Meniscus and Patella injuries in Professional Hockey

Peter MacDonald MD FRCSC Professor and Head Section of Orthopedics University of Manitoba Head Team Physician Winnipeg Jets Disclosure Institutional (Pan am Foundation) Research and Educational support from:

Linvatec Ossur Arthrex

Associate Editor JSES COA President elect Objectives

• To go over common injury patterns to the knee • Suggest treatment pathways • Role of prevention of these injuries

http://highschoolsports.nj.com/school/berkeley- heights-gov-livingston/boysicehockey/photos/ Meniscus tears

. Bucket handle . Flap or radial . Cleavage . Complex . Degenerative

Supplies periphery Originates from the synovium, capsule

Arnoczky and Warren, Am J Sports Med, 1982 Degenerative Meniscus tears

Not in professional hockey! . usually in patients > 40 . typically no history of trauma, twisting injury . pre-existing degenerative changes . minimal healing capacity . horizontal cleavage, flap or complex tear TRAUMATIC TEARS

. young, athletically active individuals . frequently trauma related . often associated with ACL tears . vertical longitudinal tears most common . followed by vertical transverse tears “RED ZONE” INJURIES . Healing requires some communication with blood supply which permits classic wound healing response . cellular fibro-vascular scar . must have a stable environment . mechanical function and strength remain suspect “WHITE ZONE” INJURIES . No reparative response . similar to articular cartilage

. “Red-white zone” . somewhere in between

Lateral Meniscus Root injury Subtle posterior horn tear Radial tear Cyst Lateral meniscus Sometimes we can be fooled!

Remember not all patients with joint line tenderness have a meniscus tear Bone bruise Remember to X-ray the player!

Repair techniques . Inside Out . Outside In . All Inside . Hybrid INSIDE-OUT REPAIR

Chuck Henning, 1980 ZONE SPECIFIC CANNULA Bucket handle excision: two portal\ Fixation Devices

Fallen out of favor Bucket handle Hybrid repair Allograft: Not for the pro-hockey player! Allograft: Not for the pro-hockey player! Patella Instability in the Hockey Player Patella Instability in the Hockey Player Outline

• Epidemiology • Anatomy • Biomechanics • Diagnosis • Treatment • Literature Epidemiology

• Literature Incidence • 5.8 per 100,000 • 29 per 100,000 ages 10-29 – Hawkins AJSM 1986 Text • “Epidemiology and natural history of Acute patellar Dislocation” • 189 acute patellar dislocations followed for 5 years. • First time dislocations 17% recurrence • Greater in females • Fithian et al AJSM 2004  Text Patellofemoral joint

• MPFL- major player in preventing lateral displacement 53%-60% at 30-60 degrees flexion • Lateral trochlea more prominent greater contact (Q angle) • Medial facet contacts only after 90 degrees of flexion • No contact in full extension (supratrochlear tubercle) • Thickest cartilage in the body at the median ridge. Text Walking Force % Body wieght Pounds of Force

Text

Walking 850N ½ x BW 100lbs

Bike 850 ½ 100

Stair ascend 1500 3.3 660

Stair Descend 4000 5x bw 1000

Jogging 5000 ??Pro7xbw hockey? 1400

Squatting 5000 7xbw 1400

Deep squatting 150000 20xbw 4000 Predisposing Risk Factors for Patellar Instability

• Femoral anteversion • Genu valgum • Patellar dysplasia • Femoral dysplasia • Patella alta • Vastus medialis obliqus atrophy • High Q angle • Pes planus • Generalized hyperlaxity LATERAL PATELLAR DISLOCATION

• Internal rotation of femur on externally rotated tibia OR direct medial blow • Rapid, transient event • Tender MPFL area • Markedly positive apprehension sign Examination

• Test for ligamentous laxity • J sign – Lateral subluxation of the patella as the knee approaches full extension Text

Text Text

Simon Gatehouse Passive Patellar tilt

• Patella tilt – Elevation of lateral patella from 0- 20 degrees from horizontal normal

– < 0 = Tight lateral retinaculum Medial-Lateral Glide

• Patellar Glide – 30 degrees flexion and relaxed quads • Lateral Glide – Normal – 0.5 to 2.5 quadrants – > 3 quadrants = medial restraint incompetence Text

Not usually in Professional Hockey Text Text

Text Text TT-TG Measurment

Text SurgicalText Procedures for PF Instability

• Soft Tissue: MPFL

• Boney: Proximal or Distal Osteotomy

• Cartilage reshaping: Trochleoplasty Text

Mostly level III/IV studies reviewed (22 relevant studies) N=1765 Incidence of osteochondral fractures 24.3% First time dislocators should be treated with nonoperatively unless there is clinical, radiographic, CT or MRI based findings of: Chondral injury Osteochondral fractures Large medial patellar stabilizer deficits Patella subluxed on plain merchant view compared with other knee (with risk factors) Text Text Text Text Episodic Patellofemoral pain with instability

Laxity or dysplasia No laxity

CT or MRI Lateral malposition degrees Patellar Tilt >20

MPFL + MPFL + Normal Anatomy distalization of TT Patella Alta lateral release

MPFL reconstruction MPFL reconstruction + distalization of TTT Distal Realignment

• Distal realignment procedures §tibial tubercle-trochlear groove distance §patella alta. • Depends on – lateral patellar facet §presence of patella alta. §Associated medial or proximal patellar chondrosis Text Text Text Text Text Text Text Text Text Text Post Op MPFL Post op MPFL Post Op MPFL Post Op MPFL Post Op MPFL Results MPFL

• Technical error common • quads dysfunction 31% • stiffness 18% • persistent minor apprehension 20% • beware drill holes across patella! Cartilage Implantation Conclusions

• Organized approach to history and physical • Classification including boney and soft tissue factors • Pre-hab and post op Rehab extremely important • Surgery to address the anatomy • Much more to learn!! Pan Am Clinic Foundation Thank You