Introduction Role of menisci

• Medial lesions are more common than 01 lateral meniscus because it is attached to the  improving articular capsule that make it less mobile thus it cannot congruency and increasing easily to accommodate the abnormal stresses. the stability of the • In increasing age – gradual degeneration and change in the material properties of the menisci Meniscus  controlling the complex thus splits and tears are more likely that usually associated with osteoarthritic articular damage or rolling and gliding actions of chondrocalcinosis. Injury the joint • In younger people - meniscal tears are usually the result of trauma, with a specific injury identified in  distributing load during the history. movement

Tear of Meniscus Pathology Pathology

• Usually, meniscus more likely to tear along its Vertical tear Horizontal tear

length than across its width because the  Bucket-handle tear  usually ‘degenerative’ or due to repetitive minor trauma meniscus consists mainly of circumferential  the separated fragment remains attached front  complex with the tear pattern lying in many collagen fibres held by a few radial strands. and back planes  The torn portion can sometimes displace towards  may be displaced or likely to displace  • The meniscus is usually torn by a twisting the centre of the joint and becomes jammed If the loose piece of meniscus can be displaced, it between femur and tibia acts as a mechanical irritant, giving rise to force with the knee bent and taking weight.  This causes a block to movement with the patient recurrent synovial effusion and mechanical describing a ‘locked knee’ symptoms • In middle life, tears can occur with relatively  posterior or anterior horn tears  Some are associated with meniscal cysts little force when fibrotic change has  the very back or front of the meniscus is  It is also suggested that synovial cells infiltrate into the vascular area between meniscus and restricted mobility of the meniscus. damaged  parrot beak tears capsule and multiply there  oblique tear pattern creates a flap of meniscus  The lateral meniscus is affected much more that may be stable (unlikely to displace) or frequently than the medial unstable (displaced or likely to displace). Clinical Features

. Mechanism of injury - twisting force . Knee joint slightly flexed with the knee bent and taking weight. . Presence of effusion . Severe pain – avoid further activities . Wasting of quadricep muscle . Locking of knee in partial flexion . Localized tenderness of joint line (suggest bucket-handle tear) . Swelling of knee after hours . ROM- may have full flexion but . Symptoms alleviate with rest and slightly limited extension aggravate after trivial twist or strains . McMurray’s test, Apley’s grinding . Intermittent knee instability followed test, Thessaly test may be by pain and swelling positive

Investigation Treatment Treatment

OPERATIVE TREATMENT  Plain X-rays DEALING WITH THE LOCKED KNEE - Should be normal in young patients with an acute . Indication meniscal injury . Usually unlock spontaneously - if the joint cannot be unlocked - Meniscal calcifications may be seen in crystalline . If not, do gentle passive flexion and rotation - if mechanical symptoms (locking or catching) are arthropathy (ex. CPPD) . Rest the knee for few days and may well unlock itself recurrent and non-operative treatment has failed  MRI . If the knee does not unlock, or if attempts to unlock it cause severe . Tears close to the periphery, which have the capacity to heal, can  reliable method of confirming the clinical diagnosis pain, arthroscopy is indicated. be sutured; at least one edge of the tear should be red (i.e.  linear high signal that extends to either superior or . If symptoms are not marked, it may be better to wait a week or vascularized) inferior surface of the meniscus indicative of a tear two and let the synovitis settle down . Tears other than those in the peripheral third are dealt with by  parameniscal cyst indicates the presence of a meniscal . If the tear is confirmed, the offending fragment is removed or excising the torn portion (or the bucket handle) tear repaired if possible . Total meniscectomy is thought to cause more instability and so  bucket handle meniscal tears indicated by “double PCL” predispose to late secondary osteoarthritis sign or “double anterior horn” sign CONSERVATIVE TREATMENT . Partial meniscectomy has lesser morbidity but no obvious  a horizontal cleavage in the medial meniscus – the advantage characteristic ‘degenerative’ lesion – or detachment of . If a peripheral tear has been identified and the lesion may be . Arthroscopic meniscectomy has distinct advantages over open the anterior or posterior horn without an obvious tear repairable, then arthroscopy and suture repair of the meniscus can meniscectomy: shorter hospital stay, lower costs and more rapid  Diagnostic knee arthroscopy be employed return to function but still have complication  Infrequently performed due to increased use of MRI . Non-operative care should be instigated . Postoperative pain and stiffness are reduced by prophylactic non- scanning steroidal anti-inflammatory drugs Introduction Pathology

 A small, well-demarcated, avascular 02  The lower, lateral surface of the medial femoral condyle is usually affected fragment of bone and overlying  An area of subchondral bone becomes avascular cartilage sometimes separates from Articular and within this area an ovoid osteocartilaginous one of the femoral condyles and segment is demarcated from the surrounding appears as a loose body in the joint bone. Defects –  At first the overlying cartilage is intact and the  Causes - trauma, either a single fragment is stable impact with the edge of the patella or Osteochondritis  over a period of months the fragment separates repeated microtrauma from contact but remains in position Dissecans  finally the fragment breaks free to become a loose with an adjacent tibial ridge. body in the joint  The small crater is slowly filled with fibrocartilage, leaving a depression on the articular surface.

