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Cute knee injury assessment, I'll talk a little bit about different ligament injuries and some cases from the athletes that I saw that I've seen on fellowship and, and thereafter, so uh there will be lots of MRI images here, I'm afraid and no shot, no shying away from that. Um In terms of elite athletes, I would just say that these patient's travel from far field and they usually have an entourage. They almost always have physio with them uh and sometimes a partner and someone else from the club. So it's about patient and expectation management and they have big injuries, a lot of forces go through, go through the knees during injuries and also a lot of forces go through the reconstruction. So they really need to be tight and solid. Um But they're also very motivated and they'll, they'll, they'll get their knees rehab very, very quickly. They have really good physiotherapy. My NHS patient's don't see a physio until about six weeks. They see physios immediately and they also have high expectations. So it's a bit a bit of a stressful area to work in. So let's talk about the typical acute knee injury. Um is it is there are these are the things that I, I consider when I, when I take a history from the patient, is there contact or no contact ACL injuries are usually non contact and they're usually as a result of poor landing or cutting, cutting injuries. If you have a contact injury, it's often a worse injury. So you're thinking about more maybe a collateral involvement or multi, like if there was an immediate, if there was immediate swelling, that means that there's a bigger injury. If it's a delayed swelling, it's probably more a meniscal thing. And you have a kind of a reactive infusion. Um, for ski injury, for example, could they, could they ski down the mountain or could they, could they finish the game? If they could, then it makes me think more of a municipal issue and if they can't, they get stretched down or helicopters or they can't play on, then it's probably a ligamentous injury, locking, locking for me is that when they, when the patient's are unable to fully extend the knee. So there's a physical block to extension. Um We, I'm a, I'm a big, big believer in. You won't, you won't, you won't pick up feeds you don't look for. So you must look, must examine, you must do near vascular, examine. So check the comparing your nerves, tibial nerves and check the pulses. Um And uh if, if there is a delayed presentation, if they're, if they're injury was a year ago. Then you talk about when they have instability, they have instability when they're going on a straight line or where they're pivoting and they're twisting and turning. It's twisting and turning. You're thinking more rotatory instability and ACL rather than something else. So, so that's the difference between them. The guy on the left has a big injury to his knee and the one on the right has been doing long distance running is probably a municipal injury, right? I'm going to skip past this and I'm going to just go through some MRI images because it made a huge difference in terms of our understanding, preoperatively. So this is the uh this is the fast forward sign. Can you see this is a flip bucket handle, tear of the lateral meniscus. Uh It looks like a fast forward sign on the old machines. Um And if we were and how about this one? Can, can someone tell me what they see on this on this slide WBC? Oh HMM double PCL. So it looks like there's two PCLS there. And this is a bucket handle, flip back handle tear of the medial meniscus on the slices when, when they flip, it looks like this. Um And on this, on this view, what you can see here is a bit more subtle but it's, you can see that's the posterior horn of the, of the medial meniscus on the MRI scan. And you can see there's a tear through the root and this is what it is essentially a root here. Uh This, this is the natural side, but this is, this is where, where it attaches to the, to the tibia, the roots can tear effectively d functioning the entirety of that meniscus. Um This is uh the actual view which I think is really, really helpful and you can see that you can clearly see that route, tear on, on that view. It's a close up version of it. Can you see that? But you won't see unless you look for it. Um This is a hot topic. It's another hot topic in sports surgery and uh lots of people are repairing these a lot more aggressively now. Okay. So here's some cases, this is a championship midfielder, 21 years old, noncontact pivoting injury couldn't play on immediate swelling. What do you guys think? A CEO it's typical, isn't it? And can you see that on, on the MRI images? Yeah. Yeah. Um These are the important slices. Can you see this here? This, this is the, this is the ACL, it should be a nice big thick band. It should have similar, similar appearance to the Meniscus big thick black thing. But you can see it's, it's, it's highly edematous. The fibers are not, the fibers are curving over. Can you see that's not straight, not under tension, the tibia has moved anteriorly as well. So that's, that's typical ACL tear