrey
b. Post Meniscofemoral lig
Wrisberg

50. 50

51. Diagnosis ?

52. Surgical reconstruction
Indications
• Acute combined injuries
• Acute bony avulsion
• Symptomatic chronic PCL

53. 53
PCL Reconstruction

54. What are the structures in the
Posterolateral Complex of the
Knee?
Function???
54

55. Posterolateral Complex
55

56. What is the function of the
Posterolateral Complex of the
Knee?
56

57. The Posterolateral Corner
(PLC)
57

58. The Posterolateral Corner
(PLC)
Isolated PLC sectioning produce a maximal
Average increase of 13° of tibial ER at 30° of knee flexion
Average increase of 5.3° of tibial ER at 90°
Isolated PCL sectioning has no effect on external tibial
rotation
Combined injury to the PCL and PLC leads to ER of 20.9°
at 90° of knee flexion
58

59. Posterolateral Complex Injury
59

60. Posterolateral Complex
Injury--Treatment
Partial
– Grade I & II Instability with a good end point
– Nonsurgical Treatment
– 1-3 week immobilisation in extension
Complete Acute
– Primary repair best
– Augment with allo/auto graft
Complete Chronic
– Reconstruct Popliteus and LCL
60

61. PLC Reconstruction
The reconstruction can be:-
✴Fibula based such as modified Larson’s technique or
✴Combined tibia and fibula based such as LaPrade’s
anatomical reconstruction.
61

62. 62

63. Vascular Injuries
63

64. Classification
64

65. Examination
Recurvatum
65

66. Management
Emergency
66

67. Management
Surgery as soon as the vascular surgeon allows
Most ACL/PCL/MCL can be treated with bracing the MCL followed by
combined ACL/PCL reconstruction once range of movement is
restarted, usually after 6 weeks.
ACL/PCL/posterolateral corner can be treated by repairing the
posterolateral corner acutely (within three weeks) and delayed ACL/
PCL reconstruction 8 weeks later. Or all in One
Open dislocation, fracture dislocation and vascular compromise
require staged procedures.
67

68. 68

69. 69

70. 70
MPFL
VMO
VMO
MPFL
VMO
Patella Quads
TendonPatella
Tendon
Medial Knee
M.E
Add.Tub
Femur

71. PATELLAR DISLOCATION
➢Re-dislocation rate is very high
➢After First Time 17-20%
➢After Second Time 44%-71%
➢High dissatisfaction following conservative Rx
➢Can be confused with ACL rupture
71

72. WHY THE PATELLA IS UNSTABLE
Lower limb Malalignment??
– Femur, tibia or foot pronation
Osseous abnormalities??
– Patella alta
– Increased Q angle
– Trochlea dysplasia
Soft Tissue??
– HMS
– MPFL Insufficiency
– Muscle or ITB
Gait ??

73. KNEE ASSESSMENT
Leg Alignment Varus/valgus
Femoral neck anteversion
Tibial rotation
Ligament assessment (ACL,PCL, MCL, LCL)
Meniscal assessment
Medial/ Lateral compartment OA
Hip , Spine, peripheral pulses
Apprehension test

74. PATELLA ASSESSMENT
Beighton Score 0---9
Patella Alignment (Q Angle)
Dislocation in extn (J Sign)
Quads Bulk/ ITB (Ober's test)
Hamstring Tightness
Patella height Alta/Baja
Patella Mobility (N@300=<1/2)
Parapatellar tenderness
Patella Apprehension
PFJ Crepitus
PFJ Compression (Clarke test)
Trochlea Depth Normal (1380)
– Shallow ,Flat , Convex , Cliff

75. IMAGING OF THE PATELLOFEMORAL JOINT
✦ AP and Lateral Knee x-ray
✦ Merchant’s view
✦ MRI Axial view
✦ CT Rotational Profile
Merchant’s

76. 76
Trochlea
dysplasia
Blumensaat's line
Normal Trochlea
Depth
NORMAL

77. MEASURING PATELLA HEIGHT
Caton – Deschamps
index =1.2
Blackburne-peel
index = 1.12

78. 78
MPFL injury
Patella pain
Articular Damage
MRI SCAN

79.
ROTATIONAL PROFILE CT
EVIDENCE BASED INTERVENTION
1. Femoral Anteversion N=50 -150
2. Knee rotation N=30
3. External Tibial torsion 250-300
4. TT:TG offset (N= 10-19mm)
5. Patella index
6. Patella Tilt (N=average QD&QC <200)
7. Trochlea Tilt (N>130)
8. Trochlea Depth Normal (1380+/- 60)

80. 80
analysis
Normal measure is 5° to 15°
Femoral anteversion

81. 81
LATERAL PATELLAR TILT

82. 82
lateral trochlear tilt
The pathologic measure is <14°

83. 83
Clinique de la
analysis
lateral tibia twisting
slices n°3 and n°4
Normal Ext rotation is 25° to 30°

84.
TRUE Q ANGLE, MEASUREMENT OF THE TIBIAL
TUBEROSITY-TROCHLEAR GROOVE (TT/TG) DISTANCE
Normally TT/TG = 2-9 mm
pathologic measure is > 19 mm

85. 85
TROCHLEAR DYSPLASIA
Dejour classification of trochlear dysplasia on
CT scans

86. 86
Shallow flat
dome-shaped medial ‘‘cliff-face.’’
Dejour classification

87. NON-SURGICAL TREATMENT OF
PATELLA INSTABILITY
Conservative first
Quads strengthening
Core stability
McConnell Taping
Insoles
Gait

88. PFJ BIOMECHANICS
Patellofemoral joint reaction force
WALKING 0.5xBW
STRAIGHT LEG RAISE 0.5xBW 0 DEG
CYCLING: 1.2 × BW
RISING FROM A CHAIR w ARMS: <3 × BW
STAIRS (UP OR DOWN) 3.3xBW 60 DEG
JOGGING & SQUAT–RISE 6xBW at 140 deg
SQUAT–DESCENT 7.6x BW at 140 deg
JUMPING UP TO 12 × BW
Ff
Ft
Fj
Trigonometry
Fjf=Ff cos(angle/2)

89. SURGICAL OPTIONS
Instability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
89

90. TIBIAL TUBERCLE TRANSFER
Patellofemoral Instability with Malalignment

91. FULKERSON'S TECHNIQUE OF
ANTEROMEDIALIZATION
A steeper osteotomy plane will produce more
anteriorization along with medialization

92. PATELLA ALTA
–Distal transfer (Distalization)

93. 93
1.4 cm
Patella alta

94. Med Epicondyle
Add Tubercle
Patella
MPFL

95. 95

96. Our Dissection

97. 97

98. TROCHLEA DYSPLASIA
TROCHLOPLASTY

99. 99

100. SURGICAL OPTIONS
Instability with Malalignment Tib Tub Medialisation
Instability without Malalignment MPFL Reconstruction
Instability with patella alta Tib Tub Distalisation
Trochlea Dyslpasia Trochleoplasty
Rotational problems Derotation Osteotomy
100

101. 101
24 years old female doctor
had a permanents
dislocation of the patella
Treated with
1. Lateral release
2. Tib Tub Medialisation
3. Tib Tub Distalisation
4. Trochleaoplasty
5. MPFL Reconstruction