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Sports medicine course for nursesSports medicine course for nurses
Dr Law KY, BillyDr Law KY, BillyMBChB (CUHK), MRCS (Ed), MScSMHS (CUHK), FRCSEd (Orth) FHKAM (OrMBChB (CUHK), MRCS (Ed), MScSMHS (CUHK), FRCSEd (Orth) FHKAM (Orth Surg), FHKCOSth Surg), FHKCOSResident specialistResident specialistDepartment of Orthopaedics and Traumatology, Prince of Wales HosDepartment of Orthopaedics and Traumatology, Prince of Wales Hospitalpital
Meniscus & Cartilage injury of knee
Meniscus anatomyMeniscus anatomy
FibrocartilagenousFibrocartilagenous structurestructure
Located between femoral Located between femoral condylecondyle & & tibialtibial plateauplateau
Crescents shapeCrescents shape
Triangular cross sectionTriangular cross section
Cover 1/2 Cover 1/2 –– 2/3 tibia plateau 2/3 tibia plateau articulararticular surfacesurface
Meniscus Meniscus anatomyanatomy
Medial meniscusMedial meniscusC shapeC shapeAttached to Attached to medial capsular structuremedial capsular structure, deep MCL, deep MCLTear more common in chronic ACL deficient kneeTear more common in chronic ACL deficient knee
Secondary restrain of anterior tibia translationSecondary restrain of anterior tibia translation
Lateral meniscusLateral meniscusCircular shapeCircular shapeAttachment: coronary ligament / Attachment: coronary ligament / meniscomenisco--femoral femoral ligamentligamentMore mobileMore mobile than medial meniscusthan medial meniscusTear more common in acute ACL tearTear more common in acute ACL tear
AnterolateralAnterolateral translation during ACL injurytranslation during ACL injury
Meniscus functionMeniscus functionShock absorptionShock absorption
Increase surface area of contact Increase surface area of contact decrease contact stressdecrease contact stress
Complete Complete menisectomymenisectomyDecrease contact area by 40 Decrease contact area by 40 –– 75%75%Increase contact stress by 136 Increase contact stress by 136 –– 236%236%
Major fiber orientation Major fiber orientation circumferentialcircumferentialResist compressive loadingResist compressive loadingBy creating hoop stressBy creating hoop stress
Mid substance fibers Mid substance fibers radialradial orientationorientationResist Resist longitudinal splitlongitudinal split
Surface fibersSurface fibers wovenwoven patternpatternResist Resist sheersheer stressstress
Meniscus functionMeniscus functionJoint stabilityJoint stabilityJoint lubricationJoint lubricationPropioceptionPropioception
Blood supplyBlood supplyMedial & lateral Medial & lateral geniculargeniculararteriesarteries
Vessels form Vessels form perimeniscalperimeniscalcapillary plexus within synovial capillary plexus within synovial & capsular tissue of knee joint& capsular tissue of knee joint
Supply peripheral 1/3 of Supply peripheral 1/3 of meniscusmeniscus
ieie medial 2/3 of meniscus medial 2/3 of meniscus relative relative avascularavascularRed Red –– RedRed zonezoneRed Red –– white zone / White white zone / White –– WhiteWhitezonezoneDifferent healing potentialDifferent healing potential
Meniscus tearMeniscus tear
HistoryHistoryRotation as the flexed knee move toward an extended Rotation as the flexed knee move toward an extended positionpositionLess mobile medial meniscus trap between the Less mobile medial meniscus trap between the femoral femoral condylecondyle and and tibialtibial plateau plateau teartear
Meniscus tear symptomsMeniscus tear symptoms
EffusionEffusionPainPainLockingLocking
Inability to extend kneeInability to extend knee
Chronic caseChronic caseClicks, catches, snaps Clicks, catches, snaps as knee movesas knee moves
Physical examPhysical exam
EffusionEffusion
Local tenderness over Local tenderness over joint linejoint line