Clinical Features Investigation Management

 Plain X-Rays  usually between 15 and 20 years of age  ‘stage’ the lesion - a line of demarcation around a lesion in situ,  Do MRI or arthroscopy  intermittent pain or swelling usually in the lateral part of the medial femoral  In the earliest stage, when the cartilage is intact and the lesion is  attacks of knee instability condyle ‘stable’, no treatment is needed but activities are curtailed for 6–  ‘locking’ sometimes occurs - Once the fragment has become detached, the 12 months. Small lesions often heal spontaneously. empty hollow may be seen – and possibly a loose  If the fragment is ‘unstable’ (i.e. surrounded by a clear boundary  The quadriceps muscle is wasted body elsewhere in the joint with radiographic ‘sclerosis’ of the underlying bone), or showing MRI features of separation, treatment will depend on the size of  may be a small effusion  MRI the lesion and the age of the patient.  tenderness localized to one femoral condyle - Most effective imaging technique to define the  A small fragment should be removed by arthroscopy and the base soon after attack (diagnostic) site, size and activity of an OCD lesion drilled, the bed will eventually be covered by fibrocartilage,  Wilson’s sign: if the knee is flexed to 90 degrees, - An OCD lesion will typically demonstrate an area leaving only a small defect of low signal intensity in the T1-weighted images,  A large fragment (more than 1 cm in diameter) should be fixed in rotated medially and then gradually with adjacent bone also appearing abnormal, situ with pins or Herbert screws, or in the younger patient with straightened, pain is felt; repeating the test with probably due to oedema open growth plates. the knee rotated laterally is painless (diagnostic)  Arthroscopy  In older patients, removal of the unstable fragment and cartilage repair techniques (e.g. microfracture or autologous cartilage - To determine if an OCD lesion is stable or implantation (ACI) can be carried out. unstable, prior to fixation or removal Introduction Pathology

 Chronic disorder of synovial joints, in which 02  articular cartilage breakdown starts in an area of there is progressive softening and disintegration excessive loading of articular cartilage accompanied by new  can affect all of the soft tissues around the knee growth of cartilage and bone at the joint margins  Disease localized to the medial compartment is (osteophyte), cyst formation and sclerosis in Articular the commonest pattern occurring, producing subchondral bone, mild synovitis and capsular to normal limb alignment fibrosis.  Other intra-articular characteristic features  The knee is the commonest of the large joints to Defects – found include peripheral osteophyte formation, be affected by osteoarthritis bone loss, degenerative change to the menisci  Often bilateral and in these cases there is a Osteoarthritis and anterior cruciate ligament (ACL) destruction strong association with Heberden’s nodes and  Concurrent chondrocalcinosis is relatively generalized osteoarthritis. common

Clinical Features Investigation Treatment

 Patients are usually over 50 years old and are often  Standard X-Ray of Knee NON-OPERATIVE TREATMENT overweight. - tibiofemoral joint space is diminished  Pain that worsen after used or walking up stairs  Educate on good information about the disease, exercise and  Joint stiffness after rest - subchondral sclerosis weight-loss if appropriate.  Pain to start move after prolong sitting - Osteophytes and subchondral cysts are  Physiotherapy - produce gradual strengthening of the quadriceps  Swelling of joint muscles and increase the level of exercise being undertaken by the usually present patient  May have knee instability and locking - soft-tissue calcification in the  Analgesic  Obvious deformity (varus deformity-medial compartment  Intra-articular corticosteroid injections more severely affected) suprapatellar region or in the joint itself  Scar of previous operation (chondrocalcinosis) OPERATIVE TREATMENT  Wasted quadricep muscle  MRI  Indication  Knee effusion which associated synovitis - Produce additional useful information - Persistent pain unresponsive to conservative treatment  Limited movement of joint accompanied by crepitus concerning the soft tissues of the knee - progressive deformity and instability  Loss of the last few degrees of terminal extension as a fixed  Replacement arthroplasty flexion deformity (shortening of the posterior capsule) - the degree of articular cartilage damage  long periods of lesser discomfort and only moderate loss of across the whole knee  Arthrodesis - if there is a strong contraindication to arthroplasty or function, followed by exacerbations of pain and stiffness to salvage a failed arthroplasty Clinical Features 02 Clinical Features