and this is typical pivot shift bruising bruising in the mid lateral femoral condyle. And also you also get bruising around the posterior uh post lateral tibial plateau. That's pivot shift pattern. Um Can you see his meniscal tear? It's in the lateral countries in the lateral side. Yeah. Uh Well, it's, it's, are you talking about this? Yeah. No, this was that little radio. Yeah. So he has an ACL tear with a radial lateral meniscus dial, test negatives isolated. So, what do we do? When do we do this? When do we do? So he probably needs an ACL reconstruction, doesn't he? Right. So, uh in the old days, they used to say a third of people cope, third of people sort of change what they do and a third of people have surgery. I think it's more a third of people cope and two thirds of people have, have surgery and if you're young and you're playing football, then you're going to need to want to have surgery. So when do we do this? Um, the evidence shows that early surgery needs to happen really early. So if you, if you can do it within about two weeks, then that's great. If he, if not, and if you're operating before they have regained their range of movement, then your risk are three fibrosis because your surgery is another insult to the knee. So I usually tell a patient's that they need to rehab together range of movement back and then we all operate and I wouldn't do that before six weeks. Um Especially with an isolated ACL tear graph choice. We'll talk about draft choice augmentation. Uh Has anyone heard of a lateral extra attic, Latino DCIS? I hope you have. Uh and uh that's something that you add in to, to reduce your rerupture rates. So this is what he had, he had a patellar tendon uh graft for his ACL. He had a lateral ecstatic of Dina uses and a lateral Minister repair. Um So we already said ACL and noncontact injuries, you often get concurrent ligamentous injury and the period of initial rehab is useful and I'll talk about surgery or not graft choice and additional procedures. Netball by the way is one of the worst, worst sports for, for ACL injury because the whole point of it is you catch the ball and you have to come to a quick land and it's played by girls who have a higher rate of ACL injury. Anyway, you can see that a valgus pattern of landing. Oh, immediate immediate pain snaps. You can't play on. There you go. There are lots of different things. There are lots of different graphs you can, you can use to reconstruct the ACL. Uh you can use hamstrings and create, create, create very big thick grafts from them. You can use the patella tendon, you can use the quad tendon with or without a bone block. So there's three easy choices that you can use from, from as an autographed and you can also use allographs, a donated tendons from, from dead people. Um The allographs have actually the worst rerupture rate. So it's something that we don't really use unless there's a multi ligament injury, Multilingual reconstruction. When you just don't have that much graph choice. The patella tendon is a big 66 stiff graft, which is fantastic. It has the lowest rerupture rate of all the graft, but it is, it is, it is a bit difficult to get over their, their big operations and patient's can have difficulty kneeling on that knee hamstring is quite common. It's probably the easiest one to use because it's, it's soft, it's all soft tissue. So it's easier to get around the knee, but it does have high rerupture rates. And quads tendon was a big fat fad a few years ago to use quad attendant for lots of things. They are useful. They kind of work in a. So they have similar function to a patellar tendon graft in that they, they have have good, good rerupture rates or lower rerupture rates and they're a bit more difficult to rehab. So these are all the different options available. Um And then we're talking about lateral tenodesis. So before intra articular ACL reconstructions, this historic Mackintosh technique would reconstruct the acl. So, so mcintosh came up with this idea of using iliotibial band, the I TB and weaving it underneath the ACL and attaching it to the femur. So essentially creating a sort of uh an extra articular check rein for, for pivot when you're pivoting the anterior tibia moves anteriorly. So what you're getting is internal rotation of the tibia on the femur and this, this, this kind of big extra articular repair or reconstruction acted as a check rein to prevent that, that, that pivot shift. Um More recently, we've got the anterolateral ligament or lateral extra articular tina DCIS, which uh you can use different grass for this, but essentially, you're creating a, a new, a new bit of tissue here uh or reconstructing the anterolateral ligament, which is on the right or lateral tenodesis where you're taking I T B and attaching it to the femur. So it's a smaller version of the Macintosh, but it has been shown to reduce re rupture rates. So, if you look at the stability trial done by al, get good in, in Candida, they showed that a lateral extra articular team DCIS reduced rerupture rates by 50%. Uh And they also showed no increase in lateral joint pressures. So it's a good