AOSSM Fellows Course: Common Knee Injuries

Matthew Smith, MD Associate Professor, Sports Medicine Team Physician- St. Louis Blues, Washington University Bears Washington University in St. Louis Disclosures

 I am an educational consultant for Arthrex. Overview

 On field plan  Case-based review of sports-related knee injuries  Patellofemoral instability  Meniscus injuries  MCL injuries  ACL injuries  PCL injuries  Posterolateral corner injuries On-field Evaluation  Understand your resources pre game – EMS, AED, etc  Triage injury severity on the field – ABCs – Spine injury  Aim for more thorough evaluation off the field – Crepitus, swelling, deformity – Functional assessment  Sports specific skills  Protective strength for return to play  Know your athlete and manage the coaches – Partner with your trainer! Case 1  18 year old male felt a pop in his knee while coming down from a rebound during a basketball game. – Noted new mechanical symptoms (locking) – Developing effusion – Lateral joint line tenderness – +McMurray’s and Thessaly tests – Negative Lachman: 1A; stable to varus/valgus – Can’t bear weight – ROM: 15 – 110 with significant pain in extension What is your differential diagnosis?

 ACL tear  Patellar dislocation – +/- loose body  Meniscus tear  Osteochondral injury  Quadriceps or patellar tendon rupture

Meniscus Criteria for Meniscal Tear  Abnormal morphology  High signal intensity on PD sequence that unequivocally touches the articular surface on two contiguous slices Meniscal Tear Treatment

 Non-operative treatment – Rest, Ice, Compression – Modified activities – Not indicated for acute bucket handle meniscus tear  Operative – Meniscus preservation – Repair or debridement  Only peripheral 10-30% of the meniscus in vascular

Meniscal Tear Debridement Meniscal Tear Repair Case 2  16 year old male soccer who sustained a non- contact injury yesterday – Planted and twisted and felt a “pop” – + effusion – ROM: 10 – 50 – Guarding on exam – Negative Lachman, stable varus/valgus – Tender of medial femoral epicondyle – Difficulty extending the knee What is your differential diagnosis?

 ACL tear  Patellar dislocation – +/- loose body  Meniscus tear  Osteochondral injury  Quadriceps or patellar tendon rupture Osteochondral Lesion Patellar dislocation relocation injury with osteochondral fracture

 Radiographic signs – Knee effusion – Medial soft tissue swelling – Look closely for loose body  MR – “Kissing Contusions” in the medial patella and lateral femoral condyle – MPFL tear – Osteochondral injury PATELLA DISLOCATION

 Most common in younger patients (<30)  Cause is multifactorial – Excess femoral anteversion – High tubercle to trochlea distance – Trochlear dysplasia  Often results in cartilage injury to the medial patella facet and/or lateral trochlea Imaging Considerations

 Lateral patellar translation  Negative patellar tilt  Trochlea morphology  Patellar height  Tibial tubercle to trochlear distance  Osteochondral injuries PATELLA DISLOCATION

Patella Alta

Patella absent from the trochlea Patellar Dislocation - Treatment

 First-time patellar dislocation WITHOUT loose body is typically treated non-operatively

 Patellar dislocation WITH loose body usually requires surgery – Arthroscopic loose body removal or ORIF – MPFL repair or reconstruction – +/- tibial tubercle transfer if tubercle-to-trochlear distance greater than 1.5-2 cm (debated) Treatment Treatment

MPFL Reconstruction with Tibial Tubercle Osteotomy Patella maltracking Patella maltracking Case 3  16 yo female soccer player with a non-contact injury 1 week ago – Planted to change directions and felt a pop – 3+ effusion – + Lachman’s; stable to varus / valgus – ROM: 5 – 45 – Mild lateral joint line tenderness to palpation – Can bear weight but feels unstable – Can’t return to play What is your differential diagnosis?

 ACL tear  Patellar dislocation – +/- loose body  Meniscus tear  Osteochondral injury  Quadriceps or patellar tendon rupture ACL Tears

 Most common in younger patients playing sports – Can happen at any age

 Most common mechanism is a deceleration non- contact injury – Hyperextension and hyperflexion injuries do occur

 Disability occurs from poor rotational stability of the knee after the ACL tears ACL Tears

 Presentation – Acute pain and swelling after a pop in the knee  Causes a hemarthrosis – Often the knee buckles or shifts (similar to patella dislocation) – Athletes are unable return to the game after injury – Many will have instability symptoms with ADLs that involved pivoting ACL Tears

 Work up – Physical exam is often diagnostic  Lachman’s is the exam of choice  Pivot shift possible but is often better with patient asleep  Anterior drawer ACL Tears

 Work up – MRI helpful to confirm the diagnosis and look for associated meniscus pathology  Bone bruises occur on the lateral femoral condyle and posterolateral tibial plateau are common with acute injuries ACL Treatment