Range of motionRange of motionMechanical blockMechanical block
McMurray testMcMurray test
McmuarryMcmuarry testtest
Medial meniscus
ER + Varus
Lateral meniscus
IR + Valgus
XRXR
Not to confirm diagnosis of torn meniscusNot to confirm diagnosis of torn meniscusExclude Exclude
OsteocartilaginousOsteocartilaginous loose bodyloose bodyOsteochondritisOsteochondritis dissecansdissecans
That mimic torn meniscusThat mimic torn meniscus
MRIMRI
Sensitivity 83%Sensitivity 83%Specificity 84%Specificity 84%
Look for concomitant ligament, cartilage Look for concomitant ligament, cartilage injuriesinjuries
TreatmentTreatment
NonoperativeNonoperativeOperativeOperative
NonNon--operativeoperative
Incomplete tearIncomplete tear
Small (5mm) stable peripheral tear with no Small (5mm) stable peripheral tear with no other pathological condition other pathological condition egeg ACL tearACL tear
Treat non operatively with good resultsTreat non operatively with good results
Operative treatmentOperative treatmentLocked kneeLocked knee
Bucket handle tearBucket handle tear
Associated Associated cruciatecruciate ligament ligament injuryinjury
Chronic tear with Chronic tear with superimposed acute injurysuperimposed acute injury
Fail conservative treatmentFail conservative treatment
Operative choicesOperative choicesPrinciple: Preserve as much as possiblePrinciple: Preserve as much as possibleMeniscus repairMeniscus repairPartial Partial menisectomymenisectomyMeniscus allograftMeniscus allograft
Meniscus repairMeniscus repairSuccess rate higherSuccess rate higher
Red Red –– RedRed zonezonePattern of tearPattern of tearChronicityChronicityConcomitant ACL Concomitant ACL reconstructionreconstruction
biochemical / mechanicalbiochemical / mechanical
Meniscus repairMeniscus repair
Arthroscopic techniqueArthroscopic technique
Medial meniscusMedial meniscusRisk of Risk of saphenoussaphenous nerve nerve injuryinjury
Lateral meniscusLateral meniscusRisk of Risk of peronealperoneal nerve nerve injuryinjury
Rehabilitation after meniscus repairRehabilitation after meniscus repair
VariesVariesPattern of tear Pattern of tear
longitudinal longitudinal vsvs radialradial
Stability of repairStability of repairSurgeon preferenceSurgeon preferencePatient demandPatient demand
Hinge braceHinge brace 00--90d x 490d x 4--6 wks6 wksPWBPWB x 4x 4--6 wks6 wksReturn to sports 4 Return to sports 4 –– 6 months6 months
Partial Partial menisectomymenisectomy
Try to Try to avoid total avoid total menisectomymenisectomyRemoval 1/3 of meniscus increase joint Removal 1/3 of meniscus increase joint contact force by 40contact force by 40--70%70%Increasing degenerative changes in post Increasing degenerative changes in post total total menisectomymenisectomy kneeknee
Partial Partial menisectomymenisectomy
Symptomatic, fail conservative careSymptomatic, fail conservative careTear beyond salvageTear beyond salvage
Allow faster rehabilitationAllow faster rehabilitationImmediate full weight bearImmediate full weight bearImmediate range of motion exerciseImmediate range of motion exercise
ConclusionConclusionMeniscalMeniscal injuryinjuryCommon, may associate with Common, may associate with ligament injuryligament injuryMost can be treated conservativelyMost can be treated conservativelyExceptExcept
Lock kneeLock kneeAssociate Associate cruciatecruciate injuryinjuryFail conservative treatmentFail conservative treatment
Surgical treatmentSurgical treatmentMeniscus repairMeniscus repairPartial Partial menisectomymenisectomy
ChondralChondral lesion in a young patientlesion in a young patient
What is cartilage?What is cartilage?What is the patientWhat is the patient’’s problem?s problem?What should I do? What should I do? What are the options? Challenge? What are the options? Challenge?
