Disclosures • Founder, RunSafe™ Common Injuries of the Knee • Founder, SportZPeak Inc. and Shoulder • Sanofi, Investigator initiated grant A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco Primary Care Medicine: Update 2017 Overview Acute Hemarthrosis • Highlight common 1) ACL (almost 50% in children, >70% in presentations adults) • Knee 2) Fracture (Patella, tibial plateau, Femoral • Shoulder supracondylar, Physeal) • Discuss basics of 3) Patellar dislocation conservative and surgical management • Unlikely meniscal lesions 1 Emergencies Urgent Orthopedic Referral 1. Neurovascular injury •Fracture 2. Knee Dislocation • Patellar Dislocation – Associated with multiple ligament injuries • “Locked Joint” - unable to fully extend the (posterolateral) knee (OCD or Meniscal tear) – High risk of popliteal artery injury • Tumor – Needs arteriogram 3. Fractures (open, unstable) 4. Septic Arthritis Anterior Cruciate Ligament (ACL) Anterior Cruciate Ligament (ACL) Tear Tear Mechanism Symptoms • Landing from a • Audible pop heard or felt jump, pivoting or • Pain and tense swelling in decelerating minutes after injury suddenly • Feels unstable (bones • Foot fixed, valgus shifting or giving way) stress • “O’Donaghue’s Unhappy Triad” = Medial meniscus tear, MCL injury, ACL tear • Lateral meniscus tears Double fist sign more common than medial 2 ACL physical exam Special Tests ACL LOOK • Effusion (if acute) • Lachman's test – test at 20° FEEL Sens 81.8%, Spec 96.8% • “O’Donaghue’s Unhappy Triad” = Medial meniscus tear, MCL • Anterior drawer – test at injury, ACL tear 90° • Lateral meniscus tears more Sens 22 - 41%, Spec 97%* common than medial • Lateral joint line tender - • Pivot shift femoral condyle bone bruise Sens 35 - 98.4%*, Spec 98%* Malanga GA, Nadler SF. MOVE Musculoskeletal Physical • Maybe limited due to effusion Examination, Mosby, 2006 or other internal derangement * - denotes under anesthesia X-ray MRI • Usually non- • Sens 94%, Spec 84% diagnostic for ACL tear ACL tear signs • Can help rule in or • Fibers not seen in out injuries continuity • Edema on T2 films • Segond fracture – • PCL – kinked or avulsion over Question mark sign lateral tibial plateau 3 MRI Initial Treatment • Sens 94%, Spec 84% • Referral to Orthopaedics/Sports Medicine for ACL tear • Consider bracing, crutches ACL tear signs • Begin early Physical Therapy • Lateral femoral corner bone bruise on T2 • Analgesia usually NSAIDs • May have meniscal tear (Lateral > medial) ACL Tear Treatment Meniscus Tear Conservative Surgery Mechanism Symptoms • No reconstruction • Reconstruction • Occurs after twisting •Catching • Physical therapy • Depends on activity injury or deep squat • Medial or lateral knee • Hamstring demands • Patient may not recall pain strengthening Reconstruction allows • Proprioceptive training better return to sports specific injury • Usually posterior • ACL bracing Reduce chance of aspects of joint line controversial symptomatic meniscal tear • Swelling • Patient should be Less giving way asymptomatic with symptoms ADL’s • Recovery ~ 6-9 months Shea KG, et al. AAOS evidence based reivew, J Bone Joint Surg Am, 2015 4 Special Tests: Meniscus Modified McMurray Testing Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186. Test Sensitivity Specificity • Flex hip to 90 Joint line tender 85.5% 29.4% degrees • Flex knee Hyperflexion 50% 68.2% • Internally or externally Extension block 84.7% 43.75% rotate lower leg with rotation of knee McMurray Classic 28.75% 95.3% (Med Thud) • Fully flex the knee McMurray Classic (Lat 50% 29% with rotations pain) Appley (Comp/Dist) 16% / 5% Courtesy of Keegan Duchicella MD X-ray MRI • May show joint space • MRI for specific exam narrowing and early osteoarthritis changes • Look for fluid (linear bright signal on T2) • Rule out loose bodies into the meniscus 5 Arthroscopy Benefit? Exercise as Good as Arthroscopy? • An RCT showed that physical therapy vs • RCT found that patients with degenerative arthrosopic partial meniscectomy had meniscus tears but no signs of arthritis on similar outcomes at 6 months imaging treated conservatively with • 30% of the patients who were assigned to supervised exercise therapy had similar physical therapy alone, underwent surgery outcomes to those treated with within 6 months. arthroscopy with 2 year follow up. – Katz JN et al. N Engl J Med. 2013 – Sihvonen R et al; N Engl J Med. 2013 Kise NJ et al., BMJ, 2016 Medial Collateral Ligament (MCL) Meniscal Tear Treatment Injury Conservative Surgery Mechanism Symptoms • Often if degenerative • Operate if internal • Valgus stress to • Pain medially tear in older patient derangement partially flexed knee • May feel unstable • Similar treatment to symptoms • Blow to lateral leg