THE DIS LOCATED KNEE CLINICAL & IMAGING EVALUATION JOO ES - - PowerPoint PPT Presentation

JOÃO ES PREGUEIRA-MENDES , MD, PhD

Chairman of Clínica do Dragão - Espregueira-Mendes S ports Centre – FIFA Medical Centre of Excellence Chairman and Professor of the Orthopaedic Department - Minho University President of the European S

• ciety of Knee S

urgery, S ports Trauma and Arthroscopy 2012-2014 Treasurer and Chairman of the Publication Committee of IS AKOS Board Member of the Patellofemoral Foundation Board Member of FIFA MCE PORTO, PORTUGAL

THE DIS LOCATED KNEE CLINICAL & IMAGING EVALUATION

• Treasurer and Chairman of the Publications Committee of the International Society of Arthroscopy,

Knee Surgery and Orthopaedic Sports Medicine (ISAKOS)

• Board Member of the Patellofemoral Foundation
• Inventor and patent holder of PKTD (no royalties and no fees)
• KSSTA Journal Editorial Board Member
• President of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy

(ESSKA and ESSKA Foundation) - 2012-2014

• Board Member of FIFA MCE

DISCLOSURE STATEMENT

The incidence of PLC inj uries in ACL-deficient knees: 7,4% to 13,9%

• probably underreported
• no consensus on the treatment of

combined ACL and PLC injuries

• Great variability in the reported incidence of PCL

inj uries:

• 1%

to 44%

• f all acute knee injuries
• reported incidence in general population: 3%

ANATOMY & BIOMECHANICS

MECHANISM OF THE LESION

Direct or indirect trauma Low-velocity High-velocity trauma

PROGNOS TIC V ALUE

S helbourn, 1991 4,6% vascular inj uries in LVT Green, 1977 32% vascular inj uries in HVT Wascher, 1997 16 t o 50% neurological inj uries HVT

KNEE DISLOCATION

(SCHENCK CLASSIFICATION)

KD I: One cruciate (plus collateral? ) KD II: Bicruciat e KD III M: Bicruciat e and MCL KD III L: Bicruciat e and LCL/ PLC KD IV: All four ligaments KD V: KD with intra-articular #

CLINICAL EVALUATION

Clinical history Type of work S ports activity Lower limb alignement Pain Effusion ROM (active & passive) Giving-way symptoms Muscle strength S tability (g.a.) Degenerative OA

LIGAMENTS VESSELS & NERVES CARTILAGE, BONE, PATELLA & PT, MENISCUS,

Compartment syndrome Popliteal artery Popliteal vein Feel the pulse (pulse deficit in 84% cases) S kin color (isquemia in 60% cases) Ankle-braquial index Duplex ultrasonography Angiogram (in all doubts!) Surveillance!!!

VESSELS LESION

INSPECTION & STANDING EXAM

Varus Thrust Gait

OFTEN ASSOCIATED WITH VARUS MALALIGNMENT

WALKING EXAM

LACHMAN

• Flexed Knee at 20º/ 30º
• Anterior knee laxity (ACL)
• End point (0,+,++,+++)
• Compare with the opposite side

ANTERIOR DRAWER TEST

• ACL + Associat ed lesions (meniscus and col. lig.)
• Knee flexed 90º

LATERAL PIVOT-SHIFT TEST

• Knee in full extension, internal rotation of the foot and valgus – antero-lateral

subluxation

(Gallaway, 1972)

• Less + if MCL or ITB rupture

VARUS STRESS 30º

• Apply stress through foot/ ankle, not on the leg
• Compare with the opposite side

VARUS EXTENSION

• FCL is primary restraint to varus
• Popliteus, posterolateral capsule and cruciates are important
• Cutting popliteus and PLC structures increases varus
• (Nielsen,1986;Grood,1988;Veltri,1995)

PERONEAL NERVE LESION

FCL ISTHE PRIMAR Y RES TRAINT TO VARUS

(VELTRI & WARREN,1995)

CABOT OR “4” TEST

30º VALGUS

• Apply stress through foot/ ankle, not on the leg - MCL
• Compare with the opposite side

VALGUS IN EXTENSION

• MCL is primary restraint to valgus
• Posteromedial corner and cruciates are important
• Cutting this structures increases valgus

(Veltri,1995)

• Knee flexion at 90º
• Hip flexion
• Foot neut ral(sit e on t he foot )
• Assess PCL st atus
• Quadriceps cont ract ion for

active reduction (PCL≠ACL)

POSTERIOR SAG

POSTERIOR DRAWER TEST

• PCL is t he only ligament for init ial

post erior rest raint at all flexion angles

(Daniel, 1987)

• PLC minor rest raint to posterior

t ranslat ion (Tria, 1991, Veltri, 1995)

• Knee flexion at 90°
• Foot 15° IR (sit on foot )
• Assess posteromedial rotat ion
• PCL (can be int act ?