 rheumatoid arthritis starts in the knee as a chronic Articular As the disease progress monarticular synovitis, then other joints become involved  knee becomes increasingly unstable Defects –  muscle wasting is marked Early stage  some loss of flexion and extension.  X-rays may show diminution of the joint space, osteopenia  characterized by synovitis Rheumatoid and marginal erosions  The patient complains of pain and chronic swelling In the late stage of the knee Arthritis  effusion of knee and the thigh muscles may be  pain and disability are usually severe  wasted marked stiffness  cartilage and bone destruction predominate  The thickened synovium is often palpable  the joint becomes increasingly unstable and deformed  May rupture the posterior capsule that cause (fixed flexion and valgus) sudden pain and swelling which closely mimic the  X-rays reveal the bone destruction characteristic of features of calf vein thrombosis Treatment advanced disease

CONSERVATIVE MANAGEMENT

 general treatment with anti-inflammatory and disease-modifying drugs  local splintage  injection of corticosteroid  introduction of anti-TNF medication, which can stop the inflammatory process within the joint and prevent longer-term joint destruction

OPERATIVE TREATMENT

 Synovectomy and debridement - Only indicated if other measures fail to control the synovitis  Arthroplasty - Total joint replacement is useful when joint destruction is advanced Introduction Mechanism of Injury

 ACL injury common in female athlete (4.5:1 ratio) 03  PCL rupture less common than ACL rupture  Pivot shaft injury  PCL is much stronger than ACL  Direct thrusting force or Function of ACL  Prevent anterior displacement of the tibia on the femur Ligamentous collision to knee  Prevent tibia being pulled anteriorly during knee flexion  Prevent hyperextension of knee  Hyperextension injury  Resists excessive tibial rotation Injury– ACL & Function of PCL  Twisting movement  Prevent posterior displacement of the tibia on the femur PCL  Prevent tibia being pulled posteriorly during knee flexion  Dashboard injury  Resists excessive tibial rotation  Pulling or stretching ligament

History Physical Examination Physical Examination

ACUTE Standing Supine

 History of twisting /wrenching injury 1. Inspection of Leg  ‘Pop' sensation in the knee 1. INSPECTION 2. Special Test  Painful, immediate swelling knee Anterior / Lateral / Posterior  Examine from the foot  Temperature  Partial tear end of bed  Feeling for crapitus  ACL - May have excruciating pain, but no abnormal • Attitude of lower limb  Watch for: movement • Skin changes -external rotation  Patella tap - Anterior - Swelling worse (Acute haemarthrosis) 70% • Wasting of muscle -internal rotation  Fluid shift -  Complete tear • Attitude of knee -genu varus and valgus - Permit abnormal movement, which sometimes causes  Mobility of patella  PCL -flexion deformity of the surprisingly little pain 2. Type of gait  Patella grinding - Posterior Drawer  Bruises or abrasion on site of impact knee • Normal gait -Q angle of the knee  Joint line tenderness Test Chronic • Antalgic gait -Quadriceps wasting - Posterior Sag Test • Short limb gait -Shortening of limb 3.  Pain – may or may not present • High stepping gait  May have some degree of instability while walking on uneven -Shortening of limb • Shuffling gait ground/ climbing up/ down flights of stairs. (compare level of malleoli) •  Loss range of motion Wind swipe gait -Measurement of limb • length discrepancy Investigation

1. Plain x-rays: o May show the ligament has avulsed a small piece of bone o ACL - avulsion fracture of the proximal lateral tibia ( AKA Segond Fracture) or Deep sulcus (terminalis) sign o PCL – AP and supine lateral or Lateral stress view 2. MRI o Can distinguish partial from complete ligament tears o Reveal areas of bone bruising 3. Arthroscopy o Diagnostic and therapeutic purposes o Main indication: for reconstruction of cruciate ligament tears

Treatment Treatment

2. Complete tears 1. Partial tears  Isolated tears of the ligament may be treated by o Usually conservative; PRICE o NSAIDS early operative reconstruction if in sportsman o Active exercise to avoid adhesion  Indications for ligament reconstruction: . Muscle-strengthening exercise - Younger, more active patients (reduces the (hamstring and quadriceps) after incidence of meniscal or chondral injury) symptoms subsides - Children (strongly consider operative as . Muscle strength can compensate for activity limitation is not realistic) stability loss - Older active patients (age >40 is not a o Aspiration of effusion in hemarthrosis contraindication if high demand athlete) o Weightbearing is allowed, but - Prior ACL reconstruction failure . The knee is protected from rotational  Otherwise, treat conservatively or angulatory strain o Movement and muscle strengthening . by a heavily padded bandage or a excercises are encouraged functional brace  Isolated tears of the PCL are usually treated conservatively Introduction Mechanism of Injury

