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AN INTRODUCTORY SURGICAL ANATOMY CASE SERIES: KNEE SURGERY Amir Salehi-Sedeh andAbdrahamanYu University of Edinburgh SSC5 Orthopaedics Project LEARNING OUTCOMES • Enhance Understanding of Knee Anatomy • Identify Important Surgical Landmarks of the Knee • Discuss Knee Ligament and Meniscal Injury ▪ Presentation ▪ Classification ▪ Operative Management • Revision of important UKMLA Orthopaedic Presentations • Provide an Introduction to real surgical procedures through images • Inspire Future Orthopaedic Surgeons! Warning! The Following Slides will Contain Pictures of RealAnatomy Specimens If you feel uncomfortable or distressed at any time, feel free to take time for as long you need then return to the teaching or contact support if you need it. Some ResourcesAvailable: • University of EdinburghAdvice Place - https://www.eusa.ed.ac.uk/adviceplace/wellbeing/mentalhealth • Samaritans – 116 123 • Nightline – 0131 557 444 ANATOMY OF THE KNEE • A lot more complex than you think! • Hinge joint with slight rotational ability • Femur,tibia and patella • Key components • Medial tibiofemoral component • Lateral tibiofemoral component • Patellofemoral component • Proximal tibiofibular component ANATOMY OF THE KNEE • Allows flexion,extension,and limited rotation of the lower limb • How does it remain stable? • LIGAMENTS! ▪ Anterior cruciate ligament (ACL) ▪ Posterior cruciate ligament (PCL) ▪ Medial collateral ligament (MCL) ▪ Lateral collateral ligament (LCL) • Menisci • Medial and lateral meniscus SURGICAL LANDMARKS • To provide essential orientation for safe and effective knee surgeries • Lateral epicondyle used for the placement of intramedullary nails • Accurate Identification ofAnatomical Structures: ▪ Ensure precise localization of ligaments,tendons,and bones during surgical procedures. o Avoidance of Neurovascular Injury: ▪ Protect critical structures such as the popliteal artery,tibial nerve,and peroneal nerve. o Efficient Surgical Planning: ▪ Facilitate preoperative and intraoperative orientation,minimising surgical time and errors. o Optimal Placement of Implants or Hardware: ▪ Aid in accurate positioning of screws,plates,and grafts,reducing the risk of complications. o Facilitation of Minimally InvasiveT echniques: ▪ Landmarks guide arthroscopic instruments for targeted and effective interventions.PA CASE #1 Presenting atA and E A 23-year-old female recreational football player presents with acute knee pain after a non-contact injury during a match.She reports hearing a "pop" at the time of injury and immediate knee swelling. PATIENT BACKGROUND • HxPC – Instability or 'giving way' sensation in knee;difficulty bearing weight due to the pain and instability • PMHx – No significant history,no previous orthopaedic or rheumatology history • DHx – Occasional paracetamol • SHx – Occasional drinking,plays football regularly,lives with parents,stairs in home • FHx – No history of orthopaedic or rheumatology disorders,no familial conditions ON KNEE EXAMINATION • Inspection:Swelling (Haemarthrosis) within hours of injury • Palpation:Tenderness around joint line • Normal Neurovascular Examination • No abnormalities on hip/ankle examination • Positive Lachman'sT est • PositiveAnterior DrawerT est • Positive Pivot ShiftestCLINICAL EXAMINATIONS INVESTIGATIONS • Bloods ▪ FBC,Group and Save,Coag Screen,(U&Es sometimes indicated if imaging with contrasts are used) ▪ NoAbnormalities • Imaging ▪ Radiographs –AP/Lateral - Normal ▪ MRI MRI MRI confirms a complete tear ofACL with associated bone contusions on lateral femoral condyle and tibial plateau CLASSIFICATION • Grade 1 (Mild): ▪Stretching