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Presentations 7/4/2019 30th Brucosport Football Medicine: What’s New 2017 Bruges, Belgium 11 March 2017 Aspetar Orthopaedic and Sports Medicine Hospital 1 Dr. Scott Gillogly Chief Medical Officer 26 February 2017 2 1 7/4/2019 Articular Cartilage Injuries in the Knee: Evaluation and Surgical Treatment Options based on Return to Play Scott D. Gillogly, MD 34th FIMS World Sports Medicine Congress Ljubljana, Slovenia 29 September - 2 October 2016 Aspetar Orthopaedic and Sports Medicine Hospital 3 ICRS Annual Meeting 29 September 2016 Aspetar Orthopaedics and Sorrento, Italy Sports Medicine Hospital 4 2 7/4/2019 Articular Cartilage Injuries in the Knee: Evaluation and Surgical Treatment Options based on Return to Play Scott D. Gillogly, MD AFC Team Physiotherapist Sports Medicine Course Doha, Qatar 13-15 June 2016 Aspetar Orthopaedic and Sports Medicine Hospital 5 Cartilage Defects in Athletes: Return To Play (RTP) Scott D. Gillogly, MD 1st GCC Sports Medicine Conference Doha, Qatar 23 April 2016 Aspetar Orthopaedic and Sports Medicine Hospital 6 3 7/4/2019 AAOS Articular Cartilage Restoration: The Modern Frontier 1 April 2016 Aspetar Orthopaedics and Sports Medicine Hospital Chicago, Illinois 7 AAOS Articular Cartilage Restoration: The Modern Frontier 2 April 2016 Aspetar Orthopaedics and Chicago, Illinois Sports Medicine Hospital 8 4 7/4/2019 8 April 2016 Aspetar Orthopaedics and Washington, D.C. Sports Medicine Hospital 9 8 April 2016 Aspetar Orthopaedics and Washington, D.C. Sports Medicine Hospital 10 5 7/4/2019 Return to Play (RTP) After Cartilage Repair of the Knee Scott D. Gillogly, MD Challenges in Football Injuries Doha, Qatar 11‐12 February, 2016 Aspetar Orthopaedic and Sports Medicine Hospital 11 Partial Osteochondral Fractures of the Condyles (Osteochondral Defects) Scott D. Gillogly, MD 3 February 2016 Val d’Isère, France 12 6 7/4/2019 Medial Fractures of the Patella (= Patellar Dislocation) Scott D. Gillogly, MD 3 February 2016 Val d’Isère, France 13 ACL Reconstruction with Quadrupled Semitendinosus Hamstring and Tape Locking Screws (“The French Technique”) Integration into Clinical Practice in the U.S. Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician, Atlanta Braves Baseball Club FH Orthopaedics The Original TLS Short Graft ACL Reconstruction Lyon, France 9 June 2015 14 7 7/4/2019 Return to Play (RTP) following Cartilage Procedures Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician Atlanta Braves AOSSM Partner Society Instructional Course ICL #09 Critical Issues in the Care of the Injured Athlete Lyon, France 9 June 2015 15 Return to Play (RTP) following Cartilage Procedures in the Knee Scott D. Gillogly, M.D. Atlanta, Georgia Team Physician Atlanta Braves MLB 41st Annual Herodicus Society Lyon, France 3‐6 June 2015 16 8 7/5/2019 Dr. Scott Gillogly Chief Medical Officer 26 February 2017 1 Scott D. Gillogly, MD • I have no relevant financial relationships with any commercial manufacturers or provider of commercial services • I do not discuss an unapproved use a commercial product or device in this presentation 2 1 7/5/2019 OBJECTIVES: Review the relevant anatomy, injury mechanism, pathophysiology and key factors in treatment decision making of common sports injuries. Discuss the essential features of surgery contributing to excellent outcomes. • Anterior Cruciate Ligament (ACL) Tears • Meniscus Tears • Knee Cartilage Defects • Ankle Syndesmosis Disruptions • Shoulder Dislocation (Bankart Lesion) 3 • Anatomy: ACL / PCL • Cruciate: means cross • ACL/PCL cross • ACL Function . Limits anterior translation of tibia (86%) . Limits internal rotation of tibia • Cause of Injury . Non-contact: Low-velocity, deceleration . Pivoting, Cutting or Landing - Flexion / internal rotation . Contact: . Side-on contact: knee valgus, hyperextension,(football tackle) 4 2 7/5/2019 . Signs / Symptoms . Knee popping- 75-90% . Knee swelling- rapid onset of swelling (blood in joint) . Knee pain and giving-way- Unable to continue play . Severity: Lachman and Anterior Drawer Tests . Grade I: 0-5 mm . Grade II: 6-10 mm . Grade III: >10 mm . Pivot Shift: 98% sensitive for tear . Partial Tears: If any fiber disruption Lachman Test present, then ACL likely to be incompetent 5 • Radiographs: • Can appear normal • Bony involvement • MRI • ACL Tear • Additional Pathology 6 3 7/5/2019 • Meniscal tears • Acute injury: 40-60% • Chronic injury: >90% • Lateral meniscus tears most common • Osteochondral and Chondral injuries • Acute: 12-23% • Chronic: > 50% • Bone Edema (Bone Bruise) • Acute: 95% 7 . Conservative vs Surgical Treatment . Patient activity and functional instability . Adolescent / Child? . Concomitant pathology (meniscus, cartilage) . ACL is necessary for Athletic function . Unstable Knee leads to further meniscus and