Medial Collateral Ligament Injury 03 Medial Collateral Ligament Injury  Most commonly due to valgus stress  Most common ligamentous knee injury ▹Usually with knee held in slight flexion & external rotation •Usually associated with ACL or medial meniscus injury  Contact injury  Incidence is likely higher than reported Ligamentous ▹More common •low grade injuries can be missed ▹Direct blow to the lateral knee with valgus force  Males> females ▹Lead to high grade/ complete lig. injury  Commonly occur in athletes Injury–  Non-contact injury ▹More common in skiing Lateral Collateral Ligament Injury ▹Pivotting or cutting activities with valgus & external rotation Collateral force  Isolated injury extremely rare (< 2% knee injuries) ▹Lead to low grade / incomplete ligament injury  7-16% of all knee ligament injury in non-isolated cases Lateral Collateral Ligament Injury •Particularly PLC injury, others: ACL, PCL Ligament  Direct blow or force to medial knee (varus stress)  Isolated LCL injury seen most in gymnasts & tennis players  Excessive varus force, external tibial rotation, and/or hyperextension

History Physical Examination Classification

MCL Tear Classification - Medial Collateral Ligament Injury MCL Injury LCL Injury LCL Tear Classification (Based on lateral HughstonModification of American Medical joint opening compared to contralateral Association (AMA) Classification side) st  Recent history of excessive valgus force applied to partially Look Look Grade I (1 degree injury)  Grade I flexed knee ▹Ecchymosis & swelling at medial  Mild, local tenderness 0 –5 mm lateral joint opening ▹Ecchymosis & swelling of soft  Firm endpoint, No joint laxity  “Pop” sound during the event of injury aspect of knee  Grade II tissue at lateral joint  Stretch injury or few MCL fiberstorn 6 –10 mm lateral joint opening nd  Pain & stiffness at medial knee Feel Feel Grade II (2 degree injury)  Grade III   Most patients are unable to ambulate after acute injury ▹Palpate with knee 25-30’ flexion ▹Palpate with knee 20’ flexion Moderate, more generalized >10 mm lateral joint opening ▹ tenderness  Erythema after several days Tenderness over medial aspect ▹Tenderness over LCL  Firm endpoint, +/-mild increase in of knee LCL Tear MRI Classification insertion/lateral aspect of knee joint laxity Grade I Lateral Collateral Ligament Injury ▹Isolated tenderness at proximal ▹Isolated tenderness at proximal  Incomplete/ partial MCL tear •Subcutaneous fluid surrounding the or distal insertion –avulsion-type Grade III (3rddegree injury) midsubstance of the ligament at one or or distal insertion –avulsion-type  Severe, generalized tenderness  History of varus force to knee Move both insertions Move  No endpoint with valgus stress Grade II  Pain & stiffness at lateral knee ▹ROM and stability ▹Hyperextension or varus(lateral)  Increased joint laxity •Partial tearing of ligament fibers at either  Most patient still able to ambulate after acute injury Special test thrust gait o Grade 1+ : 3-5 mm the midsubstance or one of the insertions ▹ o Grade 2+ : 6-10 mmm Grade III  Swelling often present Neurovascular exam: Saphenous Special test o Grade 3+: >10 mm nerve exam •Complete tearing of ligament fibers at  Instability near knee full extension ▹Neurovascular exam: Common  Complete MCL tear either the midsubstance or one of the  Erythema after several days ▹Valgus stress testing peroneal nerve exam insertions ▹Varus stress test, Dial test Investigation

 Plain Radiograph - AP and Lateral view - Stress view (joint instability) - Not specific, may find fracture/effusion  MRI - To identify location and extent of injury - To identify other injury (nerve, meniscus, lig.)

Treatment Treatment

OPERATIVE NON OPERATIVE GRADE II & III Repair Reconstruction GRADE I  NSAID  Acute injury  Indication:  NSAID  Therapy 1. Ligament avulsion - Chronic Instability  Therapy: Active  Rest reattached with suture - Insufficient tissue for Exercise  Brace, crutches & anchors repair  Brace/crutches functional bracing 2. Interstitial disruption  Rest  Return to SPORT: anterior advancement to  Graft types: origin 1. Semitendinosus  Return to SPORT:  Grade II: 2-4 weeks 2. Hamstring 5-7 days  Grade III: 4-8 3. Tibialis anterior weeks 4. Achilles tendon