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The Sporting Knee:Practical Issues
Dr Mark GillettHead of Medical Services WBA FC
Head of Science & Medicine British BasketballConsultant Physician HEFT
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Outline• General issues in sport• Diagnosis• Non operative interventions• ACL• MCL• In season meniscal injury• OCDs• MRI -ve AKP
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Issues In Professional Sport
• Players• Agents• Executives• Lay perceptions• Confounding issues: contracts, team
selection• Time scales
4
Generic Issues
• Cohesive MDT essential• All opinions have validity- the “specialist’
cannot always see the whole picture• There are no easy solutions. A jigsaw
needs to be put together and soundjudgment exercised.
• Sometimes you will get it wrong
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Interpreting Scans
• Examine the player• See the scans yourself• Discuss the scan with the radiologist• Only after evaluating all 3 viewpoints can
you make a definitive call
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Non Operative Interventions-The Sports Physician• Hyalgans- Ostenil, Durolane• Steroids- short (hydrocortisone) v long
(Kenalog, Depo-medrone)• PRP injections• Traumeel
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Hyalgans
• “The oil”• Most useful in joint with early degeneration
or OCD treated conservatively• Don’t expect to much- it’s a few %.• May achieve more if combined with rest
and active recovery
• Hyaluronan is a high molecular weight biopolymer whichis present in many of our tissues as an importantcomponent of the extracellular matrix
• In the joint cartilage, hyaluronan is the backbone of theproteoglycans, which - together with collagen fibers -forms a matrix, in which the chondrocytes areembedded. Hyaluronan, at the same time, providesviscosity to the synovial fluid for its shock absorbing andlubricating properties. It furthermore acts as a molecularsieve (picture) and coats the pain receptors
• Upgrading the concentration and the molecular weightin the synovial fluid by intra-articular administration ofexogenous hyaluronan (called viscosupplementation).
•8
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PRP Injections
• Commonly used in MCL injuries• Now permitted by WADA for injection into
ligaments but not acute muscle injuries• Status with PMI providers currently under
review
PRP Science
• MSK tissue repair begins with formation ofa blood clot and platelet degranulation
• A variety of growth factors are releasedwhich are beneficial for soft tissue andbone healing
• Blood taken and centrifuged to isolateplatelets
• Inject supernatant into injury site
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Traumeel
• Inflammatory regulatory drug• Mixture of 14 homeopathic substances
including Arnica and Echinacea• Not found it useful for intra-articular
disorders• Can be useful in soft tissue disorders
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ACL Disruption
• This is a functional diagnosis- ACLdeficient v ACL competent
• Assessment pitch side often difficult• Beware lateral sided pain• Signs can evolve over 24 hours
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Investigations
• MRI usually conclusive• Beware of who reports scans, especially if
a partial tear is reported• Beware when scanning in different
environment especially overseas
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Reconstruction Options
• Ipsilateral BPB• Ipsilateral ST• Contralateral BPB• Double bundle reconstruction• Modified Macintosh repair• Cadaver graft• Which is best?
Bone-Patellar- Bone Autograft
• Fail at 2900 N (normal ACL fails 1725 N)• Stable secure bone plugs at femoral and
tibial ends• Disadvantages- potential AKP and
difficulty attaining full extension
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Semitendinosis +/- Gracilis Autograft
• Tendon harvested from same incision site• Less risk AKP• Long term hamstring weakness not
normally an issue• Weaker than BPB graft with ST failing at
1200 N and gracilis at 860 N
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Cadaver Allograft
• Out of favour• Risk of infection
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Double Bundle Reconstruction
• Aims to replicate native anatomy• AM- taut throughout full range knee
motion should control ant translation• PL- taut towards extension better controls
rotation• Conflicting results in literature
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Trends In Rehab
• 6 months• Highest risk of rupture during initial 4-6
weeks when the graft necroses,revascularises and remodels.
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Choosing Your Surgeon
• Be aware of their style of consultation• The polished performers• Always positive• Sport- nothing different• Blunt• Know the style to suit your purpose
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MCL Injuries
• Valgus injury very common• High grade injuries will need cast bracing
at approximately 30 degrees short of fullextension.
• Is cast bracing needed to prevent longterm instability?
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• High grade MCL injury- may need surgicalreconstruction
• Lower grade injuries unlikely to create longterm issues if early extension
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• Early stage rehab in sport relativelyuncomplicated
• Notorious for pain in end stage rehabwhen multi- directional activity iscommenced and progressed
• Early PRP injection• Early v Late steroid injection
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• High incidence of acute muscle injury ingames immediately following return fromMCL injury
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Meniscal Injury
• Athletes will have meniscal degenerationon MRI
• MRI is not as helpful for in the evaluationof meniscal injury as it is in ligamentousinjury
• Treat the patient not the MRI
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In Season Management
• Off load• Is there an associated OCD?• Is it the lateral or medial causing the
issue?• How far in to the season is it?
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Surgical Options
• Conservative- higher failure rate but betterlong term prognosis
• Aggressive- may relieve symptoms but forhow long
• Repair v Resection
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OCDs• Classically on medial femoral condyle or
on trochlear groove of femur• Rotational forces direct trauma• Shearing force between articular cartilage
and subchondral bone• Weight bearing surfaces- MFC 4x more
common than lateral injuries
• Biomechanical risk factors femoralanteversion and poor gluteal controlincreasing dynamic Q angle thus strain onPFJ
• Had 2 cases of significant OCDs introchlear groove in female internationalbasketball players in last 2 years.
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• Pain at approx 30 degrees of knee flexionas patella starts to engage in trochleargroove
• Single legged squat diagnostic
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Treatment Options
• Rest and grade rehab• Debride• Microfracture• OATs /ACT
Microfracture
• Perforation of subchondral bone to recruitmesenchymal stem cells from bonemarrow into lesion
• Stem cells develop into cells capable ofproducing fibrocartilage
• Important for stable clot to fill defect
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OATs Graft/ Mosaicplasty
• Take multiple small osteochondral plugsfrom the non weight bearing periphery ofthe femoral condyle
• Limited by size of donor site• Longer rehabilitation period
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Anterior Knee Pain
• Fat pad impingement• Plica• Pes anserinus• Tendonopathy
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• Usually simple diagnoses to make• But often the MRI is -ve• Difficult situation• Glutes and single leg stability highlighted• Goal setting and time objectives are
difficult to quantify
36
Posterior Knee Pain
• Distal medial hamstrings- frictionintersection
• Popliteus spasm• Posterolateral corner injury• Posterior capsultis