of the ligament without macroscopic tear. ▪Ligament fibres remain intact • Grade 2 (Moderate): ▪Partial ligament tear,leading to some structural damage and instability. • Grade 3 (Severe): ▪Complete ligament tear,as in this case,with functional instability. MANAGEMENT • Treatment is individualised to patient based on factors such as activity level and age of the patient • Non-operative treatments;physical therapy and lifestyle modifications • Operative treatments ▪ACL reconstruction ▪ACL repair • Type of treatment depends on number of factorsOPERATIVE TREATMENT Feature ACL Reconstruction ACL Repair Technique Replacement of ligament with a graft Suturing of the nativeACL tissue Indications Complete/chronic tears,poor Acute or proximal partial tears,good tissue ligament quality Proprioception Requires graft;proprioception is Retains native proprioceptive function relearned Recovery time Longer (9-12 months) Shorter (6-9 months) Risk of failure Lower in active populations Higher,especially in high-demand individuals ACL RECONSTRUCTION - OVERVIEW 1. Patient in supine position with leg prepared for mobility in a leg holder 2. Arthroscope insertion 3. Locate nativeACL footprint via the intercondylar notch 4. Graft harvest site – patellar/hamstring tendon autograft 5. Femoral and tibial tunnel access for accurate placement in nativeACL footprint 6. Pass graft through tunnels using a guide wire and fix in place 7. Closure What landmarks is the surgeon using to guide their incision LANDMARKING of approach for the graft extraction? A PesAnserinus andTibial Tuberosity Fibular Head and Lateral B Femoral Epicondyle C Inferior Pole of Patella and Lateral Femoral Epicondyle D Tibialuberosity and Fibular Head What landmarks is the surgeon LANDMARKING using to guide their incision of approach for the graft extraction? PesAnserinus andTibial Tuberosity Fibular Head and Lateral Femoral Epicondyle Inferior Pole of Patella and Lateral Femoral Epicondyle TibialTuberosity and Fibular HeadGRAFT EXTRACTION Which tendons,commonly used GRAFT EXTRACTION in this procedure,are identified in the picture (A and B) A Gracilis and Semimembranosus A Patellaendon and B Semitendinosus C Biceps Femoris and Semimembranosus B D Gracilis and SemitendinosusGRAFT EXTRACTION Tendons Identified Tendons sutured together to form a strong durable replacementARTHROSCOPYFEMORAL AND TIBIAL TUNNEL FEMORAL TUNNEL Passing suture Graft fixed with Guide-pin graft into theACL bio-absorbable GraftT ested for placement tunnels screw stability Where does the graft FEMORAL TUNNEL exit the femoral tunnel? A Medial Femoral Condyle B Lateral Femoral Condyle C Medial Femoral Epicondyle D Lateral Femoral Epicondyle Where does the graft FEMORAL TUNNEL exit the femoral tunnel? A Medial Femoral Condyle B Lateral Femoral Condyle C Medial Femoral Epicondyle D Lateral Femoral EpicondyleCOMPLETED GRAFTACL RECONSTRUCTION VIDEO CASE #2 Presenting atA and E A 24 year old man has presented with pain and swelling of his right knee following a ski accident. PATIENT BACKGROUND • HxPC – pain and swelling around the right knee • PMHx – PreviousACL repair • DHx – nil • SHx – Occasional EtOH,skis regularly,lives with parents,bungalow • FHx – No history of orthopaedic or rheumatology disorders,no familial conditions ON KNEE EXAMINATION • Inspection:Swelling around knee • Palpation:Joint line tenderness • No abnormalities on hip/ankle examination • Positive McMurray'sT est INVESTIGATIONS • X-ray (bony rule out) • MRI • Ultrasound:effusion • Arthroscope (diagnostic/ therapeutical) • Bloods: FBC,Group and Save,Coag Screen (All normal)MRI PRESENTATION • Pain;lateral or medial • Locking of knee • Swelling • Joint line tenderness (most sensitive?) • Provocation test: ▪McMurray's test ▪Thessaly test ▪Apley compressionCLINICAL EXAMINATIONANATOMY Which structure is most commonly injured alongside the medial meniscus ANATOMY due to their anatomical attachment? A Medial Collateral Ligament B Lateral Collateral Ligament C Anterior Cruciate Ligament D Posterior Cruciate LigamentCLASSIFICATION MANAGEMENT • Conservative: ▪ NSAID ▪ REST ▪ PhysicalTherapy/ Rehab • Surgical: ▪ Partial/otal Meniscectomy ▪ Meniscal Repair ▪ MeniscalTransplantation What nerve should the surgeon take care to avoid by landmarking LANDMARKING appropriately for their anteromedial port (port for the arthroscope) A Common Peroneal Nerve B Saphenous Nerve C Femoral Nerve D Superficial Peroneal NervePARTIAL MEDIAL MENISCECTOMY SoftTissue Identification Identifying cartilage and lateral meniscus assessment Which ligament is commonly injured in conjunction with a meniscal tear that the APPROACH surgeon will be able to visualize once in the joint? A Medial Collateral Ligament B Lateral Collateral Ligament C Anterior Cruciate Ligament D Posterior Cruciate Ligament Which ligament is commonly injured in conjunction with a meniscal tear that the APPROACH surgeon will be able to visualize once in the joint? A Medial Collateral Ligament B Lateral Collateral Ligament C Anterior Cruciate Ligament D Posterior Cruciate LigamentPRE-MENISCECTOMY ASSESSMENT Medial meniscus assessment:microtears Fragment of meniscus partially dislodged on the inferior surface laterallyVISUALISING DEFECT Relocating the displaced fragment ContinuedTRIMMINGPUNCH RESECTIONPOST-MENISCECTOMY ANATOMYREFERENCES • Kruckeberg, Bradley M. et al. “Quantitative and QualitativeAnalysis ofthe Medial Patellar Ligaments: An Anatomic and Radiographic Study.” The American Journal of Sports Medicine 46 (2018): 153 - 162. • Aula de Anatomia. (n.d.). Knee anatomy. Retrieved January 7, 2025, from https://www.auladeanatomia.com/en/sistemas/253/knee • Powerful PT. (n.d.). ACL, MCL,PCL,LCL – What do these letters stand for? Retrieved January 7, 2025,from https://www.powerfulpt.com/post/acl-mcl-pcl-lcl-what-do- these-letters-stand-for • Springer. (n.d.). ACL reconstruction. In Advances inOrthopedics (pp.643–650). Retrieved January 7, 2025,from https://link.springer.com/chapter/10.1007/978-981-19- 2188-9_80 • Arthroscopy Techniques. (2017). ACL reconstruction techniques. Retrieved January 7, 2025, fromhttps://www.arthroscopytechniques.org/article/S2212- 6287(17)30115-9/fulltext#fig1 • Physiotutors. (n.d.). Lateral pivot shift test. Retrieved January 7, 2025, from https://www.physiotutors.com/wiki/lateral-pivot-shift-test/ • Orthofixar. (n.d.). Lachmantest. Retrieved January 7, 2025, from https://orthofixar.com/special-test/lachman-test/ • Hospital for Special Surgery (HSS). (n.d.). ACL surgery. Retrieved January 7, 2025, from https://www.hss.edu/condition-list_acl-surgery.asp • Dr. Khalfayan. (n.d.). Arthroscopic ACL reconstructiondetailed video. Retrieved January 7, 2025, from https://www.drkhalfayan.com/videos/arthroscopic-acl- reconstruction-detailed/ • Momaya Orthopedics. (n.d.). ACL reconstruction: Orthopedic sports medicine specialist. Retrieved January 7, 2025, from https://www.momayamd.com/acl- reconstruction-orthopedic-sports-medicine-specialist-birmingham-huntsville-montgomery/ • BBC Newsround. (n.d.). [Football Player]. Retrieved January 15,2025,from https://www.bbc.co.uk/newsround/articles/c3g3pxvlln7o • Fall Line. (n.d.).Dave Ryding during Britain's best slalom result at Kitzbühel.Retrieved January 15, 2025,from https://www.fall-line.co.uk/watch-dave-ryding-ski-race- britains-best-slalom-result-kitzbuhel/