Mike Geary MD South Shore Orthopedics

September 12, 2014

Completing the Loop

Indications for referral Ligament injury

ACL MCL Combined

Meniscus injury Patellofemoral instability

Completing the Loop

Anatomy Diagnosis

Physical exam Break out sessions

Imaging Treatment

Surgery Nonoperative

Completing the Loop

Inability to bear weight/pain with weight bearing.

Knee effusion/swelling Instability on exam or by history Decreased ROM

Completing the Loop

ACL MCL

Completing the Loop

Felt “pop” in knee Occurred while

pivoting on knee or from direct contact. Valgus load

Completing the Loop

ACL Lachman Anterior drawer Pivot shift

MCL Medial sided pain Valgus stress 0 & 30 degrees

Completing the Loop

X-Rays R/o Fracture

MRI ACL MCL

Completing the Loop

Surgical Reconstruction Recreate normal anatomy Arthroscopic Autograft tissue Hamstring tendons Patellar tendon

Address all pathology Meniscus Articular cartilage

Completing the Loop

Nonoperative Hinged Knee Brace Physical Therapy Healing time 6 – 8

weeks Degree of injury

Completing the Loop

Medial & Lateral Fibrocartilage Function

Joint stability Distribute load

Tear Patterns Zones Radial tear Debride

Peripheral tear “Bucket – Handle” Repair

Completing the Loop

Joint line tenderness Medial/lateral

Pain with full knee flexion/squatting

McMurray test

Completing the Loop

X-Rays Negative

MRI Tear pattern

Double PCL sign Bucket Handle Tear

Radial tear

Completing the Loop

Surgery Debride Repair

Post-op Rehab

Radial Tear - Debride

Bucket handle tear - Repair

Completing the Loop

Boney Constraints Trochlear groove

Soft Tissue Constraints Medial Retinaculum Medial

Patellofemoral Ligament (MPFL)

Completing the Loop

Lateral Subluxation vs.

Dislocation Acute vs. Chronic

Completing the Loop

Risk Factors Anatomic Increased Knee Valgus Shallow Trochlear

Groove Patella Alta TT-TG distance Generalized

Ligamentous Laxity Previous Dislocation Dislocation

contralateral knee Patella alta

Generalized Ligamentous laxity

Completing the Loop

May or may not recall seeing patella dislocated Spontaneous

relocation Felt a “pop”

Knee swelling and pain

Previous history

Completing the Loop

Knee Effusion Tenderness

Lateral patella Medial femoral condyle

Apprehension sign

Completing the Loop

X-Ray Fracture Patella reduced

MRI Edema: MFC Lateral Patella

MPFL injury Chondral injury

Completing the Loop

Nonoperative: First Time

Dislocation/Subluxation Patella reduced No loose body

Protocol Initial immobilization Brace Physical Therapy

Completing the Loop

Surgical Recurrent instability Loose osteochondral body

Technique MPFL reconstruction vs.

repair Medial imbrication Removal vs. repair loose

body Postoperative Physical

Therapy

Completing the Loop