with valgus mild knee osteoarthritis • Meniscal repair if possible • Analgesia • Physical therapy • General Leg Strengthening 6 Medial Collateral Ligament (MCL) MRI Injury Physical Exam • Tender medially over • X-ray non-diagnostic MCL (often (rarely avulsion) proximally) • MRI not usually • May lack ROM necessary “pseudolocking” • Rule out meniscal • Valgus stress test tear Posterior Cruciate Ligament (PCL) MCL Treatment Injury Conservative Surgery Mechanism Symptoms • Analgesia • Rarely needs surgery • Fall directly on knee • Pain with activities • Protected motion with foot plantarflexed • “Disability” > +/- hinged brace • “Dashboard injury” “Instability” +/- crutches • Early physical therapy 7 Posterior Cruciate Ligament (PCL) PCL Treatment Injury Physical Exam Conservative Surgery • Sag sign • Acute: hinged • May require surgery Sens 79%, Spec 100% post-op brace in if complete Grade 3 extension (0-10° tear and symptomatic • Posterior drawer test flexion) Sens 90%, Spec 99% • Crutches • Needs urgent surgery Rubenstein et al., Am J Sports Med, 1994; 22: 550-557 • Early physical if lateral side is therapy unstable postero- X-ray- often non-diagnostic lateral corner injury MRI is test of choice Early and urgent referral!! Patellofemoral Pain PFP Syndrome • Excessive Symptoms • Tender over facets of compressive forces • Anterior knee pain patella over articulating • Worse with bending surfaces of PFP joint • Apprehension sign (5x body wt), stairs suggests possible (3x body wt) instability Mechanism • Crepitus under • Too kneecap loose/hypermobile • May sublux if loose • X-rays may show • Too tight – XS lateral deviation or tilt pressure 8 Treatment Options What’s Hip? Too Loose/Weak Surgical (RARE) • Strengthen quads (Vastus Medialis Obliquus) • Last resort • Correct alignment (+/-orthotics) • Lateral release • Support (McConnell Taping, • Patellar Bracing) realignment Too Tight • Stretch hamstring, quadriceps, hip flexor • Strengthen quads, hip abductors • Correct alignment (+/-orthotics) Prevalence of Knee Osteoarthritis Cartilage Damage • As the number of persons over age 65 years, prevalence estimated to double to more than 70 million by 2030. • The incidence of knee OA in the United States is 240 per 100,000 person-years. Outerbridge Classification, 1961 9 Arthroscopy Arthroscopy Osteoarthritis What is Osteoarthritis? • OA is a disease characterized by Superficial Zone cartilage Transition Zone degeneration • Cartilage loss and Radial Zone OA symptoms are preceded by damage to the collagen- Tidemark Calcified cartilage proteoglycan (PG) Subchondral bone plate matrix Vascular plexus 10 Concepts Diagnosis - History Arthritis Symptoms • Pain • Irreversible Articular • Mechanical Cartilage Change – Grinding • Cure Not Possible –Catching • Try To Maintain Activity – Locking Level – Giving Way • Swelling Diagnosis - Radiographs In FWB Extension XR 11 Treatment Options • Conservative • Surgical Try Conservative Management Conservative Treatment First • Lifestyle Unloader Brace • Shoe Wear • Off Load Arthritic • Brace Wear Compartment • Rehabilitation/PT • Pain Relief Lindenfield, et al Pollo / HSS, AJSM 2002 12 Conservative Treatment Platelet Rich Plasma ? Medications • Platelet-rich plasma injections contain high concentration of platelet-derived growth factors, which regulate some • NSAID / Tylenol biologic processes in tissue repair. • Analgesics • Glucosamine / Chondroitin • A meta-analysis of 10 studies demonstrated that platelet- rich plasma injections reduced pain in patients with knee • Steroid injections OA more efficiently than placebo and hyaluronic acid • Viscosupplementation injections. However, 9 of the 10 studies had a high risk (Hyaluronic Acid of bias, and the underlying mechanism of biologic injections) healing is unknown. Laudy AB et al. Br J Sports Med. 2015 Surgical Treatment Arthroscopy Arthroscopy for OA • Prospective, Randomized Placebo • Used for Internal Controlled Study Derangement • 165 VA Patients Symptoms • Placebo vs Lavage vs Debridement had similar Knee Specific Pain • Treat Focal Lesions Scores at 1 and 2 years follow up • Remove loose bodies Moseley, New Engl J Med, 2002 • No difference in outcomes: WOMAC, • Temporizing SF-36 Physical component summary score • High Demand Kirkley, New Engl J Med, 2008 • No Malalignment 13 High Tibial Osteotomy High Tibial Osteotomy Technique Opening Wedge Results Good To Excellent • 73% - 95% @ 5 yrs • 45% - 80% @ 10 yrs • 30% – 46% @ 20 yrs • Jevsevar DS. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013 Unicondylar Arthroplasty Total Knee Arthroplasty Results 5-year survival rate was 87.8% Replace All Joint Surfaces (95% CI, 87.3% to 88.3%) • Significant negative influence Excellent, Reliable Pain