)

• MCL
• Medial capsular lig.
• Post erior oblique lig.

POSTEROMEDIAL DRAWER TEST

POSTEROLATERAL DRAWER TEST

(J. Hughston, 1980)

• Knee flexion at 90º
• Foot 15° ER (site on foot)
• Assess posterolateral rotation

PLC and posterior translation

• PCL-deficient knee
• Cutting popliteus tendon
• Large effect on posterior translation (0-90°)
• Combined PCL/ PLC cutting increases

posterior translation compared to isolated section of either

• Between 0° and 30° no difference between

isolated PLC versus isolated PCL sectioning (Gollehon, 1987)

DIAL TEST 30°

In PLC external rotation of tibial tubercle (10 ° - 15° increase)

(Fanelli,1998)

Dial test + 30º.........PLC

DIAL TEST 90°

If the external rotation increases at 90°, PCL

(Grood, 1988) and/ or ACL (Wroble, 1993) also inj ured

Dial t est + 90º.........PCL+PLC

EXTERNAL ROTATION RECURVATUM

(J. Hughston, 1980)

Lift big toe Evaluate the recurvatum Maj or knee ligaments Inj ury (PCL+PLC… )

REVERSE PIVOT SHIFT

(R. Jakob, 1981)

It is the reverse of the lateral pivot shift:

• Flexed knee, ER of the foot & valgus
• Knee extension to reduce tibia subluxation

This test has a large variability (Cooper, 1991)

IMAGING

• Dislocation (AP

, Lateral etc.)

• Ap view bone avulsion
• (fibula, medial femoral, S

econd,Pellegrini S tieda)

• Lateral view –
• Congruency – fixed posterior translation
• Patellar height & fractures
• Long standing x-Ray - malalignment

X-Ray

• Ant erior st ress 30º/ 90º
• Posterior st ress 30º/ 90º
• ACL versus PCL and / or PLC
• Post erior t ranslat ion > 12mm – combined lesions
• Valgus and varus st ress
• Helpful in equivocal cases

IMAGING

STRESS RADIOGRAPHS

IRREDUCTABLE POSTERIOR SAG

Do not repair a ligament inj ury before reduction of the posterior subluxation

CT scan – Intra-articular fractures

IMAGING

MRI

• Confirm clinical examination
• Bicruciate
• MCL versus LCL
• PLC
• Other inj uries (meniscus, cartilage, bone bruise)

PCL CARTIL MENIS PT

IMAGING

• Iliotibial band
• Fibula avulsion
• Biceps complex
• Medial and fibula col ligament

ITB BICEPS

MEASURE 360º INSTABILITY

BES INNOVATION AWARD 2012 Health technology

Porto Knee Testing Device PKTD

CHEWING-GUM EFFECT WITH PKTD

No stress –ACL Partial rupture? Stress - Total rupture

PKTD with PA stress or ext and internal rotation of the foot

ACL LESION PORTO KNEE TESTING DEVICE PKTD

PKTD with AP or/and ext and internal rotation of the foot

PCL +PLC+PMC PORTO KNEE TESTING DEVICE PKTD

PCL INJURY

LP no stress MP no stress MP AP stress (AP 9mm) LP AP stress (PA 7mm)

• After tibial AP stress, the tibial MP

moves 9mm and the LP moves 7mm posteriorly.

• This is suggestive of an isolated PCL

inj ury or deficiency.

PCL+POSTEROLATERAL CORNER (PLC)

(Lateral plateau – LP)

LP no stress LP external rotation stress (AP 6mm)

After tibial AP stress, it is possible to visualize that the tibial MP moves 15mm posteriolry and after tibial ER also moves 6mm posteriorly. This is suggestive of a PCL and PLC inj ury or deficiency.

LP AP stress (AP 15mm)

ACL+PLC INJURY

LP no stress LP external rotation stress (PA 7mm)

After applying P A stress, the tibial LP moves 14mm anteriorly. After tibial ER moves 7mm posteriorly. This is suggestive of a ACL+PLC inj ury or deficiency.

LP PA stress (PA 14mm)

POSTEROMEDIAL CORNER INJURY

MP no stress MP internal rotation stress (PA 11mm)

After applying tibial IR, it is possible to visualize that the tibial MP moves 4mm posteriorly. This is suggestive of a PMC inj ury or deficiency.

TAKE HOME MESSAGE

Full Clinical Examination (gold standard)

Need to measure AP, PA translation & rotations of the knee in stress (concept of global PA laxity and global rotation laxity)

Results support sensitivity & specificity of Porto KTD Differential diagnosis of anatomic v functional lesion

Verification of the remaining ligament function & «chewing-gum effect» Improve indications for surgery Evaluate associated lesions!!

DO NOT MIS DIAGNOS E!!!