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

THE DIS LOCATED KNEE CLINICAL & IMAGING EVALUATION 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 ociety 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

DISCLOSURE STATEMENT • 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

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% of 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 LIGAMENTS Lower limb alignement VESSELS & NERVES Pain Effusion CARTILAGE, BONE, PATELLA & PT, MENISCUS, ROM (active & passive) Giving-way symptoms Muscle strength S tability (g.a.) Degenerative OA

VESSELS LESION 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!!!

INSPECTION & STANDING EXAM

WALKING EXAM Varus Thrust Gait OFTEN ASSOCIATED WITH VARUS MALALIGNMENT

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

CABOT OR “4” TEST FCL ISTHE PRIMAR Y RES TRAINT TO VARUS (VELTRI & WARREN,1995)

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)

POSTERIOR SAG • 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 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)

POSTEROMEDIAL DRAWER TEST • 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.

POSTEROLATERAL DRAWER TEST (J. Hughston, 1980) 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 • Knee flexion at 90º (Gollehon, 1987) • Foot 15 ° ER (site on foot) • Assess posterolateral rotation

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 X-Ray • 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

IMAGING STRESS RADIOGRAPHS • 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

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

IMAGING CT scan – Intra-articular fractures

IMAGING MRI • Confirm clinical examination • Iliotibial band • Bicruciate • Fibula avulsion • MCL versus LCL • Biceps complex • PLC • Medial and fibula col ligament • Other inj uries (meniscus, cartilage, bone bruise) ITB PCL CARTIL MENIS PT BICEPS

MEASURE 360º INSTABILITY Porto Knee Testing Device PKTD BES INNOVATION AWARD 2012 Health technology

CHEWING-GUM EFFECT WITH PKTD No stress –ACL Partial rupture? Stress - Total rupture

ACL LESION PORTO KNEE TESTING DEVICE PKTD PKTD with PA stress or ext and internal rotation of the foot

PCL +PLC+PMC PORTO KNEE TESTING DEVICE PKTD PKTD with AP or/and ext and internal rotation of the foot

PCL INJURY • After tibial AP stress, the tibial MP moves 9mm and the LP moves 7mm posteriorly. MP AP stress MP no stress (AP 9mm) • This is suggestive of an isolated PCL inj ury or deficiency. LP AP stress LP no stress (PA 7mm)

PCL+POSTEROLATERAL CORNER (PLC) (Lateral plateau – LP) LP no stress LP AP stress LP external rotation stress (AP 6mm) (AP 15mm) 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.

ACL+PLC INJURY LP no stress LP PA stress LP external rotation stress (PA 14mm) (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.

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!!!