Ligaments function

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Ligaments function

• Knee is like a round ball on a flat surface
• Ligaments provide most of the support to the
  knees
• Little structure or support from the bones

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Classification of ligament injuries

• First-degree mild minimal signs and symptoms,
  minimal functional loss and resolves in a few
  days.
• second-degree moderate- partial structural
  disruption, swollen tender, may show some signs
  of instability. Performance deficit for up to 6
  weeks.
• Third-degree severe extensive structural
  disruption, extensive swelling, severe pain,
  joint unstable. Performance deficit. Minimum 6-8
  weeks.

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Classification of ligament injuries

• Third-degree

• Grade I less than a 0.5-cm opening of the joint
  surfaces
• Grade II a 0.5- to 1-cm opening of the joint
  surface
• grade III a rupture larger than a 1-cm opening

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LIGAMENTS HEALING

• Ligaments are slow to heal due to their
  hypovascular nature.
• Pathologically ligaments are a type of dense
  connective tissue, 90 type I collagen, 9 type
  III collagen and 1 fibroblast cells

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TREATMENT OPTIONS
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Operative vs. Non-operative

• FACTORS

• Degree of spain
• What?
• Where?
• Age
• Demand
• Assosiated injury

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NONOPERATIVE TREATMENT

• RICE
• Bracing
• Strengthening
• Functional brace

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OPERATIVE TREATMENT

• Repair surgical treatment of acute
  injuries(Optimal surgical dissection and repair
  become increasingly difficult beyond 7 to 10 days
  after injury)
• Reconstruction usually refers to surgical
  treatment of ligamentous laxity several months
  after injury

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ACL INJURY
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Mechanism of injury

• An ACL injury (either grade I, II or III) can
  occur during the following
• Sudden hyperextension of the knee.
• Body weight twisting across the knee joint
  causing a shearing force while the foot is still
  planted on the ground.
• Sudden deceleration.

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ACL FUNCTION

• The ACL provides both mechanical stability and
  proprioceptive feedback to the knee.
• Restrains anterior translation of the tibia on
  the femur.
• Prevents hyper-extension of the knee.
• Secondary stabilizer to valgus stress
• Controls rotation of the tibia on femur in the
  last 30 degrees of knee extension. (part of the
  locking mechanism)

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ACL Tx

• Operative vs. Non-operative
• Demand level
• Age
• lifestyle
• Other lesions

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OPERATION

• The decision to reconstruct an ACL tear should be
  based not only on the presence of symptomatic
  instability, but also on the lifestyle and
  activity level of the patient.
• Age isnt base of guide line for reconstruction
  because the more important factor is the overall
  level of activity.

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OPERATION

• Consequently, age itself should not be a
  contraindication to ACL reconstruction.
• Symptomatic patients with a more sedentary
  lifestyle and those who are willing to modify
  their level of activity can be considered for
  nonoperative treatment,

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OPERATION

• TIMING

• No swelling
• Good leg control
• Full ROM (full hyperextension)

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Non-operative

• Aggressive rehabilitation program
• functional knee brace

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MCL INJURY

• Healing is good

• Blood supply
• Relatively wide surface area
• Association with other secondary stabilizers
• Extra-articular location.

Shockwave
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Isolated MCL Injury

• Non operrative tx

• Bracing(full time for 4 to 6 weeks and daytime
  for another 4 to 6 weeks)
• Early motion and weight bearing
• Quadriceps and hamstring strengthening

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Isolated MCL Injury

• Operative tx

• Large bony avulsions identified on radiographs
• Stener-type lesions of the distal MCL
• patients with persistent functional valgus
  instability after nonoperative treatment

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Combined Injuries ACL/MCL

• Nonoperative treatment of the MCL
• ACL reconstruction
• For chronic ACL tears with residual valgus
  instability, simultaneous reconstruction of the
  ACL and MCL.
• ACL/PCL/MCL injuries with reconstruction of all
  injured ligaments

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PCL Injuries

• PCL injuries are present in up to 3 of knee
  injuries in the general population and as many as
  37 of knee injuries in trauma patients with
  acute hemarthrosis.
• PCL injury typically results following an
  excessive posteriorly directed force on the tibia

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PCL Injuries

• Non operative Tx

• Low-grade isolated PCL injuries

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PCL Injuries

• Operative Tx

• Multiligamentous injuries
• symptomatic chronic grade II or III
• PCL avulsions(Repaire)
• PCL injuries in active patients who are unwilling
  to change their lifestyle

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Fibular Collateral Ligament and the
Posterolateral Corner

• Less commonly injured than the cruciate
  ligaments or the medial knee ligament complex.
• Associated posterolateral corner injuries provide
  a potential source of residual instability
  following anterior cruciate ligament and
  posterior cruciate ligament reconstruction
• Can lead to reconstruction graft failure

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Treatment

• Non operative Tx

• Grades I and II injuries
• Knee bracing(3-6 wks)
• Full weight bearing
• In combined Injury ACL and PCL treated
  operativly and grade I ,II injury to PLC treated
  non op

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PLC TREATMENT

• Operatve Tx

• Grade III injuries
• Combined ACL ,PCL,PLC concurrent repair or
  reconstruction
• Repair and Reconstruction

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REPAIRE

• Intrasubstance repairs of the fibular collateral
  ligament and popliteus have not fared well and
  therefore should not be performed.
• Other structures of the PLC areamenable to
  intrasubstance repair. These include the coronary
  ligament of the lateral meniscus, meniscofemoral
  and meniscotibial ligaments, and fibers of the
  popliteomeniscal ligaments

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RECONSTRUCTION

• Reconstruction better and had fewer failures (9
  vs. 37) than the repair
• These include nonanatomic and anatomic
  techniques.
• Operative management provides improved outcomes
  compared with nonoperative
• Early surgical management (within 3 weeks) is
  better

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THANK YOU