ArticularArticular cartilagecartilageSpecialized connective tissueSpecialized connective tissue
Biphasic materialBiphasic materialSolid matrixSolid matrix
Water fluid phaseWater fluid phase
MatrixMatrixWater (70%), collagen, Water (70%), collagen, proteoglycanproteoglycan
ChondrocyteChondrocyteProduction of matrixProduction of matrix
AvascularAvascular, no neural supply, no neural supply
NutritionNutritionDiffusion from synovial fluidDiffusion from synovial fluid
Mechanical propertyMechanical property
ViscoelasticViscoelastic property allow tissue response to property allow tissue response to stressstressMechanical spongeMechanical sponge which absorb tremendous which absorb tremendous compressive forces, compressive forces, Load distributionLoad distributionLow frictionLow friction surface for motionsurface for motion
Response to injury Response to injury PoorPoorPoor blood supplyPoor blood supply
Few Few chondroblastchondroblastchondrocytechondrocyte
Full thickness tear Full thickness tear healed in healed in fibrocartilagefibrocartilage
Suboptimal biomechanical Suboptimal biomechanical propertyproperty
Problem of poor healingProblem of poor healing
Poor healingPoor healingPersistent cartilage defectPersistent cartilage defectAbnormal load distributionAbnormal load distribution
PainPainEarly osteoarthritis, disabilityEarly osteoarthritis, disability
What should I do? What should I do?
RegenerateRegenerateFibrocartilageFibrocartilageCartilageCartilage
ReplaceReplaceJoint Joint replacementreplacement
UKAUKATKR
SK-II「神仙水」每支含超過90% Pitera®的SK-II「神仙水」,能將Pitera®輸送至肌膚深層,從底層肌膚著手解決頑固的肌膚問題,在約14天優生期內幫助肌膚孕育健康新細胞,尤如為肌膚打好底子。 同時有助提升肌膚的新陳代謝效率,使肌膚能夠維持約28天的理想更新週期,重拾晶瑩剔透的膚質。
TKR
RegenerateRegenerateMechanical techniqueMechanical technique
Arthroscopic Arthroscopic lavagelavage & debridement& debridement
Marrow stimulation techniqueMarrow stimulation techniqueSubchondralSubchondral drillingdrillingMicrofractureMicrofracture
ResurfacingResurfacingOsetochondralOsetochondral autograftautograftAutologousAutologous chondrocytechondrocyte implantationimplantation
ResurfacingResurfacingJoint replacementJoint replacement
Success in cartilage regenerationSuccess in cartilage regeneration
Must ensure kneeMust ensure kneeStableStable
Treat concomitant ligament injuryTreat concomitant ligament injury
Normal alignmentNormal alignmentCorrect deformityCorrect deformity
………………before you go and tackle the before you go and tackle the cartilage defectcartilage defect
Arthroscopic Arthroscopic lavagelavage & debridement& debridementRemoval of impinging Removal of impinging osteophytesosteophytes, , inflammedinflammed synoviumsynovium, , loose loose chondralchondral debrisdebris
Removal of degradation enzymes, factors that cause painRemoval of degradation enzymes, factors that cause pain
Advantage: minimal invasive / simple surgery / easy rehab.Advantage: minimal invasive / simple surgery / easy rehab.
Short term improvement observed, especially patient with Short term improvement observed, especially patient with clear mechanical symptomsclear mechanical symptoms
No long term benefitNo long term benefit
Marrow stimulation techniqueMarrow stimulation technique
Creation of bleeding Creation of bleeding fibrin clot fibrin clot invade by undifferentiated cell invade by undifferentiated cell chondrocytechondrocyte like celllike cell
Synthesize matrix Synthesize matrix collagen, collagen, proteoglycanproteoglycan
DrillingDrilling
0.062 K wire0.062 K wireHoles 2Holes 2--3mm apart3mm apartDeep to Deep to cancellouscancellous boneboneTourniquet releasedTourniquet releasedBleedingBleeding
Healing with Healing with fibrocartilagefibrocartilageProblem: thermal necrosisProblem: thermal necrosis
MicrofractureMicrofractureDebridement of loose Debridement of loose cartilage edgecartilage edgeRemoval of calcified layerRemoval of calcified layerSmall holes by hand awlSmall holes by hand awl4mm depth hole4mm depth hole33--4mm apart4mm apartFormation of blood clot, rich Formation of blood clot, rich in in pluripotentialpluripotential marrowmarrow(release of tourniquet to (release of tourniquet to confirm bleeding)confirm bleeding)