thing to do when high, when you, when you're faced with a high, high risk patient. And these are my indications for doing electricity in DCIS. If you're high level athlete, I would do one because I want to reduce the risk. You're putting a lot of effort through your, a lot of energy through graft in revision surgery. Again, I would do that in high probability young patient's. And if I just don't trust the patient to do the rehab, it's a very easy procedure to do. To be honest, it takes about 15 minutes and reduces rerupture. It's about 50%. Uh So I have a very low threshold for it. Um The other thing to say is if you have had an ACL injury, you're at higher risk of injury to the contralateral side. So, injury prevention programs very useful. And this is uh this charity was set out by good people in Oxford. Uh it's called a Skip Charity and I point my patient's towards it. I think it's a useful thing for them to know for when they're rehabbed and to reduce their rupture rates of the other side. Happy with that. So far a CLS ticked. So you said with extra Ticotin A DCIS reduces erupted by 50%. Is that just in the high risk or at all? No. So in the stability trial, um, in the stability trial, I think they did it in under 20 fives. I extrapolated to, to all cases. But I think that the trial was under 25 years old. Yeah. Um, only takes um about 10 extra minutes maybe. Wouldn't be a good idea. Just do that on all your ACL patient's just unnecessary. Yeah. Good point. Um Why, why don't we do it on everyone? Um I guess the uh everything has a risk, right? Is I have seen problems with the lateral trinity exists. Uh It depends on how you fix it. I have seen people cutting through the Endobutton reconstruction. So effectively detention in the ACL while they're doing it. Um There are issues with it. So, you know, you wouldn't do things unnecessarily. I don't do it if, if it's, if they're higher risk of re rupture, uh MCL injury. So this is the most common knee injury, really most healed without surgery. That's really important to know, but they're often associated with ACL tear. So I, I see a lot of patients with ACL MCL injuries and in these cases, I tend to brace them for a, for a few for a few weeks and then that converts there to ligament injury to a single ligament injury of the MCL heals well by itself. So if I can convert a great two or three MCL to A, to a grade one MCL, uh just do an A C L reconstruction, I'd really be very happy with that. So it's quite important thing to pick up because it can increase your injury or rerupture rate if you, if it goes unnoticed. So it's important to pick it up preoperatively with an A C L. Uh But I would say the MCL injuries are very prone to stiffness. Remember we talked about how MCL is isometric. Um So it's under constant tension. Patient don't like moving there need when they're having MCL injury because it's sore throughout the range of movement. So, and at least two, quite a lot of stiffness and I've had to do a few M U S patient's who've had, uh, MCL injuries in the past. Okay. Here's a professional leak, premier league football, 27 years old. Um, he had a previous contra actual ACL injury reconstructed two years ago, very happy with it and he was injured in training during a tackle. Anyone see what's going on there? The fact that it's in the MCL section is a bit of a giveaway. All right. So, uh, this is his, his examination findings. Grade three MCL A 30 degrees. Great here and feel a zero degrees and dial test was positive due to rotatory instability. So, can anyone in this, in this corona view? Can you see this big, big black line here? Now, anything that's wavy, that's the MCL and anything that's waving nature generally means that it's been detention, then it's been pulled off the tibia here. It's, it's still attached on the fever. You can see it's detentions and it's pulled off on, on the tibia. Most, most MCL injuries heal without surgery because most MCL injuries are femoral avulsion and they tend to do well. But if you've got a tibial avulsion, they don't tend to tend to heal quite as well. And they're, they're the ones that, that might require surgery. Um, this patient has actually got a Stenner lesion. Remember the Stenner lesion in the, somewhere the avulsed on the collateral ligament, uh sits above the abductor pollicis tendon in a similar way. The MCL here is sitting above the piss, Anserinus tendons because they're very closely associated. So that, that doesn't have a very good opportunity to stick back onto the tibia and probably why the tibial avulsion injuries require surgery. Uh His PCL is, is a bit thickened but it's not too bad. Uh So this is rotate or instability. I think I might skip over this. Um And I've got some slides from Andrew Williams, which are not, not, not this case but uh quite interesting anatomy. So this is his surgical technique. You'll remember that the medial um uh aspect of the knee is in three layers. He got the superficial MCL layer too deep MCL in layer three and the superficial fascia in layer one. So his techniques to do a layer by layer, dissection and reinforcement of each layer as well as