1 / 33

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.

viola
Download Presentation

Complex Ligament Injuries of The Knee

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related