Advantage: no thermal Advantage: no thermal necrosisnecrosis
Ideal candidate for Ideal candidate for microfracturemicrofracture
Lesion < 2cmLesion < 2cm22
Preoperative symptoms < 1 yrPreoperative symptoms < 1 yrAge < 40 yrsAge < 40 yrs
MithoeferMithoefer etaletal. High impact athletics after knee . High impact athletics after knee articulararticular cartilage repair: a prospective cartilage repair: a prospective evaluation of the evaluation of the microfracturemicrofracture technique. AJSM 2006technique. AJSM 2006KreuzKreuz etaletal. Is . Is microfracturemicrofracture of of chondralchondral defects in the knee associated with different defects in the knee associated with different results in patients aged 40 years or younger. Arthroscopy 2006results in patients aged 40 years or younger. Arthroscopy 2006
Post op rehabilitationPost op rehabilitationCPMCPM
Improve quality of repair tissueImprove quality of repair tissueNutritionNutritionAccelerate cellular differentiation of marrow Accelerate cellular differentiation of marrow mesenchymalmesenchymal cells into matrix producing cells into matrix producing fibrochondrocytefibrochondrocyte
Early protected motionEarly protected motionTouch down walking x 6 weeksTouch down walking x 6 weeksGradual strengthening exerciseGradual strengthening exerciseReturn to sportsReturn to sports
44--6 months6 months
MicrofractureMicrofracture
Regenerated tissueRegenerated tissueHybrid of hyaline cartilage & Hybrid of hyaline cartilage & fibrocartilagefibrocartilage
Initial result deteriorate over time due to Initial result deteriorate over time due to poor wear poor wear characterticscharactertics of repair tissueof repair tissue
OsteochondralOsteochondral autograftautograft transplantationtransplantation
Cylindrical Cylindrical osteochondralosteochondral pulgspulgs from relative from relative non weight bearing area of knee non weight bearing area of knee
insertion to insertion to articulararticular defectdefectArthroscopic / Open surgeryArthroscopic / Open surgery
OsteochondralOsteochondral autograftautograft transplantationtransplantation
Donor siteDonor sitePatellar groovePatellar grooveArea proximal to Area proximal to intercondylarintercondylarnotchnotchSuperior medial margin of Superior medial margin of femoral notchfemoral notch
DifficultyDifficultyLimited donor siteLimited donor siteOnly suitable for small defect ~ Only suitable for small defect ~ < 2.5 cm< 2.5 cmDifficulty to reDifficulty to re--create normal create normal articulararticular contourcontour
MosaicplastyMosaicplasty --Advantages
Mosaicplasty -DisadvantagesAdvantages
Hyaline cartilageHyaline cartilage
Superior biomechanical Superior biomechanical properties
Graft dislodgementGraft dislodgement
Incongruent surface Incongruent surface →→OA of opposing surfaceOA of opposing surface
Small grafts may breakSmall grafts may break
Failure of grafts to healFailure of grafts to heal
OA of donor sites if too OA of donor sites if too many grafts and too large many grafts and too large →→ limited size of treatable limited size of treatable defect
properties
defect
AutologousAutologous ChondrocyteChondrocyte implantationimplantation
2 surgeries2 surgeries
11stst surgerysurgeryNormal host cartilage harvested Normal host cartilage harvested cell culturecell culture
22ndnd surgerysurgeryTransplant the cells under a harvested Transplant the cells under a harvested periostealperiostealpatch through patch through arthrotomyarthrotomy
Better wear Better wear charateristicscharateristics of repair tissue than of repair tissue than microfracturemicrofracture
AdvantageAdvantagePotential to restore Potential to restore normal hyaline normal hyaline cartilage
DisadvantageDisadvantageHighly technique Highly technique dependentdependentRequire 2 stage Require 2 stage procedureprocedureLaboratory supportLaboratory supportExpensive
cartilage
Expensive
Management of Management of chondralchondrallesionlesion
No perfect solutionNo perfect solution
Each technique pros & consEach technique pros & consSimple Simple –– ComplexComplexSize of defectSize of defectDonor morbidityDonor morbidityCostCostPatient demandPatient demand
Thank YouThank You