the reconstruction. Now, remember the staff on this nerve runs halfway along. So it's important to identify protective possible and this is a large reconstruction. So what you get is uh insertion into that I'm sorry, insertion into the media family. Condylox immediately handle uh coming along here and an attachment to the MCL insertion point on the tibia. And you can see these are the reinforcements that each layer. So this patient had MCL reconstruction because they had the tibial avulsion and the stem a lesion. Um, and they went on did, and it did pretty well afterwards back to, back to playing in the premier league. So that's pretty awesome. Now, most people wouldn't get an MCL reconstruction, uh, the average average Joe because they're not putting quite so much force on their knee. Um, and they usually don't have tibial avulsion injuries. So this is just to highlight, we just don't, don't go around thinking all MCL injuries need surgery. Uh This is just an elite athlete case. And then we've got a, I've got a couple of multi ligament knee injuries to discuss. I think it might be worth just to just to just to go through um multi ligament injuries. You have to have a high index of suspicion that knee has been, has been dislocated. Um Sometimes patient's can, can present to you with a reduced knee and you, you may not have a complete idea of the true um kind of amount of displacement that, that the knee would have gone under goal would have gone through before it presented to you. They usually high energy injuries and you must, must, must assess the near vascular status. You won't pick it up unless you're looking for it. This patient had a popliteal artery involvement. You can see Scots just at the level of the uh the femur, usually when these are reduced, the flow does, does return, but there's a high risk of Luminal injuries and kind of partial partial blockages. Uh patient's don't often lose anybody lose their legs because of this because there's a high rich collateral supply. But it's really important to pick it up because surgery is that second impact. Um And ligament injuries is a big spectrum. They can range anywhere from, you know, that ACL and MCL sprain that I talked about the full knee dislocations. So this is a high level rugby player, 20 year old uh in January had knee injury, awkward landing in March. He had some surgery um but he still has ongoing instability and pain. So probably something awful happened at the beginning and was misdiagnosed. Uh So clinically has an MCL and PCL laxity. Now, he, he had awkward landing during the line out. A lot of forces go through these big rugby players. So you have to have a high index of suspicion to think that there is probably a bigger injury than, than what, than, than, than initially suspected. Um These are the specifics, the specific MRI slices you can see on this, on the sagittal view that the MCL elongated, there's post here translation of the, of the tibia on the femur. Um you see that, so there's, there's, there's probably a PCL injury there and then you can see there's MCL laxity extruded medial meniscus makes you think that maybe there's a, there's a root tear. Um You shouldn't normally see this much fluid between the MCL and the bone and uh here we go. Um medial meniscus root injury, probably subacute trying to heal. Um So, eee way confirmed the diagnosis, MCL PCL injury and he had a PCL reconstruction and repair as well as a route repair. And this is his post uh post op images. That's his, that's his PCL going through there. Uh That's his MCL. You can see that's, that's the reconstruction and the repair thing that we talked about. And this, this little thing here is a swivel lock that the, that the root repair was done through another injury, 25 years old, this time, another rugby player, this is a hyper extension of the knee. Now, he, this guy had a dense comparing your nerve palsy um is really horrible. Uh no complete foot drop and reduced sensation and comparing your nerve. So his examination showed uh ACL injury which is quite interesting with a hyperextension because you think it would be PCL. But you certainly can get A C L injuries with, with pure hyperextension. Um And dial test was positive at 30 degrees. Makes you think that the post lateral corner injury? Yeah, various stress know endpoints, the lateral collateral completely gone. MCL is intact. These are his M R slices, that's his ACL completely gone. You can see that there's anti translation of the tibia. Uh There's lots of bone bruising where the tibia has been in contact with the femur and a hyper extension injury and his PCL is intact. He just goes to show hyperextension can leave the PCL intact. And this is his post bilateral corner avulsion can see this massive tissue, this wavy line here, that's his lateral collateral ligament which has been detentions. The whole thing has pulled off the proximal fibula and it's just this massive scar tissue uh difficult to make out his nerve. So this chap had exploration of his nerve, which showed that it was in continuity but very confused. So probably uh if you're looking at your, if you're thinking