• Operative treatment – Favored in athletes participating in pivoting sports – Autograft favored in young athletes

• No clinical difference between patellar tendon and hamstring grafts – Allograft ok for lower demand patients

• 4x higher failure rate than autograft

• Non-op ok for lower demand patients – Higher risk of meniscus tears in not reconstructed ACL Treatment ACL Treatment ACL Treatment Outcomes

 Recurrent ACL tears after reconstruction can happen – Younger and more active patients are more likely to re- injure their ACL.  Allograft has a 4x higher failure rate than autograft – Over 30, this difference is not clinically important  Post-operative recovery 6-12 months back to sports Case 4  24 year old professional hockey player with knee pain after get hit on the lateral knee – Medial-sided knee pain and sense of instability

 No effusion  Mild ecchymosis medially  Maximal tenderness of proximal-medial tibia  Valgus stress in extension: 3 mm  Valgus stress in 30 flexion: 7 mm  Negative Lachmans Examination  Inspection of knee – Ecchymosis – Effusion

 Palpation along medial knee

 Valgus stress laxity – 0°(extension): posteromedial capsule – 30° flexion: isolated collateral injury Clinical Grading  Grade I (mild) – Medial pain often worse with valgus stress – No laxity

 Grade II (moderate) – More pronounced swelling and pain – Stable in extension, valgus laxity at 30 degrees of flexion

 Grade III (severe) – Often more swelling – More severe injury to the MCL and deep capsule – Valgus laxity in extension and at 30 degrees of flexion – May have less pain given severity of injury Treatment

 Goals – Decrease pain – Restore ROM  Proximal injuries get stiff  Distal injuries often have residual laxity – Decrease swelling – Regain strength – Hinged knee brace – dependent on amount of laxity – Return to sports specific activities varies according severity of injury – MRI considered for higher grade laxity  Surgery usually not necessary unless the MCL is rolled up

Case 5  15 yo male injured left knee wrestling with a direct blow to the anterior knee. – ROM 0-100 – Negative Lachman – + Posterior drawer – Grade 2 – Positive Quadriceps Active Test – No varus laxity in full extension or at 30° – 3-4mm valgus laxity at 30° – Negative dial test at 30° and at 90° – Stress x-rays show 8 mm of posterior translation

Treatment Options

 Role for Surgery?  Rehabilitation Protocol?  Bracing?  Return to sports? Non-operative Plan

 Extension brace for additional 2 weeks for ADLs  Started prone range of motion  Quad strengthening  Avoid open chain hamstring strengthening 6 Weeks After Injury

 Feeling better  Working on quadriceps strength  No instability, locking, or swelling  Clinical Exam – Posterior sag unchanged – Improving laxity in the MCL on exam 4 Months Post-Injury

 Returned to wrestling in a PCL brace 3 months after the injury – Medial and anterior knee pain with ADLs – Sharp pain when he tries to wrestle preventing him from competing at a high level

Clinical exam – Regained quadriceps size and tone – Grade 2 posterior drawer Repeat Posterior Stress Xray

15mm Posterior Translation PCL Reconstruction

 Complete tear of PCL with some fibers remaining on PCL stump femoral side and a stump flipped posterior

 Double-bundle arthroscopic inlay PCL reconstruction using Achilles tendon allograft Femoral Tunnels

10 Months Post-Surgery

 Doing well  Happy with how knee feels  No pain with ADLS  Stopped wrestling due to discomfort while on his knee  Symmetric quadriceps size  Approximately 5mm laxity with posterior drawer with a firm endpoint  No varus/valgus laxity at 0° or 30 ° Case 6  34 yo M who injured his left knee doing martial arts.  Severe hyperextension injury – Toe touched his nose  Posterior and lateral knee pain and swelling  Foot drop  CT angio in ED normal Physical Exam

 Moderate effusion.  ROM 0-70 degrees  + Lachman’s  - Posterior drawer  + Recurvatum and external rotation  + Dial test at 30 degrees  Varus laxity at 0 and 30 degrees of knee flexion  Unable to fire EHL or tib ant  Dorsalis pedis pulse easily palpable Exam Findings Radiographs

Injury

 ACL, LCL/PLC, bucket handle medial meniscus tear

 Approach – Timing of surgery? – What injuries do you address acutely? – Surgical options  LCL repair vs reconstruction  Allograft vs autograft Treatment

 Acute LCL/PLC repair with semitendinosis allograft augment – Fibular-based reconstruction

 Medial meniscus debridement (white-white tear)

 Peroneal nerve exploration – 3 cm zone of injury around fibular head

Ho et al. Arthroscopy Jan 2011 Treatment LaPrade Reconstruction Treatment

 3 months post op rehabilitation to regain ROM and quad strength

 ACL reconstruction

 EMG 3 months post injury showed no recovery of the peroneal nerve

 7 months post injury peroneus longus and posterior tibial tendon transfers for foot drop

 Now back to athletic activities Thank You