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Complex Ligament Injuries of The Knee

Complex Ligament Injuries of The Knee. H.Makhmalbaf MD Consultant Knee Surgeon Assistant Professor Orthopaedics Mashad University of Medical sciences. Surgical Management of Knee dislocations.

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Complex Ligament Injuries of The Knee

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  1. Complex Ligament Injuries of The Knee H.Makhmalbaf MD Consultant Knee Surgeon Assistant Professor Orthopaedics Mashad University of Medical sciences

  2. Surgical Management of Knee dislocations • JBJS supp. 2005 Anikar Chhabra MD & Christopher Harner MD , University of Pittsburgh Medical Center Pittsburgh Pennsylvania

  3. Evaluation & Management • Characterize the pattern of injury • Determine the surgical approach • By ligament examination • After, survival of the limb is assured • And, the patient is stabilized

  4. Investigations : • Plain radiographs AP& LAT • Avulsion fx: • Fibular head, PCL, Segond’s sign • Depression • CTscan, for fractures & avulsions • MRI • Ligament injuries • Other soft tissue injuries • Bony injuries

  5. Imaging

  6. Postermedial repair

  7. PM inj.& Subluxation

  8. PCL MCL ACL injury

  9. After repair

  10. Final outcome: • Stable ,pain free, good ROM • Stiff knee • Unstable & pain free • Unstable & painful

  11. Type of instability • One plain • Rotational • Posteromedial • Posterolateral • Convert multidirectional to: • One plain instability

  12. Anatomic classification of knee dislocation • KDI ,single cruciate torn+ one corner • KDII ,ACL/PCL torn ,collaterals intact • KDIIIM ,ACL/PCL/MCL • KDIIIL ,ACL/PCL/LCL/PLC torn • KDIV ,ACL/PCL/MCL/LCL-PLC torn • KDV knee fracture dislocation

  13. Knee dislocation management • Reduce • Splint & observe then operate • External fixation • Transfix pins • Vascular repair • Soft tissue condition?

  14. Planning • Surgical & non surgical issues • Timing of surgery • Repair • Graft selection for reconstruction • Surgical techniques • Risks & benefits • Complications discussed with the patient

  15. EUA & Positioning • Position the patient • EUA • Determine ligaments injured • Arthroscopic assessment • Gravity inflow irrigation • Avoid extravasation & compartment syn.

  16. Graft selection for multiple ligament injuries • Graft choice is based on the: • Extent of the injury • Timing of the surgery • Experience of the surgeon • Autograft • Better graft incorporation & • Remodeling • Allograft

  17. ACL& PCL reconstruction • BPB allograft for ACL • Achilles tendon allograft for PCL • Or Hamstring tendon autograft • Tunnel preparation • Achilles tendon allograft or BPB for LCL • Pass PCL graft first then ACL • Fix in the femoral tunnel ,tibial at the end

  18. Lateral side injury • Repair if fresh, or reconstruct • After fixation of ACL & PCL reconstructs • Lateral incision • Expose proneal nerve • LCL,Popliteofemoral lig. ,popliteus tendon • Joint capsule • Avulsion of biceps femoris & ITB

  19. KDIIIL

  20. Lateral side reconstruction

  21. KDIIIM

  22. Critical concepts: • The majority of the knees are treated surgically • The goal of anatomic repair & reconst. • Approach with in 1st three weeks • Emergency surgery in: open, irreducible • Or with vascular injury or compartment syn

  23. Order of fixation of ligamentsin repair or Reconstruction • 1st FIX PCL in 90 flexion • Then ACL in extention • Then LCL in 30 FLEXION • Finally MCL in 30 flexion

  24. Critical concepts • In open knee dislocations : • Wound management • Adequate soft tissue coverage • Dictate : • The timing of ligament reconstruction • Never be performed acutely

  25. Irreducible Dislocations • Uncommon but needs prompt, • Surgical reduction • To avoid NV damage • Delay definitive reconstruction • Allow complete knee imaging • Planning & stabilization of the patient • Emergent vascular repair

  26. Critical concepts • Management & treatment of compartment syndrome • Simple primary repair of injured soft tissue • Avoid additional incisions • Delay definitive ligament reconstructions • In vascular repair give enough time

  27. Contraindications: • Advanced age or sedentary lifestyle • An active infection • Intra-articular or periarticular fractures • Osteoarthritis • Debilitating or posttraumatic comorbidities

  28. Pitfalls: • Well planned skin incisions • MIS, use of Allograft & arthroscopy • Open technique for medial & lateral • Low intra-articular fluid pressure • To avoid compartment syndrome • Re check to make sure the compartments are soft

  29. Causes of failure in PLC inj • Frank R Noyes et al. Am J Sport Med. 2006 57 PLC operative procedures • Untreated varus malalignment (10) • Failure to reconstruct all ruptured ligaments , including cruciates (27) • Nonanatomical graft reconstruction (23 )

  30. F. Noyes recommendationsAJSM 2006 • Anatomical graft reconstruction of one or more P Lateral ligaments • Restoration of all cruciate ligaments • & correction of varus malalignment

  31. Chronic inj.of the PLC of the knee (Covey DC.JBJS 2001) • More complex problem than acute • Scarring, secondary changes to other st. • Possible limb malalignment • The goals of operative treatment are: • Restoration of knee stability & kinematics • Return to preinjury activity level • Reduce chance OA ,

  32. THANK YOUTehran 2007

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