about the grade of your nerve injury, think about the Southern classification. Uh This is uh somewhere along the line of uh accident missus um but not, not on your ostomy. Cisco's the nervous and continuity. Um Your license was performed and he made a bit of a recovery from that. Uh He had an ACL reconstruction with contact contralateral hamstring and he had a biceps and he had post little corner reconstruct repair and uh fiber reconstruction to protect that repair. This is it. That's his ACL. You can see that there is uh screws and Endobutton reconstruction and that's, that's those are the, there's a tunnel for his post, a natural corner um repair and reconstruction. You see this big big dissection that, that required the post lateral corner uh for the post, lateral corner exploration. Um pretty often POSTOP this is a, there's a PCL MCL injury. So you've got to really, really look at, look for these things. You can see a massive test your gap with no um with no end point MCL, no endpoint, they're moving all over the place of 30 degrees. And if, if we look at that POSTOP POSTOP view solid in the AP plane and if you look at we're going to get to get to the, get to the corona plane, you see that big, big exploration on the medial side, you can see MCL is nice and solid now, nice and solid in, in, in the corona plane. Patient will still be braced, they'll still take the best part of a year to get over. And I always tell these patient's uh getting, getting back to that level of activity is very difficult. It's possible but it's very difficult with elite athletes. It's possible. But you know, with, with multi ligament knee injuries, you're just lucky to have a leg to, to work on really. So a bit of a whistle stop tour, there's lots to talk about here really. But we talked about Q A C L injuries, acute knee injuries, ACL injuries, different options available, MCL injuries and importance of picking it up. And something about multi, a little bit about multi ligament, knee injuries. There's, there's more to talk about with regards to rotate or instability and uh and all the all the kind of lateral tdc's and, and the literature, but probably for, for another time. So in summary, knee injuries are variable, very, very variable and you need to have a very early initial assessment. Barber helped by, by an experienced professional if in doubt, refer it to your cute knee surgeon. And my approach would be earlier, MRI scan cereal assessment, early surgery is indicated in a multi ligament and have a very low threshold for lateral Genisys. Thank you very much. Once again, do contact me if you want to get in touch, just go on the website and find the details. Any questions? Thank you very much. Um I just wondered the MCL in terms of isometric uh points. Yeah, for the entry, would you then tighten extension flexion or go with the there's multiple, multiple papers, there are different. Yeah, you're right. So the MCL is more than just one component, right? You've got the superficial MCL, deep MCL and the posterior bleak ligament. The superficial MCL is probably the most important one and that's active from about 15 degrees down to down to flexion and the posterior bleak ligament is active in terminal extension. So, um it depends on which that you're, you're reconstructing. Um And it depends. So, so that would determine what uh at what point you're um your uh your attention ing it. The other thing that's really important is finding out the points of which you're fixing it. So what I normally do is I drill A, I drill a wire in the medial Epicondyle drill a wire in the extent in the uh in a tibial um footprint and I tire, tire suit around it and I checked for I cemetery and if it's, if it's lax and if it lacks an extension flexion, I move the, move the points to try and get a very uh isometric point or isometric ligament. So that's kind of my tension ing I make sure that the, the, the, the femoral and tibial points uh a correct uh and they create an isometric point and then if it's isometric, then it doesn't really matter when you're mentioning it. But I tend to tension it in about 15 degrees for the MCL because I really don't want to capture the knee and I don't want to give them a fixed flexion deformity. Just a quick question on multi ligaments. Um We had an unusual case LCL and ACL injury. Uh What would you and a young patient, would you consider what timing of surgery? When would you operate? You talk about ACL and LCL? That's right. So really that's ACL and post lateral corner, isn't it? You're looking at a rotatory instability there. Um How young is how young were talking discreetly mature or immature? Uh 14, 14 boy. So there are different options here. You can either it depends on how much instability he has and what his uh what his um activities are like. You know, if he's uh if he's really keen into sport, if it's you know, academy player or something like that, then you kind of have to have to be aggressive. You don't have a choice, but this is a conversation you have with the patient and this individual circumstances, it's kind of, um, it's personalized really to them. Uh, there are.