cartilage damage . Goals for Surgical Reconstruction . Stability: allow cutting, deceleration . Full Range of Motion equal to opposite side . Symmetric Strength . Athletic Confidence . Return to prior level of competition . Restore natural history 8 4 7/5/2019 Pre-operative Essentials . Timing of Surgery . Obtain range of motion . Restore quad function . Decrease swelling . Restore tissue equilibrium . Less risk of Arthrofibrosis . Restore gait, Educate patient for rehab . No reason to hurry . Graft Selection for surgical reconstruction Graft Biomechanics Biologic Patellar Stronger, stiffer, Bone healing, 3-4 Tendon vs native ACL wks, faster Hamstrings, Stronger, stiffer, Tendon-bone DST/G, QST vs native ACL healing, 8-12 wks, slower 9 . Factors Influencing Selection . High demand athletes and younger patients . No significant pre-existing patellofemoral chondrosis or subluxation . Skeletally mature or nearly mature . Patients who are able to rehabilitate their quad function . Older players or those unable to rehabilitate quadriceps . Patellofemoral subluxation, anterior knee pain . Position requiring kneeling: Cultural as well . Previous anterior knee surgery . Small sized patellar tendon, patellar tendonitis . Surgeon preference, technique 10 5 7/5/2019 . Patellar Tendon (Bone-Tendon-Bone BTB) 11 . Hamstrings (Semitendinosus, Gracilis) 12 6 7/5/2019 •Intra-articularLM MM Pathologies: Chondral Defects ACL Lateral Meniscus Medial Meniscus 13 Outcomes After ACL Reconstruction For any Graft Selection What influences results long term ? • Stable reconstruction (negative pivot shift) • Full Extension and Flexion single most important factor after stability • Medial meniscectomy (secondary restraint) • Articular Cartilage Injury • Lateral Meniscectomy RTP when Rehab criterion met, Typically 9-12 months 14 7 7/5/2019 Meniscectomy vs Repair • Anatomy: Meniscus • Medial • Lateral • Peripheral blood supply, move during knee flexion, specialized collagen fibers • Meniscus Function . Load transmission . Peak stress by 235% . Stability: Static and dynamic . Laxity with ACL tear > 50% . Lubrication . Coefficient of Friction 20% . Joint Congruity . Contact area 75% 15 Tear Characteristics Petersen and enstrom Fig 11.34 16 8 7/5/2019 Signs, Symptoms and Imaging . Signs / Symptoms . Swelling, stiffness, locking . Pain with rotation . Difficulty straightening knee . Catching or Locking . Fairbanks Changes (1948) . Osteophytes, Flattening, and Narrowing . Degenerative Changes 17 Meniscectomy vs Repair • Tear Patterns . Longitudinal . Radial . Bucket Handle . Parrot Beak . Factors leading to best treatment option: . Extent of tear . Type of tear . Patient expectations . Associated injuries . Repairable versus non-repairable . Age of patient 18 9 7/5/2019 Meniscectomy vs Repair Best for Repair: • Longitudinal (Vertical) Tear • Peripheral Third of Meniscus • Peripheral Detachment • With ACL Reconstruction • Acute Tear • Less than 40 years old 19 . All Inside Techniques: Needs blood supply 20 10 7/5/2019 Return To Play (RTP) . Surgical Options . Partial meniscectomy (85%) . Pros . Rapid Recovery from Surgery . RTP 2-6 weeks . Cons (Fate of knee may be sealed with Injury) . Secondary effects on Stability and Cartilage wear . Steady progression to osteoarthritis (long term) . Meniscus repair (15%) . Pros . Restores anatomy and function? . Slows onset of arthritis? . Cons . Likelihood of re-tear and additional surgery . Slower rehabilitation . RTP 4-6 months + 21 Outcomes After Meniscus Injury Remove or Repair What influences results long term ? • Preserve as much of native meniscus as possible • Aggressive Repair in younger athletes when possible • Natural history of injury may be sealed at the moment of injury • Meniscus provides load absorption and stability • Meniscus Repair can lead to Recurrence and additional surgery RTP: Meniscectomy 2-6 weeks; Meniscus Repair 4-6 Months 22 11 7/5/2019 • Anatomy: Cartilage layers • Cartilage Function . Low friction articulation • Cause of Injury . Traumatic . Overuse . Approximate Return to Train / Play Time . Depends upon type of surgical procedure – next slides 23 Anatomy Femur Femoral Condyles Tibia Tibial Plateau Articular Cartilage is the smooth white surface on the ends of the bones in all joints, also called Chondral tissue 24 12 7/5/2019 Structure and Function of Articular Cartilage • Minimizes friction (1/7th coefficient of friction of ice on ice) • Load Distribution (protects bone) • Enhances Range of motion • Cartilage composition: • 5% cells (Chondrocytes) • 95% Matrix made by the cells • Matrix gives the unique properties of Hyaline Cartilage 25 Signs, Symptoms and Severity . Mechanism of Injury . Traumatic vs. Repetitive . Acute vs. Chronic . Direct hit vs Indirect (Shear) . Signs / Symptoms
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